Lower Eyelid Transcutaneous Blepharoplasty, Minimizing Complications and Correction of Lower Eyelid Malposition.

The periocular area is one of the first and most noticeable areas affected by ageing. Common signs of lower lid ageing include rhytids, prominent eye bags caused by prolapse of orbital fat pads, increased lid laxity leading to lid malpositioning, and deepening of tear troughs, all of which give a sunken aged appearance. Lower lid transcutaneous blepharoplasty can correct most of these problems providing excellent long-term aesthetic outcomes with minimal downtime for the patient. However, lower eyelid anatomy is complex, and a thorough understanding of its structure and function is needed to avoid serious complications such as lid malpositioning and blindness. In this review, we present the anatomy of the lower lid and useful surgical techniques to circumvent and avoid such complications.

Balanced Cantilever Graft for Supporting the Cartilaginous Side Wall of Nose.

BACKGROUND: Many locations for the nasal valve have been suggested, and more recently the concept of the flow-limiting segment was introduced. Rather than being controlled by an internal and external valve, flow through the nose is regulated by the cartilaginous side wall, septum, and inferior turbinate. OBJECTIVES: The aim of this study was to assess the balanced cantilever graft (BCLG) as a technique to support the lateral nasal wall. METHODS: Patients undergoing primary open septorhinoplasty over a 2-year period were studied. Follow-up period was a minimum of 6 months to a maximum of 24 months. Subjective improvement of function was measured with a visual analog scale (VAS) and aesthetic outcomes by FACE-Q score. Objective assessment of the airway was performed with a nasal peak inspiratory flow (NPIF) meter. Strips of septal cartilage of sufficient dimensions were placed in submucosal pockets created under the area of the lateral wall to be supported. RESULTS: Sixty patients received BCLGs. The VAS score for nasal obstruction increased from 2.6 preoperatively to 8.1 postoperatively. FACE-Q increased from 16.7 preoperatively to 36.6 postoperatively. NPIF was 74.9 L/minute preoperatively, improving to 95 L/minute postoperatively. Statistically significant improvements were seen in these functional and aesthetic scores. CONCLUSIONS: BCLGs support the weakened part of lateral nasal wall by their elastance. Minimal cartilage is required and the graft can be altered to support various parts of the lateral nasal wall. This graft does not cause an aesthetic deficiency whilst providing adequate support.

Rhinophyma: Combined Surgical Treatment and Quality of Life.

Rhinophyma is a progressive and disfiguring thickening of the nasal skin. It is typically found in middle-aged or elderly Caucasian males. The exact cause of the disease is unknown. There is excessive formation of scar-like tissue and hyperplasia of the sebaceous glands. This article will demonstrate our experience of treating rhinophyma using a combined surgical approach and propose a novel classification system. This is a retrospective analysis of cases operated by a single surgeon over 9 years using the Glasgow Benefit Inventory (GBI) tool. Thirty-three patients were identified. Twenty-nine patients had three techniques used in one sitting, two patients had two techniques used, and two further patients had one technique used. Total GBI showed a +50.99 result following surgery. Rhinophyma treatments can benefit patients as demonstrated by the GBI outcome. This can improve the patients' quality of life. The use of more than one technique in the same sitting potentially improves the outcome. Our classification system helps categorize the disease better as well as choosing the treatment and comparing disease and treatment. The Level of Evidence for the study is 4.

Face and Neck Lift-Postoperative Care.

Primary aim of the article is a discussion of the postoperative care after face and neck lift. A brief history of face and neck lift along with different techniques are described. Importance of preoperative assessment is stressed.

Postoperative Management of Cleft Lip and Palate Surgery.

Cleft lip and palatal clefts are one of the most common birth defects with a global incidence of 1 in 700 live births. The majority of these orofacial clefts are nonsyndromic. However, a general screening for syndromes and other organ anomalies should always be performed as their association with orofacial clefts cannot be overlooked. With the recent progress in the knowledge of cleft repair, the procedures to correct cleft lip and palate though complex, have been simplified to allow improvisation in outcome and to achieve even better finesse of surgical result. The procedural complications and the pursuit of having near perfect esthetics and functionality, make this deformity a recipient of multiple procedures. This ensures that the patient is under the care of the treating surgeon for long term and allows the surgeon to follow-up on the result, not only to provide care but also to intercept any deviation in the desired outcome. Postoperative care of cleft lip and palate surgery is largely underdiscussed and a set of fixed guidelines will help the treating surgeon to provide the most comprehensive care to the cleft patients. The authors review the practices followed at their hospitals-a high volume cleft and craniofacial care center, a tertiary care multispeciality teaching hospital, and a community teaching and training hospital. The commonly followed practices with suitable evidence in postoperative care of these patients are enlisted here.

Alar Suspension Sutures in the Management of Nasal Valve Collapse.

OBJECTIVE: This study assesses the efficacy of alar suspension sutures in the management of nasal valve collapse causing nasal obstruction. These sutures are inserted between the vestibular skin and lateral crura and hitched to the periosteum of the medial inferior orbital margin; this is a variation of the alar (change everywhere) suspension suture technique. METHOD: A retrospective review of patients who underwent alar suspension suture insertion between January 2009 and December 2010 in the management of nasal obstruction was undertaken. Symptoms of nasal obstruction were assessed using the Visual Analogue Scale (VAS) and peak inspiratory flow rate (PIFR). This was measured preprocedure and repeated at 3, 6, and 12 months postoperatively. RESULTS: A total of 35 patients were identified, and 26 were included in the study; 90% of patients were satisfied with the outcome of surgery, supported by improvement in the VAS and PIFR scores. The mean difference in VAS preprocedure and postprocedure was 4.97 (P value = 0.00), and the average improvement in PIFR was 25.5 L/min (P value = 0.00). CONCLUSION: Our study shows a significant improvement in patient's symptoms following insertion of alar suspension sutures. It is, therefore, a reliable, safe, and effective technique in treating nasal obstruction secondary to nasal valve collapse.

Management of cystic cervical metastasis.

An adult older than 40 years present with a cystic lump in the upper neck should be considered at risk of having an underlying malignancy of the head and neck-a mucosal squamous cell carcinoma or a papillary thyroid carcinoma. Although the likelihood of malignancy is small, should the diagnosis of malignancy be confirmed pathologically, this consequential diagnosis will result in devastating physical and psychologic upset to the patient and their caretakers, the treating surgeons, and possibly many other clinical groups. It is therefore recommended that all such patients be investigated by radiologic imaging-CT/MRI and fine needle aspiration cytology, followed by panendoscopy of the head and neck, which includes an ipsilateral tonsillectomy biopsy and an excision biopsy of the cystic neck lesion. Should the lesion prove to be an isolated cystic metastatic squamous cell carcinoma, a neck dissection should be performed with or without adjuvant radiotherapy. Should the lesion prove to be a metastatic papillary thyroid carcinoma, a total thyroidectomy and neck dissection should be performed. In general, patients with cystic metastasis have a better prognosis than patients who present with a noncystic neck mass.

Cancers presenting in the head and neck during pregnancy.

PURPOSE OF REVIEW: The purpose of this review is to document the information reported on cancers presenting in the head and neck area during pregnancy. RECENT FINDINGS: Accidents and cancer account for most deaths during the reproductive years. Cancer complicates approximately 0.1% of all pregnancies and, in order of frequency, the incidence of cancers by site are breast, melanoma, thyroid, cervix, lymphoma, and ovary. Some of these cancers may present in the head and neck region, as well as more uncommon cancers such as mucosal squamous cell carcinoma. SUMMARY: It is recognized that with the dramatic rise in births among "reproductively" older women and with the changing epidemiology of squamous cell carcinoma of the head and neck in nonsmoking and nonalcohol-drinking women, there is to be expected an increased incidence and presentation. Management of such patients must consider the gestational age of the pregnancy and must include alternatives to current treatments to accommodate the individual's wishes regarding her pregnancy.

Multiple primary tumors in patients diagnosed with hypopharyngeal cancer.

OBJECTIVE: There have been few series to report on the incidence of multiple primary tumors associated with hypopharyngeal cancer. A unique consecutive patient group in a closed community who were treated by a single surgeon was available. The incidence and effect of multiple primary tumors were unknown. STUDY DESIGN: We sought to assess (1) the incidence of multiple primary tumors among patients with hypopharyngeal cancer who were treated at a tertiary center, (2) the incidence of synchronous and metachronous tumors, and (3) the location of these multiple primary tumors and their effect on patient survival. METHODS: We conducted a retrospective study of case notes of 150 consecutive patients with hypopharyngeal malignancy treated by a single surgeon between 1983 and 1998. Information was compiled from the patients' medical records and death data from the Family Health Services Authority. RESULTS: Thirty-four patients had multiple primary tumors (22.6%). There were 22 men and 12 women; piriform fossa tumor was seen in 21 men and 6 women, and postcricoid space tumor was seen in 6 women and 1 man. Second primary tumors were synchronous in 7 patients, subsequent to hypopharyngeal tumor in 5 patients, and antecedent to hypopharyngeal tumor in 14 patients. Eight patients had 2 primary tumors, of which 4 were synchronous, 4 were subsequent, and 8 were antecedent to hypopharyngeal malignancy. On the last review (2001), 3 patients were alive, and 31 had died: 17 had died from primary malignancy, 11 from another malignancy, and 3 from unrelated causes. CONCLUSION: The presence of second primary tumors in hypopharyngeal cancer is higher than previously reported, and their presence had a significant effect on the patients' survival.

Immediate autogenous cartilage grafts in rhinoplasty after alloplastic implant rejection.

BACKGROUND: It is accepted in rhinoplasty that complications are more common with alloplastic implants than with autografts. There is little guidance in the literature on how to deal with the cosmetic and/or functional problems that follow alloplastic implant rejection. The conventional advice has been to remove the allograft and not place any graft at the same time. The present article presents our experience treating allograft rejection and immediately repairing any structural defect with autografts. OBJECTIVE: To demonstrate that immediate nasal reconstruction using autogenous cartilage is a good technique when an alloplastic material has to be removed because of rejection, inflammation, or infection. DESIGN: A retrospective analysis of outcome for a case series. METHODS: A retrospective review of the management of 8 patients who presented to 2 tertiary referral centers with alloplastic implant rejection following rhinoplasty. In 7 cases, the alloplastic implant had to be removed because it had migrated and caused a foreign body reaction; in 1 case, the implant had caused a bacterial infection. RESULTS: In all 8 cases, the nasal deformity that followed the removal of the allograft was so marked that the nose was immediately reconstructed with autogenous cartilage. The patients all made a good recovery after immediate reconstruction, although skin changes associated with the alloplastic implant remained after a mean follow-up of 3 years 3 months. CONCLUSION: The use of autogenous cartilage is a good option for nasal augmentation immediately after the removal of an alloplastic implant.

The place of Riedel's procedure in contemporary sinus surgery.

Many operative procedures have been described to treat frontal sinus disease with varying results. Obliteration of the frontal sinus is attempted when drainage procedures fail. Most large series of patients undergoing sinus obliteration have reported recurrent disease yet the management of these patients is rarely discussed. We believe Riedel's procedure has an important role in the management of these patients. Riedel's procedure can help eradicate frontal sinus disease and symptoms when drainage and obliteration have failed and where there is persistent disease involving the anterior wall of the frontal sinus or the sinus itself. Whilst cranialization has a role in the removal of the mucosa or contents of the frontal sinus in craniofacial resection, the morbidity associated with it make Riedel's procedure preferable for dealing with chronic infection or locally invasive disease. Riedel's procedure also maintains a barrier in the form of the posterior wall of the frontal sinus and the intracranial contents. Post-operative disfigurement, the main criticism of this procedure, can be reduced to some extent by chamfering the margins of the frontal sinus along with the supraorbital rims and reconstructing the anterior wall at a later date if necessary. The authors are aware that any report about frontal sinus surgery should be judged after several years follow-up, and whilst not all these cases have been asymptomatic for a decade, several have been reviewed for many years.

The use of maggots in head and neck necrotizing fasciitis.

Historically maggots have been used to clean necrotic war wounds. With the ready availability of sterile maggots, they are being used increasingly in surgical practice. Although maggots have most frequently been employed in the management of necrotic wounds and ulcers involving the lower limb, we have identified a particularly useful application in the head and neck and describe a case in which maggots played a significant part in the successful treatment of a florid necrotizing cervical fasciitis in a patient, who was unfit for repeated surgical debridement.

Nasal valve surgery: assessment of quality of life with the Glasgow Benefit Inventory.

We used the 18-question Glasgow Benefit Inventory (GBI) to conduct a retrospective assessment of quality of life following nasal valve surgery. We telephoned 53 patients who had undergone open rhinoplasty for the treatment of nasal valve collapse over a 2-year period. A total of 39 patients--24 men and 15 women, aged 20 to 50 years (mean: 38)--agreed to participate and answer the questions. Follow-up ranged from 3 to 12 months (mean: 8). The spectrum of possible GBI scores ranges from -100 (maximum negative outcome) to 0 (no change) to +100 (maximum benefit); in our group, the median total score was +56 (interquartile range: +32 to +90.5) and the overall total score was +58. The three subscale components of the GBI--general benefit, physical benefit, and social benefit--were analyzed individually; the respective median scores were +46 (+21 to +71), +67 (+25 to +91.5), and +50 (+17 to +100), and the respective overall scores were +60, +59, and +50. Based on these findings, we conclude that nasal valve surgery significantly improves quality of life.

A prospective randomized blinded cross-over trial using nasal drops in patients with nasal polyposis: an evaluation of effectiveness and comfort level of two head positions.

BACKGROUND: The aim of this study was to compare the efficacy and the degree of discomfort caused by the Mygind's (supine and head extended) position and the lying on the side head down (LSHD) position used for instilling nasal drops. We performed a prospective randomized blinded cross-over trial. METHODS: Twenty-three patients with nasal polyps were recruited and were given Betnesol nasal drops for 6 weeks after assessing their peak nasal inspiratory flow rate and grading the polyps. The assessor was blinded to the position used by the patient that was selected randomly. The patients were reviewed after 6 weeks when both their flow rates and their polyp grades were reassessed. They were given a visual analog chart to record the ease by which drops could be instilled and any discomfort caused by the position. After a 2-week washout period the patients were treated for another 6 weeks with the same drops using the other head position. RESULTS: Twenty-one patients completed the study. The LSHD and Mygind's positions were equally effective in controlling the nasal polypi. Mygind's position was easier to instill drops in the nose although LSHD position caused less discomfort for the patient. The nasal peak inspiratory flow increased linearly as the polyp size decreased. In 86 and 90% of the patients the nasal obstruction and nasal discharge, respectively, were well controlled. CONCLUSION: The drops were efficacious in both head positions. The LSHD position caused the least discomfort, although patients found Mygind's position easier to instill drops. Steroid nasal drops are an effective way to manage patients with nasal polyposis.

The complications of giant titanium implants in nasal reconstruction.

We present two cases where a large titanium implant has been used in nasal reconstruction without regard to the basic principles and current philosophy in reconstructive techniques. A full thickness nasal defect requires reconstruction with an inner lining, scaffolding and external skin. Autogenous grafts are preferable particularly when they are used for support or their insertion creates tension on the overlying soft tissue. We report serious complications that result from a disregard to these basic principles in two patients following the insertion of giant titanium nasal implants along with their management.

The anatomy of the sphenopalatine artery for the endoscopic sinus surgeon.

BACKGROUND: This study was performed to determine the variations in the branching pattern of the sphenopalatine artery medial to the crista ethmoidalis. Seventy-seven cadaver head sides that had been sectioned sagittally in the midline with their septum removed were used after injecting pink latex to highlight the arterial vessels. METHODS: The mucosa from the middle meatus from the level of the basal lamella was removed until the artery and its branches were seen and then was examined under the microscope to identify the position of the arterial branches. RESULTS: The sphenopalatine artery and its branches were identified in 75 specimens. Of these 75 specimens, 73 (97%) had 2 or more branches medial to the crista ethmoidalis, 49 (67%) had 3 or more branches, 26 (35%) had 4 or more branches, and 1 specimen had 10 branches. In two specimens the artery presented as a single trunk. CONCLUSION: The sphenopalatine artery normally starts to branch lateral to the crista ethmoidalis and these branches vary widely. It is important that the surgeon who undertakes ligation or cautery of the artery is aware of these variations, otherwise they may overlook some of the branches. With an endoscopic approach, removal of the crista ethmoidalis helps visualize these branches.