Banana fruit: An "appealing" alternative for practicing suture techniques in resource-limited settings.

PURPOSE: Suturing is an important core surgical competency that requires continued practice. The purpose of this study was to evaluate bananas as a medium for practicing suture techniques in resource-limited settings. MATERIALS AND METHODS: Using a crossover design, 20 University of Rwanda medical students practiced suturing on banana peels and commercial foam boards. Students were randomized into 2 groups: group A practiced on foam boards first and then bananas, and group B practiced on banana peels first and then foam boards. A post-workshop survey was then administered to students to gauge their attitude towards banana peels as a suturing practice material. Suture performance for each student was graded by three fellowship-trained facial plastic surgeons based on consistent spacing, knot location, appropriate knot, absence of air knots, and adequate bite size. RESULTS: Suture performance graded by facial plastic surgeons demonstrated that suturing outcomes with bananas were equal or superior to foam in 56.7% of instances. Twenty students participated in the workshop; 16 students responded to the survey (response rate = 80%). Students were comfortable practicing suturing with banana peels (Mdn = 4, IQR = 1) and strongly agreed that suturing banana peels was a useful activity (Mdn = 5, IQR = 1). Students thought banana peels and foam were comparable learning platforms (Mdn = 3.5, IQR = 1) and felt their suturing abilities improved with practice on banana peels (Mdn = 4, IQR = 1.3). CONCLUSIONS: Banana peels are a low cost, equally viable alternative to synthetic suture media.

Quantitative three-dimensional assessment of port-wine stain clearance after laser treatments.

BACKGROUND AND OBJECTIVE: Outcomes analysis of laser treatment for port-wine stains has been hampered by the lack of an objective measure of surface area and volume; moreover, treatment success is often gauged by clinician subjective assessment. Three-dimensional (3D) surface imaging has been applied in several medical disciplines to quantify surface changes, with promising results. We hypothesized that 3D surface imaging could be used to objectively measure changes in area and volume of port-wine stains following laser treatment. STUDY DESIGN/MATERIALS AND METHODS: We performed a retrospective review of consecutive patients with port-wine stains treated over a 20-month time period. Area and volume of the lesions were measured using 3dMD photogrammetric software (3dMD, Atlanta, GA) before and after a series of sequential pulsed dye laser and/or alexandrite laser treatments. RESULTS: Fifty-five patients with 59 port-wine stains were included in the study. The initial average measured area was 44.3 cm(2) ; final average measured area decreased to 36.9 cm(2) (P < 0.001). The average volume change was 1.20 cc for all PWS included in the study and 1.90 cc for lesions that received at least 5 laser treatments within the study period. CONCLUSION: Three-dimensional photography demonstrated area and volume changes in patients with port-wine stains after laser treatments. Future studies to determine if statistically significant changes correlate with clinically appreciable changes are warranted.

Contemporary facial reanimation.

The facial nerve is the most commonly paralyzed nerve in the human body. Facial paralysis affects aesthetic appearance, and it has a profound effect on function and quality of life. Management of patients with facial paralysis requires a multidisciplinary approach, including otolaryngologists, plastic surgeons, ophthalmologists, and physical therapists. Regardless of etiology, patients with facial paralysis should be evaluated systematically, with initial efforts focused upon establishing proper diagnosis. Management should proceed with attention to facial zones, including the brow and periocular region, the midface and oral commissure, the lower lip and chin, and the neck. To effectively compare contemporary facial reanimation strategies, it is essential to employ objective intake assessment methods, and standard reassessment schemas during the entire management period.

Head and neck free flap reconstruction in patients older than 80 years.

BACKGROUND: Free tissue transfer is a reliable method for reconstruction of head and neck defects. With the growing number of octogenarians in the population, it is important to understand how these patients respond to these procedures. METHODS: Through a retrospective chart review of patients who underwent a free-flap reconstruction from 2000 to 2010 at an academic medical center, 48 patients, aged 80 years and older, were compared with a control group consisting of 97 similar patients, aged younger than 80 years. We compared the intensive care unit (ICU) length of stay, overall hospital stay, and the incidence of perioperative complications between the cohorts. RESULTS: The average length of stay in the ICU was significantly longer for the octogenarian group as compared with the younger group (101 vs. 41 hours, p-value = 0.007). The average length of hospital stay was not significantly different between the two groups (difference = 40 hours, p-value = 0.102). The incidence of perioperative complication was 75% in the octogenarian group and 60% in the younger group (p-value = 0.095). There were two flap failures in the younger group, and none in the octogenarian group. There was a significantly higher rate of death within 30 days in the octogenarian group. CONCLUSIONS: Microvascular free tissue transfer is a reliable and safe method of reconstruction of head and neck defects in patients over 80 years of age. Patients should be counseled about the potential risks of increased incidence of medical complications, ICU length of stay, and rate of perioperative death when recommended to undergo free tissue transfer reconstruction.

Quantifying Facial Distortion in Modern Digital Photography.

BACKGROUND: Advancements in digital cameras and the advent of smartphones have magnified the importance of clinical photography in facial plastic surgery. Here, we aim to examine the effect of different camera types, focal lengths, and distances from subjects on facial distortion. METHODS: Twelve subjects underwent a series of frontal photographs using a smartphone camera and a full-frame digital single-lens reflex camera. Photos were captured at six distances from the subject. Seven focal lengths were used at each distance for the full-frame camera. Measurements of facial landmarks were made for each photo, with those made at 60 inches using the full-frame camera considered the gold standard and used for comparison. RESULTS: Distortion of facial features using the full-frame camera occurred when photos were captured 8 inches away using short focal lengths. A 12%-19% increase in vertical stretching of the midface occurred when using focal lengths of 24, 35, and 50 mm (p < 0.05 for all). The same features were distorted when a smartphone camera was used at 8 inches (18% increase, p < 0.01) and 12 inches (12% increase, p < 0.03). CONCLUSIONS: Distortion of midfacial features using both smartphones and full-frame cameras occurs with short, 'selfie' distances between the camera and subject. LEVEL OF EVIDENCE: 2 Laryngoscope, 134:1234-1238, 2024.

Quantitative three-dimensional assessment of port-wine stain clearance after laser treatments.

BACKGROUND AND OBJECTIVES: Outcomes analysis of laser treatment for port-wine stains (PWS) has been hampered by the lack of an objective measure of surface area and volume; moreover, treatment success is often gauged by clinician subjective assessment. Three-dimensional (3D) surface imaging has been applied in several medical disciplines to quantify surface changes, with promising results. We hypothesized that 3D surface imaging could be used to objectively measure changes in area and volume of PWS following laser treatment. STUDY DESIGN/MATERIALS AND METHODS: We performed a retrospective review of consecutive patients with PWS treated over a 20-month time period. Area and volume of the lesions were measured using 3dMD photogrammetric software (3dMD; Atlanta, GA) before and after a series of sequential pulsed dye laser and/or alexandrite laser treatments. RESULTS: Fifty-five patients with 59 PWS were included in the study. The initial average measured area was 45.6 cm(2) ; final average measured area decreased to 34.6 cm(2) (P < 0.001). The average volume change was 1.20 ml for all PWS included in the study and 1.90 ml for lesions that received at least five laser treatments within the study period. CONCLUSION: Three-dimensional photography demonstrated area and volume changes in patients with PWS after laser treatments. Future studies to determine if statistically significant changes correlate with clinically appreciable changes are warranted.

Gardner's syndrome in a 40-year-old woman: successful treatment of locally aggressive desmoid tumors with cytotoxic chemotherapy.

BACKGROUND: Desmoid tumors that present as a part of Gardener's syndrome can present very difficult management problems. CASE PRESENTATION: We report a case of intra-abdominal desmoid tumor causing distal small bowel obstruction that complicated the management of a more proximal enterocutaneous fistula from the jejunum. After failure of more conventional management options including imatinib, the patient's disease responded to doxorubicin and ifosfamide. The response resolved the bowel obstruction and allowed small intestinal resection to resolve the enterocutaneous fistula. CONCLUSION: Systemic cytotoxic therapy with doxorubicin and ifosfamide can be useful for patients with complications from intra-abdominal desmoid tumor.

Clinician-Graded Electronic Facial Paralysis Assessment: The eFACE.

BACKGROUND: The subjective nature of facial aesthetics and the difficulties associated with quantifying facial function have made outcomes analysis in facial paralysis challenging. Clinicians rely on photographs, subjective descriptions, and scales, limiting assessment, communication among providers, and communication between providers and patients. The authors describe the development and validation of a comprehensive, electronic, clinician-graded facial function scale (eFACE), which generates an overall disfigurement score and offers simple graphic output for clinician communication, assessment of various interventions, and patient understanding. The eFACE application may be used in a variety of electronic devices, including smartphones, tablets, and computers. METHODS: An instrument consisting of 16 items in a visual analogue scale format was developed to assess facial function and symmetry (the eFACE). Video recordings of subjects performing facial expressions were viewed, and the eFACE instrument was applied, along with an overall facial disfigurement score. A multiple regression analysis was performed to determine the best linear relationship between overall expert-determined disfigurement and the eFACE items. The resulting equation was tested by three independent facial nerve clinicians, using an additional series of patients, to determine both interrater and intrarater reliability of the instrument. RESULTS: Multiple regression analysis produced good fit of eFACE parameters to overall expert-rated global facial disfigurement when dynamic parameters were weighted twice as heavily as static and synkinesis parameters. eFACE scores demonstrated very high interrater and intrarater reliability. CONCLUSION: The eFACE is a reliable, reproducible, and straightforward digital clinical measure with which to assess facial function and disfigurement in patients with facial paralysis.

Development and validation of a spontaneous smile assay.

IMPORTANCE: Smiling can be a voluntary or involuntary movement. Facial reanimation procedures differ in their ability to restore a spontaneous smile, and an assay designed to evoke and evaluate a spontaneous smile is not available. OBJECTIVE: To develop and validate an assay to assess the spontaneous smile of patients with facial paralysis. DESIGN, SETTING, AND PARTICIPANTS: This was an exploratory cohort study. A series of short video clips were administered to laypersons via an online survey service from January 1, 2014, to March 31, 2014. Respondents rated how funny each video was on a visual analog scale from 0 to 100. The 4 funniest videos were selected to generate a 1½-minute spontaneous smile assay. The assay was then administered from July 1, 2014, to December 31, 2014, to 2 different study groups: the first was composed of 100 healthy individuals (control group) and the second was composed of 30 patients with facial paralysis. We analyzed the capability of this assay to provoke at least 1 spontaneous smile and calculated smile excursion in both groups. Statistical analysis was performed using analysis of variance. INTERVENTION: Spontaneous smile assay administered to both healthy and diseased groups. MAIN OUTCOMES AND MEASURES: Ability of the assay to elicit smiles, as defined by an oral commissure excursion greater than 3 mm, as well as difference in commissure excursion. RESULTS: Ninety-five (95.0%) participants in the control group and 29 (96.7%) patients with facial paralysis experienced at least 1 oral commissure excursion that appeared to be a spontaneous smile while viewing the assay. Mean oral commissure excursion with spontaneous smile was 9.08 mm (95% CI, 2.77-15.39) in controls, 6.72 mm (95% CI, 3.13-10.31) on the healthy side in patients with flaccid facial paralysis (P=.004 vs controls), and 9.64 mm (95% CI, 3.52-15.76) on the healthy side in patients with nonflaccid facial paralysis (P=.74). Among patients with flaccid facial paralysis, a statistically significant difference was found between smile excursion of the affected and the unaffected sides (P = .03). There was no statistically significant difference in the measurement between sides for the control group (P = .67). CONCLUSIONS AND RELEVANCE: Although humor is a challenging construct to universalize, our assay was able to elicit a smile in almost all individuals in the group with facial paralysis and the control group. The spontaneous smile assay will facilitate future research on the ability of facial reanimation procedures and other interventions to restore a spontaneous smile. LEVEL OF EVIDENCE: NA.

Epidemiology of iatrogenic facial nerve injury: a decade of experience.

OBJECTIVES/HYPOTHESIS: To determine the procedure-specific incidence, risk factors, and injury patterns in patients with iatrogenic facial nerve injury as seen at a tertiary care facial nerve center. STUDY DESIGN: Retrospective chart review. METHODS: Facial Nerve Center patient records from 2002 to 2012 were reviewed for cases of iatrogenic facial nerve injury. These were analyzed by type of inciting procedure, injury location, patient demographics, and referral pattern. RESULTS: Out of 1,810 patient records, 102 were identified that involved iatrogenic facial nerve injury. Oral and maxillofacial surgical procedures accounted for 40% of injuries, resections of head and neck lesions 25%, otologic procedures 17%, cosmetic procedures 11%, and other procedures 7%. The most common operation resulting in facial nerve injury was temporomandibular joint replacement. The most frequent pattern of injury was total hemifacial weakness. CONCLUSIONS: Iatrogenic facial nerve injury occurs most commonly in temporomandibular joint replacement, mastoidectomy, and parotidectomy. Direct visualization of the nerve may decrease the incidence of injury, and early referral for facial nerve exploration may result in improved outcomes.

Refinements in nasolabial fold reconstruction for facial paralysis.

OBJECTIVES/HYPOTHESIS: The objective of this study was to describe a methodology for creation of a nasolabial fold in patients with facial paralysis and to report patient-reported outcome measures following this procedure. STUDY DESIGN: Retrospective case series. METHODS: All patients who underwent nasolabial fold modification at our institution since July 2010 were included in our analysis. Patient demographics and characteristics of their facial paralysis were noted. Preoperative Facial Clinimetric Evaluation scores were compared with postoperative scores to quantify outcomes. Pre- and postoperative photos were then presented to an observer for ratings of overall midfacial appearance. RESULTS: Thirty-one patients were included in the review. Most of the patients were male. The average onset of paralysis was 50 years, and the average age at time of surgery was 61 years. The majority of patients had flaccid paralysis, with 10% of patients having synkinesis. Most patients presented with complaints of oral incompetence or drooling and generalized facial asymmetry. Facial Clinimetric Evaluation scores (P < .004) and overall midfacial appearance (P < .05) improved significantly following surgery. CONCLUSIONS: The nasolabial fold is an important aesthetic component of the face commonly affected in patients with facial paralysis. We demonstrate quantitative improvement in quality of life scores and aesthetic appearance following nasolabial fold refinement and describe the procedure in depth. LEVEL OF EVIDENCE: 4.

Objective outcomes analysis following microvascular gracilis transfer for facial reanimation: a review of 10 years' experience.

IMPORTANCE Objective assessment of smile outcome after microvascular free gracilis transfer is challenging, and quantification of smile outcomes in the literature is inconsistent. OBJECTIVE To report objective excursion and symmetry outcomes from a series of free gracilis cases and investigate the predictive value of intraoperative measurements on final outcomes. DESIGN, SETTING, AND PARTICIPANTS A retrospective medical chart review was undertaken of all patients who underwent microvascular free gracilis transfer for smile at our institution over the past 10 years. MAIN OUTCOMES AND MEASURES Outcome measures included the following: smile excursion, angle of smile with respect to the vertical midline, and facial symmetry during repose and with smile. Measurements were obtained using an automated tool for assessment of facial landmarks (FACE-Gram). An exhaustive set of intraoperative parameters including degree of recoil of the gracilis muscle following harvest, the degree to which the muscle foreshortened during stimulation of the obturator nerve, final stretched length of the inset muscle, surgeon assessment of neurorrhaphy and pulse pressure, ischemia time, number of sutures used during neurorrhaphy, nerve used to innervate the flap, and surgeon assessment of oral commissure overcorrection were recorded and placed into a linear regression model to investigate correlations with smile. RESULTS From March 2003 to March 2013, 154 microvascular free gracilis transfers were performed for facial reanimation at our institution, 14 (9%) of which were deemed failures. Of the remaining 140 flaps, 127 fulfilled inclusion criteria and constituted the study cohort. Smile excursion, angle excursion, and symmetry of the oral commissure at repose and with smile all improved following gracilis free flap (P < .05). Associations between selected outcomes measures and intraoperative gracilis measurements were identified. CONCLUSIONS AND RELEVANCE Facial reanimation using free gracilis transfer results in quantifiable improvements in oral commissure excursion and facial symmetry both at rest and with smiling. Associations between contractility and internal recoil of the flap and final outcome were identified. LEVEL OF EVIDENCE 4

The effects of intensive care unit staffing on patient outcomes following microvascular free flap reconstruction of the head and neck: a pilot study.

OBJECTIVE: To determine if the implementation of the closed intensive care unit (ICU) at our institution altered clinical outcomes in patients who had undergone microvascular free flap reconstruction of the head and neck by the Otolaryngology-Head and Neck Surgery Service. DESIGN: Retrospective medical chart review. SETTING: A single tertiary medical center. PATIENTS: The open ICU cohort had 52 flaps performed on 50 patients, and the closed ICU cohort had 52 flaps performed on 52 patients. MAIN OUTCOME MEASURES: Fifty-two free flap reconstructions of head and neck defects were performed on 50 patients who were admitted to an open ICU. The length of stay (LOS) in the ICU and hospital and incidence of complications were compared with those of 52 patients who underwent 52 free flap reconstructions and were admitted to a closed ICU over a separate period. RESULTS: The mean length of stay in the ICU was 44 and 45 hours in the open and closed ICU cohorts, respectively (P = .90). The incidence of surgical and medical complications was similar in the open and closed ICU cohorts (P > .05). CONCLUSIONS: There does not appear to be a significant difference in patient outcome between open and closed ICU care in our study.

Improved airway visualization during direct laryngoscopy using self-retaining laryngeal retractors: a quantitative study.

OBJECTIVE: To measure the degree to which the Lindholm laryngeal distending forceps improve visualization during direct laryngoscopy in selected pediatric patients. STUDY DESIGN: Case series with chart review. SETTING: Pediatric hospital. SUBJECTS AND METHODS: Subjects included children undergoing direct laryngoscopy using the Lindholm laryngeal distending forceps. Intraoperative endoscopic photos with and without false cord retraction via the Lindholm laryngeal distending forceps were obtained from the Seattle Children's Hospital airway endoscopy photo library. Analysis was performed using imaging software. Comparisons of visible vocal cord and glottic opening areas as well as anterior commissure angles with and without the Lindholm laryngeal distending forceps were performed with a paired and unpaired Student t test. RESULTS: The use of the Lindholm laryngeal distending forceps increased the glottic opening by a mean of 359% (95% confidence interval [CI], 255%-463%) and increased visualized true vocal cord area by 337% (197%-477%). Angle at the anterior commissure increased from a mean of 24.9° to a mean of 71.5°, resulting in a net mean angle increase of 46.6° (95% CI, 40.2°-52.9°). All measured changes were statistically significant with P values <.01. CONCLUSIONS: When placed at the level of the false vocal folds, Lindholm laryngeal distending forceps will, at least in certain cases, greatly increase the visible area of the superior surface of the vocal folds, the anterior commissure, and, by increasing the glottic opening, the subglottic region. This improved visualization may enhance the surgeon's ability to diagnose and treat pathologies in these anatomic regions during direct laryngoscopy.

A novel model for examining recovery of phonation after vocal nerve damage.

OBJECTIVES/HYPOTHESIS: Recurrent laryngeal nerve injury remains a dominant clinical issue in laryngology. To date, no animal model of laryngeal reinnervation has offered an outcome measure that can reflect the degree of recovery based on vocal function. We present an avian model system for studying recovery of learned vocalizations after nerve injury. STUDY DESIGN: Prospective animal study. METHODS: Digital recordings of bird song were made from 11 adult male zebra finches; nine birds underwent bilateral crushing of the nerve supplying the vocal organ, and two birds underwent sham surgery. Songs from all the birds were then recorded regularly and analyzed based on temporal and spectral characteristics using computer software. Indices were calculated to indicate the degree of similarity between preoperative and postoperative song. RESULTS: Nerve crush caused audible differences in song quality and significant drops (P<0.05) in measured spectral and, to a lesser degree, temporal indices. Spectral indices recovered significantly (mean=43.0%; standard deviation [SD]=40.7; P<0.02), and there was an insignificant trend toward recovery of temporal index (mean=28.0%; SD=41.4; P=0.0771). In five of the nine (56%) birds, there was a greater than 50% recovery of spectral indices within a 4-week period. Two birds exhibited substantially less recovery of spectral indices and two birds had a persistent decline in spectral indices. Recovery of temporal index was highly variable as well, ranging from persistent further declines of 45.1% to recovery of 87%. Neither sham bird exhibited significant (P>0.05) differences in song after nerve crush. CONCLUSION: The songbird model system allows functional analysis of learned vocalization after surgical damage to vocal nerves.