Periorbital rejuvenation in the clinic: A state-of-the-art review.

Objective: To provide an overview of the various treatment options available in the clinic to achieve periorbital rejuvenation. Data Sources: Literature review and expert opinion. Conclusions: Periorbital rejuvenation in the clinic can be accomplished through a variety of treatment modalities, including topical therapies, skin resurfacing, and fillers and injectables. Furthermore, some surgical approaches, such as upper blepharoplasties, ptosis, and brow lifts, can be performed in the clinic under local anesthesia with only mild oral sedation. However, the successful execution of such procedures depends on proper patient selection and maximizing patient comfort.

A Complication of Mycobacterium chelonae Infection Following Orbital Floor Fracture Repair.

ABSTRACT: Mycobacterium chelonae is a rare, atypical nontuberculous bacterium that has been reported to be an underlying cause of persistent wound infections. Although there are several studies highlighting the role of M chelonae as the putative cause of other postoperative wound infections, to our knowledge there are no reports of infection following implant placement for repair of an orbital floor fracture. The authors present a unique case describing the management of a persistent postoperative infection in a young, immunocompetent patient with an orbital floor fracture repaired with a Stryker Medpor Titan implant. The patient was initially treated with broad-spectrum antibiotics with minimal clinical improvement. Following culture-proven M chelonae, a second surgical intervention was undertaken to remove the implant and later, a third intervention for scar revision. The patient has remained free of infection utilizing a long-term tailored 2-drug antibiotic regimen. This case emphasizes the need for recognition of M chelonae as a potential pathogen in certain clinical situations and the difficulty in eradicating M chelonae in the context of infected implantable devices. The comprehensive treatment protocol required to ensure adequate therapy is reviewed.

Congenital Midline Cervical Cleft: First Report and Genetic Analysis of Two Related Patients.

OBJECTIVES: Congenital midline cervical cleft (CMCC) is a rare congenital anterior neck anatomical anomaly. We present the case of two related patients (grandchild and maternal grandmother) who were both born with a congenital midline cervical cleft along with genetic analysis. METHODS: Clinical examination of both patients and surgical excision of the grandchild was performed. Genetic analysis with exome sequencing (ES) was conducted for both patients. RESULTS: Genetic analysis with exome sequencing (ES) revealed apparently novel single nucleotide variants in 66 genes present in both proband and grandmother. Five of these variants are predicted to cause frameshifting in the coding region of the respective genes and truncated proteins (OVGP1, TYW1B, ZAN, SSPO, FOLR3). Two of these genes (TYW1B and SSPO) have homozygous indel mutations in both patients. CONCLUSIONS: To our knowledge, this is the first case of two related patients with a congenital midline cervical cleft. The results of our genetic analysis reveal potential relevance to CMCC development.

Teaching nasal analysis to otolaryngology residents.

PURPOSE: This prospective cohort study was completed to evaluate a systematic approach for teaching nasal analysis to otolaryngology-head and neck surgery residents. METHODS: Residents from each post graduate year (PGY) were randomized to the control group or study group. Residents in the study group were given a 10-slide PowerPoint (Microsoft Corp) instruction on nasal analysis using the standard sequence of photographs and anatomic elements to describe in each view. All residents were given the standard sequence of photographs of 3 patients for assessment on nasal analysis. Then 12-14 weeks later all residents were re-evaluated using photographs of 3 new patients. The results were blinded and graded using an 18 point scale modified from a previous publication [1]. RESULTS: Twenty otolaryngology-head and neck surgery residents completed the study. Analysis was performed with and without multivariate regression modeling to adjust for PGY, sex, and number of rhinoplasties performed. The study group had overall higher scores in both the initial and follow up assessment, specifically with subsite-specific dorsal deviation, tip projection, and nostril symmetry. Neither group obtained high scores in facial symmetry, skin thickness, tip shape and contour, and radix position at initial or re-assessment. CONCLUSION: Nasal analysis is a complex task. A lecture on a systemic approach to facial analysis given to a group of residents, who performed significantly better on facial analysis cases than controls. Further research in providing feedback, periods of rehearsal or testing, or focused selected elements with serial exposure can be considered.

Surgical simulation and applicant perception in otolaryngology residency interviews.

OBJECTIVE: The traditional resident applicant interview involves multiple oral interviews. The implementation of surgical simulations adds an additional dimension of assessment but can be perceived in a stressful way by applicants. The purpose of this project is to describe low-fidelity simulations that were implemented for the 2016 to 2017 residency interviews and obtain applicant perception of these simulations. METHODS: Six simulation modules were created, which reflected tasks used in six subspecialties within otolaryngology (pediatrics, otology, laryngology, facial plastics, rhinology, and head/neck). Applicants were guided in the procedures by both an attending and resident. Afterward, applicants were anonymously surveyed on their perception of the tasks using a 5-point Likert scale (1 = Strongly Disagree, 2 = Somewhat Disagree, 3 = Neutral, 4 = Somewhat Agree, 5 = Strongly Agree). RESULTS: A total of 41 applicants were interviewed. The following were measured: enjoyable (98.5% strongly agree, 2.5% somewhat agree; mean: 4.97; 95% confidence interval [CI], 4.92, 5.02), educational (88% strongly agree, 12% somewhat agree; mean: 4.88; 95% CI, 4.78, 4.98), recommended for future use (92.7% strongly agree, 7.3% somewhat agree; mean: 4.93; 95% CI, 4.85, 5.01), and stressful (63.5% strongly disagree, 19.5% somewhat disagree, 17% neutral; mean: 1.54; 95% CI, 1.30, 1.78). CONCLUSION: Implementation of a low-fidelity multi-station surgical simulation experience is feasible in an interview day. Majority of applicants viewed the simulations in a positive manner. Surgical simulations may provide a useful holistic evaluation of an applicant in future interviews, especially if done in a setting that minimizes stress and maximizes the educational experience. LEVEL OF EVIDENCE: 2b. Laryngoscope, 2503-2507, 2018.

Comparison of Airflow Between Spreader Grafts and Butterfly Grafts Using Computational Flow Dynamics in a Cadaveric Model.

IMPORTANCE: Nasal valve compromise is a major cause of nasal obstruction, and multiple methods have been developed to address it. OBJECTIVE: To compare nasal airflow resistance, airflow partitioning, and mucosal cooling (heat flux) before and after 2 surgical interventions, butterfly and spreader graft placement, used to treat nasal valve compromise. DESIGN, SETTING, AND PARTICIPANTS: In this cadaveric tissue study, 4 fresh cadaveric heads underwent both spreader graft and butterfly graft surgical procedures in alternating sequence in March 2016. Preoperative and postoperative computed tomographic scans were used to generate 3-dimensional (3-D) models of the nasal airway. These models were then used in steady state computational fluid dynamics simulations of airflow and heat transfer during inspiration. INTERVENTION: Butterfly and spreader graft techniques. MAIN OUTCOMES AND MEASURES: Nasal airflow resistance, airflow partitioning, and heat flux. RESULTS: Donors 1, 2, and 3 were white males; donor 4, a white female. Computational fluid dynamics simulations during inspiration in 3-D models generated from preoperative and postoperative computed tomographic scans of the 4 cadaveric heads indicated reductions from preoperative values in nasal airflow resistance associated with both butterfly grafts (range, 20%-51%) and spreader grafts (range, 2%-29%). Butterfly grafts were associated with a greater reduction in nasal airflow resistance in models of all 4 cadaveric heads. Changes from preoperative values for heat flux, a biophysical variable that correlates with the subjective sensation of nasal patency, were more variable, ranging from -11% to 4% following butterfly grafts and -9% to 10% following spreader grafts. The preoperative airflow allocation in the left and right nostrils improved consistently with the butterfly graft. With the spreader graft, there were improvements for donors 1 and 4, but the allocations were worse for donors 2 and 3. CONCLUSIONS AND RELEVANCE: The results of this study suggest that the more recently developed butterfly graft technique may be associated with a similar level of improved nasal airflow as that observed with the use of a spreader graft in nasal valve compromise. Both interventions were associated with comparable changes in heat flux. Because this study addressed only static internal nasal valve stenosis, even greater differences in air flow and heat flux between the 2 techniques may be anticipated in a dynamic model. Further investigation in patients is warranted. LEVEL OF EVIDENCE: NA.

Repair of the unilateral cleft lip/nose deformity.

Successful surgical repair of the unilateral cleft lip and nose deformity, defined as normal orbicularis oris function and near-perfect symmetry of the repaired lip and nose, demands that the surgeon possess complete understanding of the embryology and anatomy of the midfacial defects. The surgical approach to repair of the unilateral cleft lip/nose should place great emphasis on achieving symmetry, not only with the lip segments but also perhaps even more importantly with the nasal tip. The reconstruction should recreate an intact fully functional orbicularis oris muscle across the cleft and camouflage the scar optimally. We have found that modification of the Millard rotation-advancement flap technique, with particular attention to the primary nasal repair, provides the best outcomes. In patients who have undergone primary repair of the lip and/or nose deformity, secondary rhinoplasty is generally required, regardless of the technique used at the primary repair. The degree of nasal deformity, however, is less severe following primary repair of the asymmetric nasal tip. We have found that the sliding flap cheliorhinoplasty, Wang's modification of the Vissarionov technique, provides excellent results for most secondary cleft rhinoplasties.

Decellularized dermal grafting in cleft palate repair.

OBJECTIVE: To assess the efficacy of decellularized dermal grafting used as an adjunct to the performance of primary repair of wide cleft palates. DESIGN: Retrospective review. SETTING: Tertiary referral center for large managed care organization. METHODS: Seven consecutive patients with clefts of the hard and soft palates wider than 15 mm as measured at the posterior edge of the hard palate. Palates were repaired in the standard 2-flap approach with intravelar veloplasty. The decellularized dermal graft (AlloDerm) was applied immediately deep to the oral mucosal closure. Patients were followed up with serial postoperative examination. Palates were assessed for dehiscence, fistula, infection, rejection, scarring, and contracture. RESULTS: There were no fistulas. In 2 patients, the oral mucosa dehisced, exposing the dermal graft. In 2 other cases, nasal mucosal tears were inadvertently created during closure of the nasal layer. In all cases, the decellularized dermal graft mucosalized and, by clinical examination, became incorporated into the wound. There were no cases of local inflammation or infection. The degree of scarring and contracture was indistinguishable from the adjacent scar. CONCLUSIONS: Decellularized dermal graft is safe and effective for use in primary closure of wide clefts involving the hard and soft palates. Its application to wide clefts otherwise at risk of fistula is justified. Its use in repair of an existing fistula is also promising.

The 'butterfly' graft in functional secondary rhinoplasty.

OBJECTIVE: To describe a surgical technique (the conchal cartilage "butterfly" graft) which, when used in properly selected patients, has been found to be a dependable method for alleviation of postrhinoplasty internal nasal valve dysfunction. STUDY DESIGN: Retrospective chart review. METHODS: Analysis of consecutive patients with weakness and/or collapse of the upper lateral cartilages following rhinoplasty. Seventy-two patients (37 women and 35 men, age range 17-76 y) had severe nasal obstruction and were found to have indications for this procedure. All patients had undergone at least one rhinoplastic procedure. All patients were followed for a minimum of 2 years after surgery. RESULTS: All 72 patients experienced significant subjective improvement in relative nasal obstruction. Two patients (3%) reported less than total resolution of their difficulty breathing through their nose; the remaining 70 patients (97%) reported complete resolution of their nasal airway problems. No patients reported their postoperative nasal obstruction as the same or worse than their preoperative baseline. Sixty-two patients (86%) reported improvement in the appearance of their nose, 8 patients (11%) felt that their appearance was unchanged, and 2 patients (3%) felt that the appearance of their nose was made worse by the procedure. CONCLUSIONS: Patients presenting with nasal obstruction after rhinoplasty are frequently found to have collapse and/or weakening of their upper lateral cartilages with resulting nasal valve dysfunction. The conchal cartilage "butterfly" graft is a technique which, when properly performed during revision rhinoplasty, yields predictable functional and cosmetic results with minimal morbidity.

Immediate reconstruction of extruded alloplastic nasal implants with irradiated homograft costal cartilage.

OBJECTIVE: To describe a novel surgical protocol for the management of patients presenting with extruded nasal implants. STUDY DESIGN: Retrospective chart review. METHODS: Analysis of consecutive patients presenting with extruded nasal implants from 1986 to 2000. Patients were selected from a large database of revision rhinoplasty cases. Inclusion criteria were: 1) at least one previous rhinoplasty procedure, 2) an extruded nasal implant that was documented preoperatively, 3) immediate reconstruction that was carried out with irradiated homograft costal cartilage (IHCC), and 4) at least 1 year of follow-up recorded, including standard postoperative rhinoplasty photographs. A total of 18 patients met the inclusion criteria and form the basis of this study. Data gathered from the charts included date of surgery, last date of follow-up, location of implant extrusion, alloplastic material, specific use of IHCC for reconstruction, percent of clinical IHCC resorption at last follow-up, and presence of warping of the IHCC. RESULTS: All 18 patients were satisfied with the cosmetic outcomes of their nasal reconstructions. The most common extruded alloplast was Silastic, followed by Gore-Tex (W.L. Gore & Associates, Inc., Flagstaff, AZ). There were no cases of extrusion or infection of the IHCC implant subsequent to immediate reconstruction of the extruded alloplast. Clinical resorption of the IHCC was minimal, with a mean follow-up of 26 months. Only one patient had a complication, warpage, resulting in removal of the IHCC. In that patient, the IHCC still had carving markings on the implant after 2 years in vivo. CONCLUSIONS: In this series of patients, a novel surgical protocol was used. The extruded implant was removed and immediate reconstruction with irradiated rib cartilage was done. All patients were evaluated for postoperative infection, graft extrusion, and satisfaction with cosmetic result. There was one major complication in this series of 18 patients, warping of the IHCC, which necessitated removal and replacement. This approach appears to be a reasonable method for reconstruction of extruded nasal alloplasts.