Are More Medically Complex Patients Who Undergo Complex Septorhinoplasty at an Increased Risk for Surgical Site Infection?

BACKGROUND: Prophylactic antibiotics are routinely prescribed by surgeons for their patients who undergo septorhinoplasty. However, the literature to support this remains controversial, especially in complex cases, those that require grafts, revision cases, extended surgical time, and an American Society of Anesthesiologists (ASA) value greater than or equal to 3. PURPOSE: The study purpose was to evaluate for a potential association between increased anesthetic complexity and the risk for surgical site infection (SSI) following complex septorhinoplasty. STUDY DESIGN, SETTING, SAMPLE: Retrospective cohort study of patients who underwent a complex septorhinoplasty between 2005 and 2022 at the Dallas Veterans Affairs Medical Center. Patients were excluded if they did receive a septorhinoplasty, did not follow up, or had insufficient records. INDEPENDENT VARIABLE: All patients were assigned an ASA value prior to surgery, with an ASA value of 3 serving as this study's independent variable. MAIN OUTCOME VARIABLE: The main outcome variable of interest was the development of a postoperative SSI, defined as findings consistent with cellulitis, purulence, or fistula development necessitating antibiotic treatment. COVARIATES: The demographic covariates included patient age and sex. Clinical covariates included diabetes status, history of nasal trauma or surgery, and smoking status. The operative covariates were surgical duration, perioperative antibiotic, intraoperative complication, and type of cartilage graft used. ANALYSES: χ2 Analysis and t-tests were used for calculations, with P values < .05 being considered significant. RESULTS: A total of 182 patients were included in this study, 81 (45%) with an ASA ≤2 and 101 (55%) with an ASA of 3. A patient's age (P < .01), male sex (P < .01), and a diagnosis of diabetes (P < .01) were associated with an ASA value of 3. In total, there were 6 (3.3%) SSIs, with 2 (1%) occurring in those with an ASA of 3. An ASA value of 3 (P = .27, relative risk of .40) was not shown to be associated with an increased risk of SSI. CONCLUSION AND RELEVANCE: Our results suggest that an ASA of 3 is not significant with regard to postoperative infection in patients who undergo a complex nasal septorhinoplasty, and prophylactic postoperative antibiotics are not warranted.

Low Insertional Torque and Early Dental Implant Failure.

PURPOSE: There is lack of uniformity regarding the ideal insertional torque with which dental implants need to be placed. The purpose of this retrospective analysis is to compare the incidence of early dental implant failures with an insertional torque less than 30 N-cm to implants placed with an insertional torque 30 N-cm or greater. METHODS: A retrospective cohort study was conducted to evaluate dental implants placed between 2015 and 2016 at the Veterans Affairs North Texas Health Care System in Dallas. The primary predictor variable was dental implant insertional torque, measured at the time of implant placement as either greater than or equal to 30 N-cm or less than 30 N-cm. The primary outcome variable was early implant failure, defined as implant exfoliation noted by the patient or failure due to implant movement or pain necessitating explantation before prosthesis loading. The study conducted a time-to-event analysis to examine a group difference in time to implant failure between insertional torque group greater than or equal to 30 N-cm and less than 30 N-cm using Kaplan-Meir curves and a frailty model. The time to follow-up was censored at 6 months. RESULTS: One hundred three patients had 214 implants placed, with early failures occurring in 14 implants (6.5%). Implants placed with an insertional torque less than 30 N-cm were nearly 14 times more likely to have an early failure compared to implants placed with an insertional torque 30 N-cm or greater (hazard ratio = 13.909; 95% confidence interval, 1.835 to 105.416), which was statistically significant (P = .0108). CONCLUSIONS: The results of this retrospective cohort study suggest that insertional torque values less than 30 N-cm are associated with early dental implant failures. Future, prospective studies will be performed to further elucidate the association between insertional torque and early dental implant failure.

Contemplations and Ruminations of Methodological Error.

PURPOSE: Journal articles in our field of oral and maxillofacial surgery are rife with case studies, cohort reviews, meta-analysis, basic science studies, surgical techniques, and anatomic studies. The data found in these studies often rely on multiple measurements by which the authors draw their conclusions. Accurate measurements play a critical role in the design of the study, which in turn affects the conclusion that the author is attempting to convey. Investigators must determine and develop the processes to determine the methodological errors associated with each project to help with determining the accuracy of these measurements. The aim of this study is to highlight some of the methodological errors contained in the material and methods in oral and maxillofacial surgery studies over the calendar years of 2018 and 2019 and how best to evaluate them. MATERIALS AND METHODS: The inclusion criteria involved articles that used measurements where discrepancies could exist such as clinical measurements, histological measurements, and radiological measurements. The number of specimens or subjects measured in each study was tabulated. RESULTS: Over the 2-year period considered, 744 articles were published, and 116 (15.6%) of them met the inclusion criteria. Of these articles, 37 (32%) reported a methodological error, while 79 (68%) did not. In addition, 31 (84%) of the articles with a methodological error were radiographic, while only 6 (16%) were not radiographic. Among the studies that reported methodological error, there were approximately 7 different types used with no rationale given for the choice. CONCLUSIONS: We believe that it is important to ensure sound methods and materials, including a stated methodological error. An attempt at standardization will help to serve to enhance and strengthen the different research studies seen in our field.

Anatomic Variability of the Human Orbit.

PURPOSE: Knowledge of the bony orbit and how its volume changes are clinically important in addressing traumatic injuries. Restoration of orbital volume in some patients is critical to achieving successful outcomes after such injuries. In this large cadaveric study, we aimed to assess the average volume, range of bony orbit volumes, degree of volume discrepancy between the right and left orbits, and percentage of skulls with 1- and 1.5-mL orbital volume differences via alginate impressions and volume displacement. MATERIALS AND METHODS: This study used 121 skulls (242 orbits) from the University of Texas Southwestern Department of Cell Biology/Anatomy. Seal-press wrap was first adapted to each bony orbit to ensure no damage to the internal orbits, foramina, or fissures. Alginate impressions were then taken and trimmed to encompass the bony orbit. The volume of each impression was calculated via the volume-displacement method. RESULTS: The average orbital volume was 26.75 mL for the right side and 26.65 mL for the left. The average right-to-left difference between orbits was 0.8 mL, with a range from 0.02 to 3.64 mL. The calculated methodologic error was 0.91% for the right orbit and 1.05% for the left. Approximately 14% and 21% of skulls showed normal left-to-right orbital volume differences of 1.5 mL or greater and 1.0 mL or greater, respectively. CONCLUSIONS: Our data suggest that the average normal asymmetry between the right and left orbital volumes is 0.8 mL, which is 50 to 80% of the orbital volume increase implicated in traumatic enophthalmos. Of the skulls, 17 (14%) showed a right-to-left orbital volume asymmetry of 1.5 mL or greater and 25 (21%) showed an asymmetry of 1.0 mL or greater. The skull-to-skull orbital volume range approached 200%. Thus, this study provides surgeons with important information to consider when reconstructing a traumatized orbit using a computed tomography scan of the unaffected, contralateral orbit.

The Use of Allogeneic Cartilage for Grafting in Functional and Reconstructive Rhinoplasty.

PURPOSE: Allogeneic cartilage grafting has multiple uses in rhinoplasty. Autogenous cartilage is frequently used in cases of nasal obstruction or reconstruction, but harvesting grafts can cause complications or might be contraindicated. Rhinoplasties on the patient with a cleft might require costochondral grafts. Allogeneic rib is an effective and safe alternative to autogenous grafts, prevents complications, and obviates postoperative admission after rib harvest. MATERIALS AND METHODS: Patients who had allogeneic cartilage placed during functional or reconstructive rhinoplasty were studied from 2 institutions, including 19 who had functional rhinoplasty using allogeneic Cartiform patellar cartilage grafts and 15 patients who underwent reconstructive cleft rhinoplasty with allogeneic rib cartilage. Postoperative follow-up was at least 6 months, and graft handling characteristics and improvement in breathing were assessed. Internal and external nasal valve (INV and ENV, respectively) patencies were evaluated in patients who received the Cartiform grafts, and cosmetic outcomes were rated for patients with reconstructed clefts. RESULTS: The average age of patients who underwent functional rhinoplasty was 57.3 years, and all were men with compromised nasal breathing. Cartiform cartilage was used to repair INV or ENV collapse. Postoperatively, all patients had patent INVs and ENVs and reported improved nasal breathing. Patients who received the rib allograft had an average age of 18 years and 40% were male; all had severe nasal deformities secondary to cleft or craniofacial conditions. Patients rated their preoperative nasal breathing as 4 of 10 on average and cosmetic appearance as 3 of 10; postoperatively, these were rated as 9 of 10. Complications were not noted, except for 1 superficial infection (unrelated to the graft) and 1 hypertrophic scar. There were no postoperative admissions. The mechanical and handling properties of the Cartiform and allogeneic rib were appropriate. CONCLUSION: Allogeneic cartilage is an acceptable alternative to autologous cartilage in functional and reconstructive rhinoplasty.

Maximum Quantity of Bone Available for Harvest From the Anterior Iliac Crest, Posterior Iliac Crest, and Proximal Tibia Using a Standardized Surgical Approach: A Cadaveric Study.

PURPOSE: The 3 most common sites for obtaining autogenous bone grafts are the anterior iliac crest (AIC), posterior iliac crest (PIC), and proximal tibia (PT). The purpose of this study was to determine the maximum amount of corticocancellous bone that could be harvested from the AIC, PIC and PT when using a standardized surgical approach. MATERIALS AND METHODS: The maximum volume of cortical and cancellous bone from the AIC, PIC, and PT was harvested from 44 cadavers using approaches from a review of the literature. Uncompressed and compressed corticocancellous bone volumes were measured by water volume displacement. Bivariate analyses of bone volumes, gender, and medical comorbidities were performed using the exact Wilcoxon rank-sum test. A general linear model using ranks was used to assess the effect of gender, medical comorbidity, and site separately for total uncompressed and compressed bone measurements. RESULTS: Forty-two AIC corticocancellous grafts provided an uncompressed total average of 26.29 mL and a compressed total average of 20.58 mL. Thirty-three PIC grafts yielded a total average of 33.82 mL of uncompressed bone and 24.11 mL of compressed. Thirty-eight PT samples provided a total average of 18.11 mL of uncompressed bone and 9.03 mL of compressed bone. No statistically relevant correlations were found between compressed bone volumes and body mass index or age. No statistically relevant association was found between bone quantity and medical comorbidity for any of the graft sites. The average rank of bone volume per site after controlling for gender and medical comorbidity showed that the PIC yielded the most and the PT yielded the least compressed and uncompressed bone amounts (P < .001). CONCLUSION: Results indicate that the PIC has a larger maximum amount of corticocancellous bone than the AIC and PT with a standardized approach. The maximum volumes of attainable bone from the AIC, PIC, and PT were lower than commonly cited in the literature.

The effect of mandibular advancement for mandibular deficiency dentofacial deformities on laryngeal grade and intubation difficulty: a preliminary study.

OBJECTIVE: The purpose of this study was to evaluate mandibular advancement for cases of mandibular deficiency with changes in vocal cord grade and intubation difficulty at subsequent surgery requiring intubation. STUDY DESIGN: This retrospective case series included patients with a diagnosis of mandibular deficiency (Class II skeletal dentofacial deformity) who underwent mandibular advancement surgery (T1) followed by a subsequent surgery (T2) which required intubation. The primary predictor variable was mandibular advancement. The primary outcome variable was the change in laryngeal grade-Cormack and Lehane-after mandibular advancement. A secondary outcome was intubation difficulty after mandibular advancement. RESULTS: Eight patients were included in the study. At T1, the average laryngeal grade was 1.6. There was 1 difficult intubation. The average time to T2 was 9 months. At T2, all patients were intubated on their first attempt, and all had a Cormack-Lehane Grade I view of the vocal cords. There were no difficult intubations at T2. Analysis showed a significant association between mandibular advancement and laryngeal grade at T2 (P = .03; 95% CI 0.07-1.13). CONCLUSIONS: This preliminary investigation found an association between mandibular advancement for cases of mandibular and improved laryngeal grade at subsequent intubation without any difficult intubations.

Anatomical variation of the nasal septum: analysis of 57 cadaver specimens.

OBJECTIVES: The purpose of this study was to examine the anatomical variation of the osseous and cartilaginous components of the nasal septum. STUDY DESIGN: Fifty-seven cadaver specimens were digitally scanned and analyzed utilizing Bersoft Image software. Anatomical data were statistically analyzed utilizing SPSS 13.0. Evaluation of the area of the osseous/cartilaginous nasal septum as well as an estimation of the available cartilage for grafting was performed. RESULTS: Septal specimens revealed males had greater variation in cartilaginous area compared to female specimens. The intranasal/extranasal cartilage contributes about 45%/55% of the total cartilage, respectively. The data indicate that the mean area of cartilage available for grafting is around 420 mm(2). CONCLUSIONS: Significant variability in the cartilaginous elements of the nose is the rule rather than the exception. Key differences exist in the anatomic location of the graft material between males and females. This has important surgical implications given the critical attention required during graft harvesting in order to maintain support of the nose.

Problems and complications of full-face carbon dioxide laser resurfacing for pathological lesions of the skin.

OBJECTIVE: Facial resurfacing with a CO2 laser has been used for treatment of pathologic lesions and for cosmetic purposes. Postoperative complications and problems after laser resurfacing include infections, acneiform lesions, and pigment changes. This retrospective study describes the most common problems and complications in 105 patients and assesses postoperative pain in 38 patients. STUDY DESIGN: All patients received CO2 laser resurfacing for treatment of malignant/premalignant lesions and had postoperative follow-up to assess problems and complications. Some had follow-up to assess postoperative pain. All patients had Fitzpatrick I-III skin types and underwent the same perioperative care regimen. RESULTS: There were 11 problems and 2 complications. Problems included infection, acneiform lesion/milia, and uncontrolled postoperative pain. Complications included hyperpigmentation. Among the postoperative pain group, 53% reported no pain and the rest had mild or moderate pain. CONCLUSION: Complications are rare. Infection and acneiform lesions/milia were the most common problems, as previously reported. Most patients do not experience postoperative pain.

Observations of the marginal incision and lateral crura alar cartilage asymmetry in rhinoplasty: a fixed cadaver study.

OBJECTIVE: This anatomical cadaver study was intended to incrementally determine the precise relationship between the alar rim skin margin and the caudal aspect of the lateral crus of the nose. The second intention was to preliminarily test the hypothesis of sexual dimorphism in the lateral crura size and of right to left asymmetry of the lateral crura in the same individual. STUDY DESIGN: Demographic information of 39 Caucasian cadavers was collected. Dissection of 28 unilateral and 11 bilateral noses included the removal of all of the soft tissue from the lateral surface of lateral crura cartilages. The distance from the caudal edge of the lateral crus to the alar margin was measured beginning at the junction of the middle and lateral crura moving posteriorly. The lateral crus was then completely dissected out from the remaining surrounding soft tissue for measurement of the length, height, and thickness. RESULTS: Comparison of the cartilage dimensions between the sexes showed significant differences between the length, height, and thickness of the cartilages. The distance between the caudal aspect of the lateral crus and alar skin margin was less than 6.7 mm on average for the anterior 15 mm of the lateral crus. Comparison for intraindividual right to left asymmetry showed significant differences in 3 infracartilaginous-alar skin margin distance measurements and in cartilage length and height. CONCLUSION: The marginal incision can be close to the alar skin margin in the first 15 mm. Right to left intraindividual asymmetry in the first 20 mm was significant. Intraindividual right to left asymmetry was significant in the lateral crura length and height. Sexual dimorphism in the lateral crura length, height, and thickness was observed.

Long-term efficacy of carbon dioxide laser resurfacing for facial actinic keratosis.

PURPOSE: To evaluate the efficacy and long-term effectiveness of carbon dioxide laser resurfacing in the treatment of patients with facial actinic keratosis. PATIENTS AND METHODS: A retrospective chart analysis was conducted of 31 patients who underwent full face carbon dioxide laser resurfacing for facial actinic keratosis from July 1998 to November 2002. RESULTS: Of 31 patients, 18 (58%) were free of lesions at their longest visit. The average actinic keratosis free period, excluding 2 deceased patients, was 27.4 months. CONCLUSION: Carbon dioxide laser resurfacing is an effective tool in the management of patients with facial actinic keratosis.