Nasal Sesamoid Cartilages: Fact or Fiction? An Anatomical Study of the Lateral Nasal Ala.

OBJECTIVES: To evaluate the presence of cartilage in the lateral nasal ala (LNA) via histological analysis of alar Mohs surgical specimens. An accurate understanding of nasal anatomy is essential to optimize esthetic and reconstructive surgical outcomes. LNA anatomy is typically pictured to include discreet accessory and sesamoid cartilages; however, the authors debate the actual presence of these structures. METHODS: A blinded reviewer analyzed 101 lateral nasal alar histologic specimens from 362 tissue blocks using a Hematoxylin and Eosin (H&E) stain to assess for the presence of cartilage. RESULTS: Out of the 362 tissue blocks histologically analyzed, only 1 included cartilaginous components. CONCLUSIONS: We conclude that the presence of sesamoid and accessory cartilages in the LNA within our sample set is exceedingly rare.

Disparities in Index of Care for Otolaryngologic Procedures Performed in Ambulatory and Inpatient Settings.

OBJECTIVE: To compare the same surgical procedure performed in ambulatory and inpatient settings to determine the demographics associated with this selection, the differences in 30-day revisit rates, and the total 30-day cost of care. STUDY DESIGN: Retrospective cohort analysis. SETTING: Ambulatory and inpatient centers in Florida, New York, and Maryland. METHODS: The Healthcare Cost and Utilization Project, the State Ambulatory Surgery and Services Database, and the State Inpatient Database were used to identify patients undergoing commonly performed otolaryngologic procedures in 2016. The State Emergency Department Database and State Inpatient Database were used to identify 30-day revisits. RESULTS: A total of 55,311 patients underwent an otolaryngologic procedure: 51,136 (92.4%) ambulatory and 4175 (7.6%) inpatient. Adjusted odds of receiving care in the ambulatory setting was significantly lower for Black patients (odds ratio, 0.69 [95% CI, 0.55-0.85]; P = .001) and nonspecified other races (odds ratio, 0.71 [95% CI, 0.52-0.95]; P = .001) as compared with White patients. Women had 1.16-higher adjusted odds of undergoing a procedure in the ambulatory setting (95% CI, 1.05-1.29; P = .005). Insurance status and income were associated with location of care in the subcategorization of head and neck surgery. Adjusted inpatient procedure costs were significantly more than ambulatory (median, $59,112 vs $14,899); 30-day adjusted costs were $71,333.07 (95% CI, $56,223.99-$86,42.15; P < .001) more expensive for inpatient procedures vs ambulatory; and the adjusted 30-day odds of revisit were 2.23 times greater (95% CI, 1.44-3.44; P < .001) for ambulatory surgery across all procedures. CONCLUSIONS: Disparities exist in the use of ambulatory settings to provide otolaryngologic surgery. Additional research is required to ensure equitable triaging of surgical care setting.

Intraoperative Imaging Changes Management in Orbital Fracture Repair.

PURPOSE: Intraoperative imaging is gaining widespread use in the management of facial fracture repair. The aim of this study was to determine whether intraoperative imaging changes the management of orbital fracture repair. MATERIALS AND METHODS: A retrospective case series was performed of all cases of orbital fracture repair from 2008 to 2015 in which the intraoperative O-arm was used at Regions Hospital (St Paul, MN), a level I trauma center. The primary outcome variable was a change in management, ranging from orbital plate repositioning to proceeding with orbital floor exploration. RESULTS: The study sample was composed of 101 patients with a mean age of 40 ± 15 years. Approximately 75% (76 of 101) of patients were male and 25% (25 of 101) were female. All cases were secondary to assault, motor vehicle accident, fall, or gunshot wounds. Use of the O-arm resulted in a change in management in 44% (44 of 101) of cases. In 48% (21 of 44) of these cases in which intraoperative imaging resulted in a change in management, the orbital plate was repositioned to optimize repair. In 16% (7 of 44) of these cases, the orbital plate was exchanged for a different size or type of plate. In 7% (3 of 44) of these cases, the orbital plate was reshaped by bending to improve contour for the repair. In another 7% (3 of 44) of these cases, the orbital plate was reshaped by trimming the plate to optimize the length or width of the plate for repair. In 7% of these cases, the orbital floor required exploration based on intraoperative imaging. In 5% of these cases, the orbital floor was found to be adequately reduced after zygoma reduction based on intraoperative imaging and did not require exploration. CONCLUSIONS: Use of intraoperative imaging allows the surgeon to make real-time changes in operative management ranging from orbital plate repositioning to deciding whether to proceed with orbital floor exploration. This not only allows for immediate optimization of repair but also could decrease the need for revision procedures, thus decreasing patient morbidity and improving patient outcomes.

Orthodromic temporalis tendon transfer: anatomical considerations.

OBJECTIVES: To define (1) at-risk structures during the orthodromic temporalis tendon transfer and (2) achievable tendon length without temporal releasing incisions or perioral lengthening materials. METHODS: Ten fresh cadavers provided 20 hemifaces for dissection. Measurements and photographic documentation were used to examine the parotid duct, masseteric artery, inferior alveolar nerve, internal maxillary artery, and mobilized tendon relative to adjacent landmarks. RESULTS: The parotid duct was found in a reproducible region posterior to the melolabial crease and inferior to a parotid duct reference line. The masseteric artery was found posterior to the posterior-most attachment of the tendon at its exit from the sigmoid notch (mean, 14.5 mm). The inferior alveolar nerve was found posterior to the anterior edge of the ascending ramus (mean, 18.3 mm). The internal maxillary artery coursed superiorly from posterior to anterior along the medial mandible near the coronoidectomy site. The tendon reached beyond the melolabial crease in 17 of 20 hemifaces (85%). CONCLUSIONS: The parotid duct reference line and the melolabial crease allow estimation of the parotid duct location. Anatomical relationships between the tendon, parotid duct, neurovasculature, and anatomical landmarks underscore the importance of deliberate soft-tissue retraction and subperiostial elevation to minimize injury. The tendon alone usually provides adequate length for orthodromic suspension.

Assessing fundamental 2-dimensional understanding of basic soft tissue techniques.

OBJECTIVE: To develop a written practical examination and scoring system for assessing trainee skills in basic soft-tissue techniques. DESIGN: A brief written practical examination was developed to assess the ability of trainees to sketch preoperative plans and postoperative results for common soft-tissue techniques: simple-excision, M-plasty, geometric broken line closure, Z-plasty, V-to-Y flap, and rhombic flap. A scoring system was developed to assign 0 to 5 points to each of 10 items on the examination for a total score of 0-50. The 15-minute examination was administered as a pretest, posttest, and 3-month posttest assessment as part of a soft-tissue course at our institution. SETTING: University of Minnesota, Otolaryngology Department. RESULTS: Three raters reviewed all examination answer sheets independently. The pretest scores of examinees correlated strongly with their level of training; the average pretest for junior residents (PGY 1-2) compared with senior residents (PGY 4-5) was 17.3 (of 50) versus 26.0 (p < 0.01). The scoring system showed a high intrarater reliability and high interrater reliability with correlation coefficients of r = 0.99 and r = 0.95, respectively and agreement coefficients of κ = 0.82 and κ = 0.77, respectively. CONCLUSION: This written practical examination and scoring system may be used to assess the skills of trainees accurately in basic soft tissue techniques and to expose areas of deficiency that can be addressed in future training sessions.

Comparison of incision closures with subcuticular and percutaneous staples.

OBJECTIVE: Incision closures should yield safe, effective healing with excellent cosmesis. Subcuticular absorbable staples may combine the advantages of subcuticular suturing with the efficiency of percutaneous stapling. This study compares absorbable subcuticular staples with percutaneous metal staples as a means of incision closure in facial rejuvenation surgery. METHODS: Sixteen patients undergoing endoscopic eyebrow-lift and/or rhytidectomy were studied. Each patient had 50% of their temporal and postauricular skin incisions closed with subcuticular staples oversewn with 5-0 plain gut and the remaining 50% closed with percutaneous metal staples. Incisions were evaluated intraoperatively and at regular intervals for 1 year postoperatively. Intraoperative assessments included device handling, bleeding, tension, and cosmesis. Postoperative assessments included incision integrity, inflammation, and cosmesis. Patients were also interviewed regarding incision appearance and comfort. RESULTS: During the early postoperative period, metal staples produced greater incisional erythema and crusting. Subcuticular staples produced better tissue eversion, less erythema, equivalent if not superior comfort, and shorter office visits. These differences faded over time. The need to properly engage the subcuticular stapler in the dermis was the principal impediment to optimal stapler use. CONCLUSIONS: Subcuticular staples represent a safe, comfortable, and potentially more rapid alternative to percutaneous staples. Modifications of the subcuticular stapler device are required before its full potential can be realized.

An overview of nasal dorsal augmentation.

Structural deficiencies of the nasal dorsum most commonly derive from congenital, traumatic, and iatrogenic etiologies. Alternatively, dorsal deficiency may be a manifestation of a generally underprojected nose with otherwise appropriate relationships between the radix, dorsum, and tip. In analyzing dorsal deficiency, associated anatomic abnormalities leading to compromise of both aesthetic form and respiratory function must be recognized and incorporated into the reconstructive plan. The cornerstone of augmentation rhinoplasty employs either autologous graft or alloplastic implant material to restore dorsal height and structural support to the nasal skeleton. Many autologous and alloplastic materials are currently available to the rhinoplasty surgeon, each of which carries a characteristic profile of relative advantages and limitations. Although most rhinoplasty surgeons prefer autologous materials, the choice of material must be individualized to each patient. The reconstructive plan ultimately formulated emerges after thoughtful consideration of the extent of the dorsal deficiency, characteristics of the overlying skin-soft tissue envelope, history of prior surgery, associated structural abnormalities, preferences of the surgeon, and views of the patient. Regardless of the specific methods used to augment the nasal dorsum, optimizing the aesthetic profile and maximizing respiratory function in a sustainable manner with minimal patient risk and morbidity remain the primary objectives.

Peripheral facial nerve regeneration using collagen conduit entubulation in a cat model.

OBJECTIVES: Facial nerve (FN) injuries are functionally, psychologically, and financially debilitating. Facial nerve autograft repairs produce significant donor nerve morbidity and functional results that rarely exceed House-Brackmann (HB) grade III over VI. In this study we sought to enhance FN regeneration via collagen conduit entubulation. METHODS: Five control cats underwent right ("cut-side") FN transection and immediate microsurgical anastomosis repair. Five experimental cats underwent identical repairs plus collagen conduit entubulation of each anastomosis. RESULTS: Postoperative behavioral observations revealed gradual FN functional recovery in all cats, who attained adapted HB grades of II to III over VI after 6 weeks. Electromyographic latencies and amplitudes from the bilateral orbicularis oculi and orbicularis oris muscles indicated restoration of FN continuity in all 10 cats. In comparison with FN repairs without conduits, repairs with conduits significantly enhanced recovery of amplitude in cut-side orbicularis oculi muscles (p = .037) and latency in cut-side orbicularis oris muscles (p = .048). In comparison with intact left ("uncut-side") FN latencies and amplitudes, more statistically significant differences in cut-side FN function were observed in repairs without conduits than in repairs with conduits. Conduits therefore facilitated a more complete return of electrophysiological function. Histologic analyses confirmed FN continuity and revealed more organized FN regenerative architecture in conduit-implanted repairs. CONCLUSIONS: The overall results support enhanced FN regeneration with collagen conduit entubulation.

DNA biomarkers antecede semiquantitative anthracycline cardiomyopathy.

Adriamycin (ADM, or doxorubicin hydrochloride) is an effective antineoplastic agent whose use is restricted by its well-described, dose-dependent cardiotoxicity. This study measures ADM DNA adduct formation by 32P-radiolabeling DNA, enzymatically digesting radiolabeled DNA, separating the formed adducts on two-dimensional thinlayer chromatography (2D-TLC), and quantitating the adducts with autoradiography and densitometry. Thirty-six male Sprague-Dawley rats are randomized to receive ADM at varying intraperitoneal (i.p.) injection concentrations: 0.9% saline i.p. controls, 4 mg/kg ADM i.p., and 6 mg/kg ADM i.p. Myocardial and pulmonary tissues are harvested 48 hours after i.p. injection for autoradiographic and histopathologic analyses. The results indicate differences in the amount and type of adduct formation as a function of ADM concentration. Increased partial depurination of dGMP and dAMP occurs with increasing ADM concentration at equal incubation times. This depurination correlates with the emergence of new adducts HM-dUMP, 8-OH-dGMP, HM-dCMP, and Me-dCMP. The quantification of these adducts can potentially represent an early marker of ADM cardiotoxicity and thereby optimize the efficacy of individual chemotherapy regimens while minimizing adverse effects.