A Multidisciplinary Approach to Penetrating Neck Trauma in a Patient with Self-Inflicted Gunshot Injuries to Zones 1-3 of the Neck.

Penetrating neck trauma comprises 5%-10% of all traumatic injuries in adults and carries up to a 10% mortality rate for those affected. Management of penetrating neck trauma can be challenging and often requires a multidisciplinary approach. A case of penetrating neck trauma via self-inflicted gunshot wound to zones 1-3 of the neck in an intoxicated, suicidal 60-year-old man is presented. Immediately after stabilization by the trauma surgery team, surgical reconstruction using a pectoralis major pedicled myocutaneous flap was completed by the plastic and reconstructive surgery team. The patient's hospital course was complicated by injury to the left phrenic nerve, oropharyngeal swallowing dysfunction, and left diaphragmatic dysfunction. The trauma team initiated prompt multidisciplinary responses to each of these complications as they arose by involving the plastic and reconstructive surgery, otolaryngology, gastroenterology, and speech language pathology teams. Early involvement of the physical medicine and rehabilitation, psychiatry, dietary, and pharmacy teams allowed for early optimization and monitoring of the patient's mobility, psychological, and nutritional statuses. The timely initiation of multidisciplinary care in this patient's case allowed for the patient to not only to survive a potentially fatal penetrating neck trauma, but to be discharged to a rehabilitation facility with an independent level of function. Given the complications due to severe penetrating neck trauma of zones 1-3 in this case, it is essential for early involvement of the appropriate subspecialty teams in order to achieve the best possible outcome for the patient.

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.

Cervicogenic dizziness alleviation after coblation discoplasty: a retrospective study.

OBJECTIVE: Little is known about the therapeutic relationship between coblation discoplasty and cervicogenic dizziness (CGD). CGD can be caused by abnormal proprioceptive inputs from compressed nerve roots, intradiscal mechanoreceptors and nociceptors to the vestibulospinal nucleus in the degenerative cervical disc. The aim was to analyze the efficacy of coblation discoplasty in CGD through intradiscal nerve ablation and disc decompression in a 12-month follow-up retrospective study. METHODS: From 2015 to 2019, 42 CGD patients who received coblation discolplasty were recruited as the surgery group, and 22 CGD patients who rejected surgery were recruited as the conservative group. Using intent-to-treat (ITT) analysis, we retrospectively analyzed the CGD visual analogue scale (VAS), neck pain VAS, CGD frequency score, and the CGD alleviation rating throughout a 12-month follow-up period. RESULTS: Compared with conservative intervention, coblation discoplasty revealed a better recovery trend with effect sizes of 1.76, 2.15, 0.92, 0.78 and 0.81 in CGD VAS, and effect sizes of 1.32, 1.54, 0.93, 0.86 and 0.76in neck pain VAS at post-operative 1 week, and 1, 3, 6, 12 months, respectively. The lower CGD frequency score indicated fewer attacks of dizziness until postoperative 3 months (p < 0.01). At post-operative 12 months, the coblation procedure showed increased satisfactory outcomes of CGD alleviation rating (p < .001, -1.00 of effect size). CONCLUSIONS: Coblation discoplasty significantly improves the severity and frequency of CGD, which is important inbridging unresponsive conservative intervention and open surgery.Key messagesThere is a correlation between the degenerative cervical disc and cervicogenic dizziness (CGD).CGD can be caused by abnormal proprioceptive inputs from a compressed nerve root and intradiscal mechanoreceptors and nociceptors to the vestibulospinal nucleus in the degenerative cervical disc.Cervical coblation discoplasty can alleviate CGD through ablating intradiscal nerve endings and decompressing the nerve root.

Infrared thermography-guided designing and harvesting of pre-expanded pedicled flap for head and neck reconstruction.

BACKGROUND: Pre-expanded pedicled flaps possess a more flexible transfer pattern and higher tissue utilization than random flaps, but the perfusion is fully dependent on the chosen axial vessels. A precise mapping of the vessels would assist the surgical design and increase the likelihood of success. The application of Infrared thermography (IRT) has been previously reported for perforator location. The aim of this study is to report the use of IRT in mapping the course and distribution of axial vessels in the pre-expanded flap to guide the designing and harvesting. METHODS: Patients who underwent head and neck reconstruction using pre-expanded flaps were included. After tissue expansion, IRT was used to mark the vessel distribution along the expanded flap. The results were compared with color Doppler ultrasound (CDU) and/or computed tomographic angiography (CTA). The flap was designed and raised based on the pre-operative marking by IRT. The mark was verified intraoperatively. RESULTS: A total of 26 expanded flaps were performed, including 20 pedicled flaps and 6 free flaps. IRT succeeded to map the vessel distribution in all cases. All marked results were verified by CDU, CTA, and intraoperative dissection (26/26, 100%). IRT showed more comprehensive distribution of vascular branches than CDU or CTA, and could be utilized intraoperatively to identify the arteries. CONCLUSION: IRT provides accurate and comprehensive mapping of the axial vessel distribution in the pre-expanded flaps, assisting with flap design and harvest. It is easy to use and non-invasive as an important tool pre- or intraoperatively to ensure the safe elevation.

Successful management of the supraclavicular artery island flap combined with a sternohyoid muscle flap for hypopharyngeal and laryngeal reconstruction.

This retrospective study evaluated operative outcomes when using a supraclavicular artery island flap (SAIF) combined with a sternohyoid muscle flap (SHMF) to reconstruct defects after hypopharyngeal carcinoma resection. Reconstructive surgery for hypopharyngeal and laryngeal defects was performed with the SAIF + SHME combination in 6 patients during 2016 to 2018. Within 14 to 16 days after the surgery, all 6 patients could ingest food and block the tube (avoiding aspiration), with no pharyngeal fistulas. They then underwent irradiation up to a total of 60.5 Gy during the 4 weeks postoperatively. All 6 flaps survived, and there were no donor-site complications except minor dehiscence in 1 patient. Thus, the SAIF + SHMF combination can be used to reconstruct hypopharyngeal and laryngeal defects after hemi-laryngectomy in patients with hypopharyngeal carcinoma involving the unilateral larynx. This technique effectively preserved the swallowing function and phonation of the patients, thereby improving their quality of life.

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.

Innovative techniques for thread lifting of face and neck.

BACKGROUND: To investigate the efficacy and outcomes associated with eyebrow, midface, mandibular, and neck lifting using the innovative techniques. MATERIALS AND METHODS: In this prospective review chart study, a total of 151 patients, were included in the study from January 2016 to May 2017. All participants underwent thread lifting using our innovative thread-lift technique for head and neck. The patients were followed up first week, first, third, and sixth month after lifting surgery. Outcomes were assessed by two surgeon and patients based on the GAIS score. All data were analyzed by SPSS-17 software with chi-square test. RESULTS: A total of 151 patients (mean age: 52.49 ± 10.67, range: 27-78 years), 16 (10.6%) men and 135 (89.4%) women, were included in the study. The most common sites for the face-lifting surgery were the mandible (49.7%), midface (37.1%), neck (7.9%), and eyebrow (5.3%), respectively. The level of satisfaction increased from 77.5% in the first week after surgery to 89.4% in the sixth month after surgery for patients, remained unchanged, 96% for the surgeon, and increased from 74.8% to 94.7% for the independent surgeon. The highest rate of potential complications after the lifting surgery was related to ecchymosis (23.2%), followed by complications of tumefaction (6.6%), pain (6.6%), and pain (5.2%). CONCLUSION: The results showed that the level satisfaction of patients and surgeons increased over time. It seems that facial rejuvenation thread lifting with this innovative technique is effectiveness, safe, and cosmetically more acceptance with minor complications than other face-lifting techniques.

Cervical nodal metastasis after malignant conversion of sinonasal inverted papilloma: Report of a rare case and literature review.

Malignant conversion of sinonasal inverted papilloma (SNIP) occurs in approximately ten percent of cases. These tumors are classically described as locally destructive, but without metastatic potential. Only four cases of malignant conversion with cervical nodal metastases have been described in the English literature. We present the rare case of a 61-year-old Caucasian male with a nasopharyngeal recurrence of malignant SNIP with cervical and retropharyngeal nodal metastases. The patient underwent endoscopic transpterygoid with nasoseptal flap reconstruction, followed by staged bilateral and retropharyngeal node dissection. Histopathology of the specimens demonstrated poorly differentiated invasive nonkeratinizing squamous cell carcinoma with inverted-type features. Three months after surgery, the patient suffered from C1-C2 fractures consistent with osteoradionecrosis and expired. Although the rate of malignant conversion of SNIP is low, this case highlights the need for aggressive, definitive treatment and surveillance.

Supraclavicular flap as a salvage procedure in reconstruction of head and neck complex defects.

The supraclavicular island flap (SCIF) is an interesting therapeutic option in head and neck reconstruction. Since popularized by Pallua in the late 90s, several clinical series have been published showing its versatility and usefulness. However, only a few studies have focused on factors associated with complications from SCIF use. In this study, we analyzed the factors contributing to SCIF unreliability. We performed a retrospective review of the data of 87 patients undergoing SCIF reconstruction between 2008 and 2015. No significant differences in mean complication rates were observed when the SCIF was used for primary or salvage reconstruction (28% versus 25%, respectively, p = 0.816) or for cutaneous or intraoral reconstruction (27% versus 28%, respectively, p = 0.932). Flap folding, preoperative radiotherapy, and microsurgery were associated with significantly increased complication rates (p = 0.002, p = 0.043, and p = 0.001, respectively), whereas smoking (p = 0.431) had no impact with regard to this. In conclusion, the SCIF is a versatile flap and an important therapeutic tool for use in salvage surgeries, particularly in those performed in patients with poor clinical conditions and limited flap options.

Autologous dermis-fat grafts in head and neck patients: Indications and evaluation in reconstructive surgery.

PURPOSE: The aim of this study was to examine the indications and results of autologous dermis-fat grafts in the reconstruction of maxillofacial soft-tissue defects. MATERIALS AND METHODS: A total of 93 patients with dermis-fat graft reconstruction due to a soft tissue defect in the head and neck region were enrolled in this retrospective clinical study between March 2002 and January 2017. They were classified into the subgroups 'parotid surgery', 'orbital surgery', and 'facial surgery'. All the patients were evaluated for wound complications, and the general indications were discussed. RESULTS: In all, 96 dermis-fat grafts were performed in 93 patients. A total of 34 complications that arose in 30 patients were assessed. The dermis-fat graft was primarily transplanted in 50 cases and secondarily in 46. Of the patients, 90 showed well-integrated dermis-fat grafts. A major complication occurred in three patients. CONCLUSION: Dermis-fat grafts for the reconstruction of maxillofacial soft-tissue defects represent a reliable method with a low rate of major complications. The graft can be used as a primary as well as secondary transplant. Especially in parotid and orbital surgery, the dermis-fat graft appears to be a transplant of choice. It can also be used as an alternative in facial surgery, lip enhancement, and special individual cases.

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.

[Incisions and baseline operative technique of cervicofacial lifting]. / Incisions et technique opératoire de base du lifting cervicofacial.

Cervicofacial lifting is one of the most iconic procedure of plastic surgery and is about hundred years old. In the following chapters of this report, numerous technical points will be specify. A baseline reliable and reproducible technique, appealing to the largest possible audience is presented in order to begin this surgery in optimum conditions. Pre- and postoperative management is also exposed. The aim of this chapter is to precise incisions and baseline operative technique of cervicofacial lifting, with description of SMAS and platysma suspensions as well as complementary procedures like liposuccion and lipofilling. This chapter will lay the foundation of more complex elements that will be described in the various following chapters.

[Cervical lift: An update]. / Le lifting cervical : évolutions récentes.

The neck is an aesthetic unit for which a rejuvenation request is sometimes very targeted or ore often encompassed in a global surgical project of face-lift. To obtain a long lasting outcome, the plastic surgeon has to make a full, detailed, and exhaustive analysis of the neck in order to choose the best indication within the multiple surgical tools. A full clinical examination is the key point, every aspects are outlined. The numerous surgical choices are described, illustrated, and sometimes revisited in the light of targeted anatomical studies. A didactic and graduated way is used to explain the recent evolutions of the surgical tools of the cervical lifting. Complications and insufficiencies in outcomes must be identified and explained. Finally, we illustrate this development by clinical cases. The surgical improvement of the cervical region is, for us, centered on the reconstruction of a cervical retaining structure: the Cervico-Mandibular Angle Suspensor (CMAS) ligament. This element makes it possible to understand and integrate the large number of technical proposals for cervical lifting.

[Clinical analysis before surgery in facial and neck rejuvenation]. / Analyse clinique avant chirurgie de rajeunissement cervico-facial.

The first step to determine a medical or surgical intervention is the clinical exam. The clinical exam is the paramount step to provide a treatment plan that can be modified and individualized accounting the patient preferences. During the consultation for facial rejuvenation, attention should be paid to understand the patient's motivation and expectations. A thorough understanding of the anatomy and the natural history of ageing will facilitate the analysis of the face. Not only the degree of ptosis but also the degree of volume loss will need to be assessed, as well as the influence of the facial muscles, the skin quality, and the different causes of rythids. The comprehensive age-related anatomical changes are often perceived and described as tiredness or sadness. Patients very commonly only point out a single anatomical region. During the consultation, the surgeon should provide the patient with the information of the comprehensive interplay of the different anatomical regions and their individual ageing process. Obtaining a harmonious, natural appearing outcome is the result of excellent surgical skills and applied knowledge. The clinical exam should also find out traps and technical difficulties. Although standardized photographs allow a static evaluation of one's result, video may deliver additional information about the postoperative result, and may contribute to the understanding of the technique used. Spending the additional time by performing a thorough facial analysis and preoperative planning is well-invested time. Having a good understanding of the possible surgical improvements and limitations will be beneficial for both, the patient and the surgeon. Managing the expectations of the patient and careful preoperative planning will increase patient's satisfaction. At the same time, the surgeon will able to critically assess his/her own result and taking pleasure improving their own technique.

[Use of Harmonic blade in face lifting]. / Apport de l'ultracision dans les liftings cervico-faciaux.

INTRODUCTION: Rapid recovery and return to social activities are what every patient wishes when considering to undergo a face lifting procedure. In our practice, the use of the Harmonic scalpel in order to achieve this goal has greatly improved the postoperative period. PATIENTS AND METHODS: We have performed 920 face lifting procedures exclusively using the Harmonic scalpel from 2001 to May 2017. RESULTS: A retrospective chart review was performed. Mean operative time was 110minutes for facelift involving SMAS plication only, and 180minutes for facelift involving SMAS plication with the addition of submental approach for anterior platysma plasty. Return to normal social life was achieved on the 8th postoperative day for the majority of cases. CONCLUSION: The use of the Harmonic scalpel, once properly integrated in the face lifting procedure, significantly reduces postoperative ecchymosis and oedema and allows a prompt return to normal social life.