Functional outcomes of temporomandibular joint reconstruction with vascularized tissue.

OBJECTIVE: To determine how current temporomandibular joint (TMJ) reconstruction methods affect functional outcomes. METHODS: Retrospective review from January 2006 to July 2017 at a single tertiary care center. All patients who underwent mandibulectomy with subsequent reconstruction with vascularized free tissue were included in the study. Condylar segments were reconstructed with vascularized free tissue flap in conjunction with autologous tissue or allograft in the joint space. Preoperative, 3 month, 1 year, and 2 year postoperative records were assessed for trismus, need for tube feeds, and Functional Oral Intake Scale (FOIS). RESULTS: Joint space was reconstructed with autologous tissue (n = 10), allograft (n = 15) or both (n = 9). At three months, FOIS scores significantly decreased from 5.4 preoperatively to 4.8 post operatively (P = .024) and need for tube feeds significantly increased from 15.8% preoperatively to 35.1% (P ≤0.027). Trismus significantly decreased from 63.2% to 27% (P = .006). At one-year, there were no significant changes in functional status compared to pre-operative state. Patients who had previous RT had significantly worse FOIS scores preoperatively (p = .002), at three months (p < .001), one year (p < .001), and two years (p = .008). There was no significant difference in postoperative functional status of patients based on the method of TMJ reconstruction. CONCLUSION: Reconstruction of the TMJ with vascularized free tissue is a viable option and yields acceptable long-term outcomes. While functional status may improve or worsen in the immediate postoperative period, long term results mirror preoperative function. Preoperative trismus will likely improve. LEVEL OF EVIDENCE: Level 3; Retrospective Comparative Study.

The Role of Free Tissue Transfer in the Management of Chronic Frontal Sinus Osteomyelitis.

OBJECTIVES/HYPOTHESIS: Chronic frontal sinus infection is managed with a combination of medical and surgical interventions. Frontal bone osteomyelitis due to recurrent infection following trauma or prior open surgery may require more significant debridement. Free tissue transfer may allow for extensive debridement with replacement of tissue, and definitive eradication of osteomyelitis. STUDY DESIGN: Retrospective chart review. METHODS: Patients undergoing free flap obliteration of the frontal sinus for frontal bone osteomyelitis at a single institution were included in the study. Clinical, radiologic, and surgical data were collected. Surgeries before and after free flap obliteration were compared by Wilcoxon signed rank test. RESULTS: Fifteen patients were identified; however, one patient had less than 6 months of follow-up and was excluded from analysis. Of the remaining 14 patients, mean follow-up duration was 26 months (range, 6-120 months). Mean number of surgeries prior to free flap was 3.7 (range, 1-8 surgeries). Free flap obliteration resolved chronic frontal sinusitis in all patients. Two patients experienced postoperative infection, and the overall complication rate was 29%. Eight patients underwent cranioplasty (six immediate, two delayed) without complication. All patients received planned courses of postoperative antibiotics. A statistically significant decrease in the number of surgeries after free flap obliteration was observed P ≤ .01). CONCLUSIONS: Extensive debridement followed by free tissue transfer and antibiotics offers a definitive treatment for complicated, recurrent frontal osteomyelitis. Simultaneous cranioplasty provides immediate protective and aesthetic benefit without complication. Consideration should be given for free tissue transfer and cranioplasty earlier in the algorithm for treatment of refractory frontal sinus osteomyelitis. LEVEL OF EVIDENCE: 4 Laryngoscope, 129:1497-1504, 2019.

Harvesting multipotent progenitor cells from a small sample of tonsillar biopsy for clinical applications.

BACKGROUND: Human adult stem cells hold the potential for the cure of numerous conditions and degenerative diseases. They possess major advantages over pluripotent stem cells as they can be derived from donors at any age, and therefore pose no ethical concerns or risk of teratoma tumor formation in vivo. Furthermore, they have a natural ability to differentiate and secrete factors that promote tissue healing without genetic manipulation. However, at present, clinical applications of adult stem cells are limited by a shortage of a reliable, standardized, and easily accessible tissue source which does not rely on specimens discarded from unrelated surgical procedures. METHOD: Human tonsil-derived mesenchymal progenitor cells (MPCs) were isolated from a small sample of tonsillar tissue (average 0.88 cm3). Our novel procedure poses a minimal mechanical and enzymatic insult to the tissue, and therefore leads to high cell viability and yield. We characterized these MPCs and demonstrated robust multipotency in vitro. We further show that these cells can be propagated and maintained in xeno-free conditions. RESULTS: We have generated tonsillar biopsy-derived MPC (T-MPC) lines from multiple donors across a spectrum of age, sex, and race, and successfully expanded them in culture. We characterized them by cell surface markers, as well as in vitro expansion and differentiation potential. Our procedure provides a robust yield of tonsillar biopsy-derived T-MPCs. CONCLUSIONS: Millions of MPCs can be harvested from a sample smaller than 1 g, which can be collected from a fully awake donor in an outpatient setting without the need for general anesthesia or hospitalization. Our study identifies tonsillar biopsy as an abundant source of adult MPCs for regenerative medicine.

Inflammatory Pseudotumor of the Temporal Bone: A Case Series.

OBJECTIVE: Inflammatory pseudotumor of the temporal bone is a benign, idiopathic inflammatory process that is locally invasive and a cause of significant morbidity. This study reviews our experience with seven patients and is currently the largest series to date. STUDY DESIGN: Retrospective review from January 1, 2014 to January 1, 2016. SETTING: Single tertiary medical center. PATIENTS: There were five male and two female (n = 7) subjects with a diagnosis of temporal bone inflammatory pseudotumor. The mean age at presentation was 41 years old. The most common presenting symptoms were hearing loss (7/7) and headache (4/7). Four patients demonstrated an inflammatory aural polyp. Two patients experienced facial nerve paralysis. INTERVENTION(S): Seven patients underwent computed tomography and six underwent magnetic resonance imaging. Corticosteroids and antibiotics were the initial treatment of choice. Five patients also underwent surgery. As adjuvant therapy, two patients received Rituximab, one patient received radiation, and one received mycophenolate mofetil. MAIN OUTCOME MEASURE(S): Clinical courses were followed with focus on symptoms, disease recurrence, duration, and treatment. Mean follow-up was 17.8 months. RESULTS: The primary lesions demonstrated T2 hypo-intensity and enhancement as well as diffuse dural thickening on magnetic resonance imaging in five of six patients. Histopathology demonstrated chronic inflammation in the setting of hyalinized fibrosis (7/7). All the patients are currently symptomatically stable. CONCLUSION: Inflammatory pseudotumor of the temporal bone can cause devastating effects on neurological function and quality of life. Recognition of characteristic imaging and histopathology can expedite appropriate treatment. Patients may require chronic steroid therapy. Adjunctive therapy with radiation and immuno-modulation are currently being explored.

A novel computer algorithm for modeling and treating mandibular fractures: A pilot study.

OBJECTIVES/HYPOTHESIS: To describe a novel computer algorithm that can model mandibular fracture repair. To evaluate the algorithm as a tool to model mandibular fracture reduction and hardware selection. STUDY DESIGN: Retrospective pilot study combined with cross-sectional survey. METHODS: A computer algorithm utilizing Aquarius Net (TeraRecon, Inc, Foster City, CA) and Adobe Photoshop CS6 (Adobe Systems, Inc, San Jose, CA) was developed to model mandibular fracture repair. Ten different fracture patterns were selected from nine patients who had already undergone mandibular fracture repair. The preoperative computed tomography (CT) images were processed with the computer algorithm to create virtual images that matched the actual postoperative three-dimensional CT images. A survey comparing the true postoperative image with the virtual postoperative images was created and administered to otolaryngology resident and attending physicians. They were asked to rate on a scale from 0 to 10 (0 = completely different; 10 = identical) the similarity between the two images in terms of the fracture reduction and fixation hardware. RESULTS: Ten mandible fracture cases were analyzed and processed. There were 15 survey respondents. The mean score for overall similarity between the images was 8.41 ± 0.91; the mean score for similarity of fracture reduction was 8.61 ± 0.98; and the mean score for hardware appearance was 8.27 ± 0.97. There were no significant differences between attending and resident responses. There were no significant differences based on fracture location. CONCLUSION: This computer algorithm can accurately model mandibular fracture repair. Images created by the algorithm are highly similar to true postoperative images. The algorithm can potentially assist a surgeon planning mandibular fracture repair. LEVEL OF EVIDENCE: 4. Laryngoscope, 2016 127:331-336, 2017.

Midline approach to pediatric nasofrontal dermoid cysts.

IMPORTANCE: To highlight the advantages of the vertical midline incision in providing satisfactory cosmesis with complete excision of pediatric nasofrontal dermoid cysts. OBSERVATIONS: Retrospective case series of nasofrontal dermoid cysts in 4 patients treated at a single tertiary medical center from June 1, 2010, through July 31, 2012. The mean age at surgery was 2.5 years. The anatomical location of the nasofrontal dermoid cysts differed: (1) supratip extending through the upper lateral cartilages to the cartilaginous septum, (2) upper dorsum and subcutaneous tissue, (3) tip and supratip extending deep to the nasal bones with involvement of the anterior cranial fossae and dura, and (4) nasal tip extending deep to the level of the rhinion and involving the upper lateral cartilages and below the left medial canthus. Preoperative imaging was performed on all patients. There was one case of intracranial extension. All patients underwent surgical excision with the vertical midline incision. Nasal reconstruction was performed with local soft-tissue flaps (1 patient), regenerative tissue matrix (2 patients), and bone dust pate (1 patient). The patient with intracranial involvement also underwent a frontal craniotomy. All lesions were histologically confirmed as dermoid cysts. Mean follow-up was 1.5 years. There were no complications or recurrences. All patients had cosmetically acceptable scars. CONCLUSIONS AND RELEVANCE: A vertical midline incision with modifications to excise involved skin provides a satisfactory and cosmetically sound approach to congenital lesions of the nasofrontal region. It affords adequate exposure for complete excision and reconstruction. A multidisciplinary team consisting of a neurosurgeon, facial plastic surgeon, and pediatric otolaryngologist is needed to optimize outcomes.

Subcutaneous vs intramuscular botulinum toxin: split-face randomized study.

IMPORTANCE Much has been published regarding rejuvenation of the upper face with botulinum toxin A injection; however, the optimal target tissue layer has not been specifically examined. OBJECTIVE To seek a difference between subcutaneous (SC) and intramuscular (IM) administration. DESIGN, SETTING, AND PARTICIPANTS Prospective, randomized study at a tertiary care university facial plastic surgery practice. Nineteen patients who underwent botulinum toxin A treatment to the forehead were randomized so that each patient received IM injection on one side of the face and SC injection on the contralateral side. INTERVENTION Patients were assessed on the basis of eyebrow elevation before treatment, and at 2 weeks, 2 months, and 4 months following injection. Patients also completed a subjective questionnaire examining discomfort during injection, bruising, and tenderness, as well as their perception of their appearance after treatment. MAIN OUTCOME AND MEASURE Eyebrow height measurements between SC and IM techniques. RESULTS There was no difference in eyebrow height measurements between SC and IM techniques (0.00 [95% CI, -0.02 to 0.02]). Patients did report greater discomfort when receiving IM injections compared with SC injections (-0.76 [95% CI, -1.53 to 0.0005]). Patient satisfaction scores did not demonstrate a statistically significant difference between IM and SC techniques when measured on the first and second posttreatment visits; however, there was a trend toward significance on the final follow-up visit. CONCLUSIONS AND RELEVANCE Subcutaneous injection of botulinum toxin A is equally effective in achieving paralysis of the underlying frontalis muscle as IM botulinum toxin A administration. In addition, the SC route may result in less pain to patients receiving botulinum toxin A injection for rejuvenation of the upper face.

Evaluating the role of postoperative prophylactic antibiotics in primary and secondary breast augmentation: a retrospective review.

BACKGROUND: The use of postoperative prophylactic antibiotics following augmentation mammaplasty remains a controversial topic, with many surgeons opting for extended prophylaxis. OBJECTIVES: The authors evaluate the role of postoperative prophylactic antibiotics in both primary and secondary cosmetic breast augmentation. METHODS: A five-year retrospective chart review was performed on all patients undergoing cosmetic breast augmentation at a single institution from January 2005 to December 2009. The four attending physicians in this study utilized similar perioperative protocol and implant materials. Patients were divided into two cohorts: those who had received three days of postoperative antibiotics (primarily cephalosporins) and those who had not. End points of particular interest included infection, capsular contracture (CC), and local wound complications. The mean follow-up time was 3.8 years. RESULTS: A total of 605 implants were included over the five-year study period. The overall infection rate was 0.66%. For primary augmentation, 493 implants were studied, with 52% of those patients having received postoperative antibiotics. There was no statistically significant reduction in infection, CC, or total complication rate for those receiving postoperative antibiotics. Similarly, 112 implants were studied for secondary augmentation, and again, postoperative antibiotics were not associated with a reduction in complications. CONCLUSIONS: The data suggest that there was no reduction in the overall rate of total complications, infection, or CC with postoperative prophylactic antibiotics for either primary or secondary cosmetic breast augmentation. This study provides Level 3 evidence in support of discontinuing prophylactic postoperative antibiotics following cosmetic breast augmentation.