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1.
J Am Acad Dermatol ; 79(5): 853-859, 2018 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-29787841

RESUMO

BACKGROUND: Undifferentiated pleomorphic sarcoma (UPS) encompasses rare neoplasms that can arise either in the dermis or in the subfascial soft tissue. The behavior of UPS ranges from indolent to aggressive, but data predicting outcomes are limited. OBJECTIVE: Identify predictors of poor outcomes by analyzing a large collection of UPS cases. METHODS: We evaluated all available cases of UPS (including those termed atypical fibroxanthoma, malignant fibrous histiocytoma, pleomorphic dermal sarcoma, and subfascial UPS) across 3 tertiary care centers. RESULTS: Among the 319 patients, 45 experienced recurrence, 33 experienced metastasis, and 96 died of any cause. Risk factors for recurrence were clinical tumor size larger than 5 cm and invasion beyond subcutaneous fat. Risk factors for distant metastases were tumor site, tumor size larger than 2 cm, invasion beyond subcutaneous fat, and lymphovascular invasion. Risk factors for overall mortality were age, immunosuppression, tumor size larger than 2 cm, and lymphovascular invasion. History of skin cancer was associated with a lower risk of recurrence and metastasis. LIMITATIONS: This was a retrospective study. CONCLUSIONS: Using the unbiased approach of pooling all UPS cases regardless of terminology, we identified clinical and histologic factors predicting poor outcomes. We propose subcategorization of UPS (into superficial versus deep UPS), which is consistent with the American Joint Committee on Cancer staging of soft-tissue sarcoma.


Assuntos
Histiocitoma Fibroso Maligno/patologia , Cirurgia de Mohs/métodos , Recidiva Local de Neoplasia/patologia , Sarcoma/patologia , Neoplasias Cutâneas/patologia , Neoplasias de Tecidos Moles/patologia , Adulto , Idoso , Análise de Variância , Biópsia por Agulha , Carcinoma/mortalidade , Carcinoma/patologia , Carcinoma/cirurgia , Estudos de Coortes , Intervalo Livre de Doença , Feminino , Histiocitoma Fibroso Maligno/mortalidade , Histiocitoma Fibroso Maligno/cirurgia , Humanos , Imuno-Histoquímica , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Recidiva Local de Neoplasia/mortalidade , Recidiva Local de Neoplasia/cirurgia , Valor Preditivo dos Testes , Prognóstico , Modelos de Riscos Proporcionais , Sistema de Registros , Estudos Retrospectivos , Medição de Risco , Sarcoma/mortalidade , Sarcoma/cirurgia , Neoplasias Cutâneas/mortalidade , Neoplasias Cutâneas/cirurgia , Neoplasias de Tecidos Moles/mortalidade , Neoplasias de Tecidos Moles/cirurgia , Análise de Sobrevida , Estados Unidos
2.
Facial Plast Surg ; 33(2): 120-124, 2017 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-28388790

RESUMO

Due to its central location, the nose plays a prominent role in facial aesthetics. As tastes have shifted and techniques have advanced, the accepted "ideal" appearance and proportions of the nose have evolved over time. By assessing the aesthetics of the nasal dorsum through the use of lines and angles, one can more precisely elucidate a goal for the patient's postoperative nasal shape, which should, in turn, guide the surgeon to execute specific operative maneuvers needed to achieve that contour. In assessing the aesthetics of the nasal dorsum, practitioners calculate and observe aspects such as the paired dorsal aesthetic lines, the nasofrontal angle, and the nasofacial angle. There is also additional consideration given to nasal tip position as this must fit harmoniously with the shape of the dorsum. In contrast to the established aesthetic lines and angles, using nasal geometric polygons for the aesthetic evaluation and development of operative goals in rhinoplasty has recently been described in the literature. Constructed ideals, in the form of proportions, lines, and angles, should be used with caution, as there are many factors to consider in the aesthetic analysis of the nasal dorsum, including ethnic differences, and subjective and changing views of beauty.


Assuntos
Estética , Nariz/anatomia & histologia , Humanos , Iluminação , Nariz/cirurgia , Rinoplastia
3.
Clin Plast Surg ; 50(3): 411-419, 2023 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-37169407

RESUMO

Nonsurgical periocular rejuvenation presents varied options to the practitioner. The most common current inject modalities for rejuvenation include hyaluronic acid (HA), platelet-rich plasma (PRP), calcium hydroxyapatite, and poly-L-lactic acid. This article provides a summary of recent publications regarding each injectable as well as the description of pertinent periocular anatomy. The modern injector should possess an understanding of each modality for a safe and rejuvenated result.


Assuntos
Técnicas Cosméticas , Plasma Rico em Plaquetas , Envelhecimento da Pele , Humanos , Rejuvenescimento , Ácido Hialurônico/uso terapêutico , Face
4.
Facial Plast Surg Clin North Am ; 30(3): 321-329, 2022 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-35934434

RESUMO

Nonsurgical periocular rejuvenation presents varied options to the practitioner. The most common current inject modalities for rejuvenation include hyaluronic acid (HA), platelet-rich plasma (PRP), calcium hydroxyapatite, and poly-L-lactic acid. This article provides a summary of recent publications regarding each injectable as well as the description of pertinent periocular anatomy. The modern injector should possess an understanding of each modality for a safe and rejuvenated result.


Assuntos
Técnicas Cosméticas , Plasma Rico em Plaquetas , Envelhecimento da Pele , Humanos , Ácido Hialurônico , Rejuvenescimento
6.
Plast Reconstr Surg ; 147(1): 56-62, 2021 01 01.
Artigo em Inglês | MEDLINE | ID: mdl-33370050

RESUMO

BACKGROUND: The misuse and abuse of opioids, including overprescription, has led to the current opioid epidemic and national crisis. There is a national effort to eliminate the unnecessary prescription of opioids for analgesia. METHODS: Seventy patients were randomized to receive postoperative analgesia with either 5 mg hydrocodone with 325 mg acetaminophen (opioid control group) or 400 mg of ibuprofen [nonsteroidal antiinflammatory drug (NSAID) experimental group]. Pain levels were assessed on postoperative days 1, 2, and 7. Outcome measures included numeric pain rating scores and assessments of frequency and amount of analgesic used. RESULTS: There was no significant difference in gender (p = 0.81) or age (p = 0.61) between groups. On postoperative day 0, the NSAID group (mean ± SD, 2.54 ± 1.57) was found to be noninferior to the opioid group (mean ± SD, 3.14 ± 1.75; p = 0.003). On postoperative day 1, the NSAID group showed a lower mean pain score (mean ± SD, 1.84 ± 1.29) than the opioid group (mean ± SD, 2.46 ± 1.90; p = 0.01). However, on postoperative day 7, the difference in pain scores between the NSAID (mean ± SD, 3.29 ± 2.14) and opioid (mean ± SD, 3.14 ± 2.12; p = 0.17) groups lost statistical significance. There was no significant difference in mean day of medication cessation between the NSAID (mean ± SD, 4.73 ± 1.57) and opioid (mean ± SD, 4.28 ± 2.23; p = 0.26) groups. Seventy-six percent of patients who were prescribed opioids took fewer than eight tablets. Five patients escalated from NSAIDs to opioids. There were no adverse effects related to NSAID use. CONCLUSIONS: NSAIDs are an acceptable and safe alternative to opioids for postoperative analgesia in rhinoplasty and potentially lead to better overall pain control in some patients. Significantly reducing or eliminating opioid prescriptions may be considered in light of the current opioid epidemic. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, II.


Assuntos
Procedimentos Cirúrgicos Ambulatórios/efeitos adversos , Analgesia/métodos , Analgésicos Opioides/administração & dosagem , Anti-Inflamatórios não Esteroides/administração & dosagem , Dor Pós-Operatória/diagnóstico por imagem , Rinoplastia/efeitos adversos , Adulto , Analgesia/efeitos adversos , Analgésicos Opioides/efeitos adversos , Anti-Inflamatórios não Esteroides/efeitos adversos , Feminino , Humanos , Masculino , Epidemia de Opioides/prevenção & controle , Transtornos Relacionados ao Uso de Opioides/epidemiologia , Transtornos Relacionados ao Uso de Opioides/etiologia , Transtornos Relacionados ao Uso de Opioides/prevenção & controle , Medição da Dor , Dor Pós-Operatória/diagnóstico , Dor Pós-Operatória/etiologia , Estudos Prospectivos , Rinoplastia/métodos , Resultado do Tratamento
7.
JAMA Otolaryngol Head Neck Surg ; 146(6): 537-542, 2020 06 01.
Artigo em Inglês | MEDLINE | ID: mdl-32297916

RESUMO

Importance: The fibula free flap donor site is associated with both short-term and long-term morbidity. Split-thickness skin graft (STSG) loss can lead to long delays in donor site healing and is associated with significant adverse sequelae. Patients may experience initial good STSG uptake after bolster removal but may have subsequent partial or total loss related to contact pressure or shearing. Objective: To determine if increased duration of bolster use is associated with increased STSG uptake rates following fibula free flap reconstruction. Design, Setting, and Participants: This retrospective cohort study included patients 18 years and older undergoing fibula free flap reconstruction following head and neck extirpative surgery at a tertiary care academic medical center from May 2013 to March 2019. The donor sites were photographed 4 weeks postoperatively, and areas of graft uptake were measured using image processing software. The baseline demographic, comorbidity, and operative characteristics were also collected. Interventions: A fine mesh gauze with 3% bismuth tribromophenate and petrolatum blend bolster was sutured over leg STSGs placed on fibula free flap donor sites intraoperatively, and the ankle and lower leg were immobilized for 5 days in a plaster splint. Bolsters were either removed on postoperative day 5 or 14. Thereafter, the STSGs were covered with a petroleum and bismuth gauze and a cotton dressing. Main Outcomes and Measures: Rates of donor site infection and STSG percentage uptake at 4 weeks. Results: Of the 42 included patients, 31 (74%) were male, and the mean (SD) age was 62.1 (13.1) years. A total of 20 patients were included in the 5-day group, and 22 were included in the 14-day group. The 14-day bolster group had a higher mean percentage skin graft uptake rate compared with the 5-day bolster duration group (77.5% vs 59.9%), with an effect size of -0.632 (95% CI, -1.260 to -0.004). Patients with Adult Comorbidity Evalution-27 scores of 3 had poorer rates of STSG uptake compared with patients with Adult Comorbidity Evalution-27 scores of 0 to 2 (65.9% vs 82.9%), with an effect size of 0.599 (95% CI, -0.191 to 1.389). No donor site infections were noted in either group. Conclusions and Relevance: Fourteen-day bolster application to the fibula free flap donor site was associated with better STSG uptake rates than 5-day bolster application.


Assuntos
Bandagens , Fíbula/cirurgia , Retalhos de Tecido Biológico , Procedimentos de Cirurgia Plástica/métodos , Transplante de Pele/métodos , Cicatrização , Idoso , Feminino , Fíbula/fisiologia , Sobrevivência de Enxerto , Humanos , Masculino , Pessoa de Meia-Idade , Bases para Pomadas/administração & dosagem , Vaselina/administração & dosagem , Fenóis/administração & dosagem , Complicações Pós-Operatórias/prevenção & controle , Procedimentos de Cirurgia Plástica/efeitos adversos , Estudos Retrospectivos , Transplante de Pele/efeitos adversos , Contenções , Fatores de Tempo , Sítio Doador de Transplante
8.
Ann Otol Rhinol Laryngol ; 128(1): 62-65, 2019 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-30347990

RESUMO

INTRODUCTION:: Congenital unilateral lower lip palsy is an infrequently encountered condition that manifests as lower lip asymmetry during smiling, laughing, and crying. Treatment options are not well characterized. METHODS:: The authors present the case of a 51-year-old woman who was referred for surgical intervention for facial paralysis. Physical examination demonstrated a symmetric face at rest that became asymmetric when smiling. The asymmetry, evident by inappropriate inferior displacement of the lower lip, was secondary to unilateral contraction and presence of the depressor labii inferioris. The depressor anguli oris was symmetric bilaterally. Her presentation was consistent with congenital unilateral lower lip palsy. RESULTS:: Lidocaine was injected into the depressor labii inferioris on the side of the face that demonstrated unilateral presence and contraction. This resulted in symmetry of the smile and lower lip without untoward effect. Onabotulinum toxin A was thereafter injected into the depressor labii inferioris. In-office treatment with botulinum toxin injection resulted in a 4-month improvement in smile symmetry. CONCLUSION:: Chemodenervation is a safe and minimally invasive method to improve smile symmetry and lower lip position in cases of congenital unilateral lower lip palsy.


Assuntos
Toxinas Botulínicas Tipo A/administração & dosagem , Paralisia Facial , Doenças Labiais , Bloqueio Nervoso/métodos , Músculos Faciais/fisiopatologia , Paralisia Facial/congênito , Paralisia Facial/diagnóstico , Paralisia Facial/fisiopatologia , Paralisia Facial/terapia , Feminino , Humanos , Injeções Intramusculares/métodos , Lábio/fisiopatologia , Doenças Labiais/congênito , Doenças Labiais/diagnóstico , Doenças Labiais/fisiopatologia , Doenças Labiais/terapia , Pessoa de Meia-Idade , Neurotransmissores/administração & dosagem , Sorriso/fisiologia , Resultado do Tratamento
9.
JAMA Facial Plast Surg ; 20(1): 57-62, 2018 Jan 01.
Artigo em Inglês | MEDLINE | ID: mdl-29167864

RESUMO

IMPORTANCE: Otoplasty is performed to correct prominauris, one of the most common head and neck congenital deformities. Advances in combination hybrid approaches enable surgeons to achieve greater precision and accuracy. OBJECTIVE: To describe a hybrid cartilage-modifying approach and evaluate the procedure's effectiveness and safety. DESIGN, SETTING, AND PARTICIPANTS: Medical record review including patients undergoing otoplasty by the present technique from January 2006 to December 2016 as performed by the senior author at a tertiary academic referral center. Twenty-three patients underwent 24 total procedures including both bilateral (n = 17) and unilateral (n = 7) procedures. Two procedures were revisions. INTERVENTIONS: Hybrid cartilage-modifying otoplasty procedure. MAIN OUTCOMES AND MEASURES: Preoperative and postoperative measurements were recorded. Paired sample t testing was performed to assess changes between preoperative superior, middle, and inferior helical measurements and corresponding postoperative measurements for all operated ears. Two-tailed, independent sample t testing was performed to compare postoperative differences between right and left ears within separate superior, middle, and inferior measurements in patients undergoing bilateral otoplasty. RESULTS: Twenty-four surgeries were performed on 23 patients. The mean (SD) age at surgery was 16.3 (13.6) years with 13 patients (58%) between the ages of 4 and 10 years. Preoperatively, the mean (SD) superior, middle, and inferior helical rim-to-mastoid distance of the 41 discrete ears measured 16.5 (3.1) mm, 24.1 (3.8) mm, and 19.3 (4.4) mm, respectively. Mean (SD) postoperative measurements were 12.1 (2.4) mm, 14.7 (2.5) mm, and 14.0 (2.8) mm, respectively, for mean (SD) decreases of 4.4 (2.7) mm, 9.4 (3.4) mm, and 5.3 (3.6) mm. For the 17 bilateral procedures, the mean (standard error) postoperative scores between ears measured 0.7 (0.9) mm for the superior, 0.5 (0.9) mm for the middle, and 0.2 (1.0) mm for the inferior. The unaffected ear was measured in 4 of 7 (57%) of patients undergoing unilateral otoplasty, and the mean (SD) postoperative differences between left and right ears were 1.3 (0.8) mm, 3.0 (1.2) mm, and 1.0 (0.7) mm for the superior, middle, and inferior, respectively. Preoperative-to-postoperative differences for all ears (n = 41) were significant (P < .001 for all) for superior, middle, and inferior measurements. There were no significant absolute differences identified for superior (P = .41), middle (P = .58), and inferior (P = .88) measurements regarding left vs right postoperative comparisons for bilateral otoplasties. One patient undergoing bilateral repair required subsequent revision surgery of 1 ear. Two patients developed chronic suture site irritation, and 1 patient developed a hematoma. CONCLUSIONS AND RELEVANCE: The present technique allows multiple opportunities to adjust the auricular parameters. The results indicate a low revision rate and high degree of symmetry. LEVEL OF EVIDENCE: 4.


Assuntos
Cartilagem da Orelha/cirurgia , Procedimentos de Cirurgia Plástica/métodos , Adolescente , Criança , Pré-Escolar , Cartilagem da Orelha/anormalidades , Feminino , Seguimentos , Humanos , Masculino , Resultado do Tratamento , Adulto Jovem
10.
JAMA Facial Plast Surg ; 20(1): 31-36, 2018 Jan 01.
Artigo em Inglês | MEDLINE | ID: mdl-28817752

RESUMO

IMPORTANCE: Severe anterior septal deviation and resultant nasal obstruction represent a difficult surgical task to correct. The goal of surgery is to straighten the anterior dorsal and caudal struts, while maintaining nasal tip and midvault support. This study presents a novel extracorporeal septoplasty technique to straighten the crooked anterior septum. OBJECTIVE: To describe the novel anterior septal transplant technique, which consists of complete resection of the caudal septum and reconstruction with extended spreader grafts and a columellar strut, without a separate caudal septal replacement graft. DESIGN, SETTING, AND PARTICIPANTS: This study was a retrospective case series at a tertiary academic referral center. Participants were sequential adult patients undergoing anterior septal transplant from January 1, 2008, to December 31, 2015. MAIN OUTCOMES AND MEASURES: Patient-reported nasal obstruction using Nasal Obstruction Symptom Evaluation (NOSE) scores and objective photographic analysis. Nasal tip deviation, projection, and rotation were measured. Preoperative and postoperative outcomes were compared. Complications are reported. RESULTS: Seventy-one patients (mean age, 46 years [age range, 16-72 years]; 48 [67.6%] female and 23 [32.4%] male) were included in the case series. Postoperative NOSE scores (mean [SD], 24.00 [24.58]) were significantly better than preoperative NOSE scores (mean [SD], 72.25 [14.55]) (P < .001). A separate cohort of 32 patients (mean age, 42 years [age range, 13-72 years]; 23 [71.9%] female and 9 [28.1%] male) had photographs available for analysis. In the frontal view, nasal deviation improved from a mean (SD) of 2.9 (2.0) degrees before surgery to a mean (SD) of 1.4 (1.7) degrees after surgery (P = .004). In the base view, the deviation was corrected from a mean (SD) of 4.9 (2.8) degrees to a mean (SD) of 1.7 (1.2) degrees (P < .001). Tip rotation and projection were unchanged after surgery. Four patients had mild dorsal irregularities after surgery. CONCLUSIONS AND RELEVANCE: Anterior septal transplant by the described technique is a safe and effective treatment option for severe anterior septal deviation. LEVEL OF EVIDENCE: 4.


Assuntos
Obstrução Nasal/cirurgia , Septo Nasal/cirurgia , Rinoplastia/métodos , Adolescente , Adulto , Idoso , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Obstrução Nasal/etiologia , Septo Nasal/anormalidades , Fotografação , Estudos Retrospectivos , Resultado do Tratamento , Adulto Jovem
11.
Curr Opin Otolaryngol Head Neck Surg ; 25(4): 265-272, 2017 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-28604403

RESUMO

PURPOSE OF REVIEW: To provide an overview of the treatment options for nonflaccid facial paralysis including physical rehabilitation, botulinum toxin injection and surgical intervention. To also describe recent technique advances regarding facial synkinesis in each zone of facial movement. RECENT FINDINGS: Physical therapy and neuromodulation with botulinum toxin continues to be the main treatment strategy for facial synkinesis. Treating the orbicularis oculi, mentalis and platysma muscles with neurotoxin has been well described. A symmetric smile can also be improved with ipsilateral depressor anguli oris and the contralateral depressor labi inferioris weakening. Novel surgical techniques to selectively ablate specific facial muscles have also been recently described. SUMMARY: Nonflaccid facial paralysis is a spectrum of hypokinetic and hyperkinetic movement following facial nerve injury that is best treated in a patient-tailored graduated fashion. Novel techniques are evolving to maximize patient function while minimizing morbidity.


Assuntos
Paralisia Facial/terapia , Sincinesia/terapia , Toxinas Botulínicas/uso terapêutico , Músculos Faciais/efeitos dos fármacos , Músculos Faciais/cirurgia , Humanos , Neurotoxinas/uso terapêutico , Sorriso , Sincinesia/etiologia
12.
Case Rep Otolaryngol ; 2017: 7631673, 2017.
Artigo em Inglês | MEDLINE | ID: mdl-28536664

RESUMO

Spontaneous hematoma within the iliopsoas muscle (SIH) is a rare complication most commonly seen in coagulopathic patients. Often, patients undergoing microvascular free tissue transfer are anticoagulated for anastomotic patency. Here we describe two cases of postoperative SIH following contralateral anterolateral thigh (ALT) free tissue transfer for reconstruction of oncologic head and neck defects. Both patients described hip pain after mobilization and had a corresponding acute blood loss anemia. Diagnosis of SIH was confirmed by CT and both patients were managed conservatively. Given that anticoagulation is a common practice following head and neck free tissue transfer, surgeons should be aware of this potential complication.

13.
Curr Opin Otolaryngol Head Neck Surg ; 23(4): 297-301, 2015 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-26164856

RESUMO

PURPOSE OF REVIEW: Free tissue transfer is a versatile and valuable method for reconstructing select head and neck defects following trauma or oncologic resection. Microvascular reconstructive cases are among the longest, most technically challenging, and most labor-intensive operations performed by departments of otolaryngology/head and neck surgery. However, technical advances, increased experience, and robust training programs have permitted realization of microvascular success rates in excess of 97% at most high-volume centers. Given this unprecedented degree of success, research emphasis has shifted to advancing techniques, expanding indications, and increasing efficiencies. RECENT FINDINGS: Although numerous topics are important for discussion, this update focuses on recent notable advances in reconstruction. These include expanding utility of the anterolateral thigh free flap in soft tissue reconstruction, prefabricated plating for fibula free flap mandibular reconstruction, use of venous couplers, and postoperative free tissue monitoring techniques. SUMMARY: Improvements in technique, technology, and monitoring continue to improve success rates, reduce operative time and associated morbidity, improve overall functional outcomes, and improve patient-specific quality of life. These highlighted recent advances, amongst others, promote further advancement and simplification of reconstructive capabilities.


Assuntos
Traumatismos Craniocerebrais/cirurgia , Retalhos de Tecido Biológico , Neoplasias de Cabeça e Pescoço/cirurgia , Lesões do Pescoço/cirurgia , Procedimentos de Cirurgia Plástica/métodos , Humanos , Microcirurgia
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