Adverse events in facial plastic surgery: Data-driven insights into systems, standards, and self-assessment.

PURPOSE: Complications in facial plastic surgery can lead to pain, suffering, and permanent harm. Yet, the etiology and outcomes of adverse events are understudied. This study aims to determine the etiology and outcomes of adverse events reported in aesthetic facial plastic surgery and identify quality improvement opportunities. MATERIAL AND METHODS: A cross-sectional survey analysis was conducted using an anonymous 22-item questionnaire distributed to members of the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) and American Academy of Facial Plastic and Reconstructive Surgery (AAFPRS). Participants were queried on demographics, practice type, and adverse events related to aesthetic facial surgeries. RESULTS: Two hundred fifty-three individuals participated; nearly half of respondents (49.0%) held membership in both AAO-HNS and AAFPRS. Of these, 40.8% of respondents reported at least one adverse event within the past 12 months of practice. A total of 194 adverse events were reported, most commonly related to facelift (n = 59/194, 30.4%), rhinoplasty (n = 55/194, 28.4%), and injection procedures (n = 38/194, 19.6%), with hematoma or seroma being the most commonly described. Most adverse events were self-limited, but approximately 68% resulted in further procedures. Surgeon error or poor judgement (n = 42) and patient non-adherence (n = 18) were the most commonly ascribed reasons for adverse events; 37.1% of participants reported a change in clinical practice after the incident. CONCLUSIONS: Adverse events were not infrequent in facial plastic surgery. Understanding these adverse events can provide impetus for tracking outcomes, standardization, and engagement with lifelong learning, self-assessment, and evaluation of practice performance.

Head and neck melanoma.

BACKGROUND: Melanoma of the head and neck and its treatment are complex issues. The behavior of head and neck melanoma is aggressive, and it has an overall poorer prognosis than that of other skin sites. METHODS: The authors review current data on the treatment of head and neck melanoma, including both cutaneous and mucosal melanoma. RESULTS: Current understanding of the behavior of head and neck melanoma is reviewed and treatment stratagems are presented. Controversies in treatment include lymphoscintigraphy with sentinel node biopsy, nodal dissection, margin size, role of radiation therapy, and reconstruction. The management goal is to treat melanoma aggressively while minimizing the effects of treatment on patient quality of life. CONCLUSIONS: Due to its aggressiveness, head and neck melanoma should be treated aggressively when morbidity is not significantly increased. Patient specific treatment is imperative.

Anterior skull base fractures.

Anterior skull base trauma evaluation and management has historically been difficult to systematically study secondary to the relative rarity of its occurrence, associated major morbidity and high mortality, and poor radiographic techniques. It has only been recently that improved care has allowed for decreased morbidity and mortality. The advent of computed tomography imaging techniques has led to anatomic characterization and detailed study of injury patterns. This article reviews current techniques for evaluation and management of the associated sinonasal, orbital, and neurologic sequelae of anterior skull base injuries.

Effects of the nasal muscles on the nasal airway.

BACKGROUND: The nasal muscles and their function are not clearly defined. The nasal muscles generally are thought to act synergistically to produce mimetic motion and affect the nasal airway. We proposed direct examination of the effects of the nasal muscles on the nasal airway. METHODS: Rhinomanometry was performed on volunteers. After paralysis of the nasal muscles with lidocaine, rhinomanometry was performed again to measure nasal airway function with the patient at rest and attempting to flare his/her nostrils. Each patient's rhinomanometric results (at rest and attempting to flare the nostrils) taken before injection of lidocaine served as the control for comparison of his/her results postinjection. The structural tension of the ala at rest and with active flaring of the nostril was measured also, and the results pre- and postparalysis with lidocaine were compared. RESULTS: The data from both the stiffness (structural tension) and the airflow portions, taken together, support the following conclusions. First, the paralysis was significant, although not complete. Clinical and stiffness data supported complete paralysis. Airflow data, which we think most sensitive, support a statistically significant affect of the injection, although incomplete paralysis. CONCLUSION: All of the evidence supports an important role for the nasal muscles when actively used to increase nasal airflow. Second, the majority of the evidence supports an important resting nasal muscle tension that opens the nasal airway.

Malignant tumors of the anterior skull base.

BACKGROUND: Cancers of the paranasal sinuses or nasal cavity are the most common malignant tumors of the anterior skull base. Several types of tumors occur in this location, including cancers of endodermal, mesodermal, and epidermal origins. Although anterior skull base surgery is a relatively recent approach in treating these tumors, widespread changes have already occurred in procedural methods and treatment goals. METHODS: We review the tumor types that occur in the anterior skull base and discuss the current treatment options, including multimodal therapy and the team approach to surgery. Surgical techniques are also described. RESULTS: Management of anterior skull base cancer is complex due to the anatomic detail of the region and the variety of cancers that occur in this area. Currently, the "gold standard" for surgery is the anterior craniofacial approach. Combined with adjuvant radiation therapy, 5-year disease-free survival rates have increased to 50%, with some tumors such as adenocarcinomas and esthesioneuroblastomas reaching up to 80% 5-year survival rates. Potential complications include cerebrospinal fluid leakage, meningitis, abscess formation, and pneumocephalus. CONCLUSIONS: Treatment of anterior skull base cancer is complex due to the significant anatomic detail of the region and the variety of cancers that occur in this area. Multimodal therapy through a team approach is the optimal management approach for these tumors.

Identification of NY-ESO-1, MAGE-1, and MAGE-3 in head and neck squamous cell carcinoma.

BACKGROUND: Certain tumor antigens have been identified that stimulate an immune response, thus making them targets for immunotherapy. NY-ESO-1, MAGE-1, and MAGE-3 are such antigens. This study was undertaken to determine their presence or absence in head and neck squamous cell cancers and to correlate this with patient characteristics. METHODS: Reverse transcriptase polymerase chain reaction (RT-PCR) and immunohistochemistry (IH) were used to identify NY-ESO-1, MAGE-1, and MAGE-3 in surgical specimens. Patient data (previous treatment, gender, age, primary site, metastasis, tumor grade, tumor stage, smoking history, and alcohol history) were collected by chart review and examined for correlation with presence or absence of antigen. RESULTS: Three tumors were found to be positive for NY-ESO-1 by RT-PCR. All of these tumors were also positive for MAGE-1 and MAGE-3. IH was only positive for NY-ESO-1 in one patient. Eighteen of the 45 tumors (40%) were positive for MAGE-1 by RT-PCR. By IH, only six tumors were positive for MAGE-1. Five (83.3%) of those that were positive by IH were positive by RT-PCR. Twenty of the 45 tumors (44.4%) were positive for MAGE-3 by RT-PCR. By IH, 12 tumors were positive for MAGE-3. Nine (75%) of those positive by IH were also positive by RT-PCR. Overall, of the 45 tumors, 27 (60%) were positive by RT-PCR for at least one of the antigens. None of the patient characteristics correlated with the presence or absence of antigen. CONCLUSIONS: There is high expression of MAGE-1 and MAGE-3 antigens in head and neck squamous cell carcinomas, whereas NY-ESO-1 is not significantly expressed. IH correlates but is not as sensitive as RT-PCR for detection of these antigens. There is no correlation between antigen expression and patient data. On the basis of the high levels of MAGE-1 and MAGE-3 expression, use of these antigens may serve as a potential approach to immunotherapy for squamous cell carcinoma from head and neck sources.

A grading system for nasal dorsal deformities.

There is no uniform grading system for nasal dorsal deformities currently in general use among surgeons who perform rhinoplasty. Given the popularity of this procedure among both the general public and surgeons, it is time that there was a uniform system describing dorsal deformities. Such a system has value in the education of students of rhinology and cosmetic nasal surgery. We have developed one such system, and applied it to 100 cases. In all cases it accurately describes the major pathological conditions of the dorsum, if present, as noted on physical examination. We have found application of this system to be facile.