Safety and feasibility of colonoscopy in nonagenarians: A systematic review, meta-analysis and meta-regression analysis.

AIM: The aim of this work was to evaluate the safety and feasibility of performing colonoscopy in patients aged 90 years or over. METHOD: In compliance with PRISMA statement standards, a systematic review of studies reporting the outcomes of colonoscopy in patients aged ≥90 years was conducted. A proportional meta-analysis model was constructed to quantify the risk of outcomes and a direct comparison meta-analysis model was constructed to compare outcomes between nonagenarians and patients aged between 50 and 89 years via random-effects models. RESULTS: Seven studies enrolling 1304 patients (1342 colonoscopies) were included. Analyses showed that complications related to bowel preparation occurred in 0.7% (95% CI 0.1%-1.6%), procedural complications in 0.6% (0.00%-1.7%), 30-day complications in 1.5% (0.6%-2.7%), procedural mortality in 0.3% (0.0%-1.1%) and 30-day mortality in 1.1% (0.3%-2.2%). Adequate bowel preparation and colonoscopy completion were achieved in 81.3% (73.8%-87.9%) and 92.1% (86.7%-96.3%), respectively. No difference was found in bowel preparation-related complications [risk difference (RD) 0.00, p = 0.78], procedural complications (RD 0.00, p = 0.60), 30-day complications (RD 0.01, p = 0.20), procedural mortality (RD 0.00, p = 1.00) or 30-day mortality (RD 0.01, p = 0.34) between nonagenarians and patients aged between 50 and 89 years. The colorectal cancer detection rate was 14.3% (9.8%-19.5%), resulting in therapeutic intervention in 65.9% (54.5%-76.6%). CONCLUSIONS: Although the evidence is limited to a selected group of nonagenarians, it may be fair to conclude that if a colonoscopy is indicated in a nonagenarian with good performance status (based on initial less-invasive investigations), the level 2 evidence supports its safety and feasibility. Age on its own should not be a reason for failing to offer colonoscopy to a nonagenarian.

Low versus standard central venous pressure during laparoscopic liver resection: A systematic review, meta-analysis and trial sequential analysis.

To compare the outcomes of low central venous pressure (CVP) to standard CVP during laparoscopic liver resection. The study design was a systematic review following the PRISMA statement standards. The available literature was searched to identify all studies comparing low CVP with standard CVP in patients undergoing laparoscopic liver resection. The outcomes included intraoperative blood loss (primary outcome), need for blood transfusion, mean arterial pressure, operative time, Pringle time, and total complications. Random- effects modelling was applied for analyses. Type I and type II errors were assessed by trial sequential analysis (TSA). A total of 8 studies including 682 patients were included (low CVP group, 342; standard CVP group, 340). Low CVP reduced intraoperative blood loss during laparoscopic liver resection (mean difference [MD], -193.49 mL; 95% confidence interval [CI], -339.86 to -47.12; p = 0.01). However, low CVP did not have any effect on blood transfusion requirement (odds ratio [OR], 0.54; 95% CI, 0.28-1.03; p = 0.06), mean arterial pressure (MD, -1.55 mm Hg; 95% CI, -3.85-0.75; p = 0.19), Pringle time (MD, -0.99 minutes; 95% CI, -5.82-3.84; p = 0.69), operative time (MD, -16.38 minutes; 95% CI, -36.68-3.39; p = 0.11), or total complications (OR, 1.92; 95% CI, 0.97-3.80; p = 0.06). TSA suggested that the meta-analysis for the primary outcome was not subject to type I or II errors. Low CVP may reduce intraoperative blood loss during laparoscopic liver resection (moderate certainty); however, this may not translate into shorter operative time, shorter Pringle time, or less need for blood transfusion. Randomized controlled trials with larger sample sizes will provide more robust evidence.

Patterns of Craniomaxillofacial Trauma at an Urban Level I Trauma Center.

Background: There is a paucity in the literature concerning craniomaxillofacial trauma (CMF) in the USA. Better recognition of these fracture patterns and their management clarifies how to best evaluate and treat them. Methods: A retrospective chart review was conducted of CMF trauma patients who required surgical intervention at a level I trauma center between 2015 and 2018. Descriptive statistics and univariate and bivariate analyses were conducted (α = 0.05). Results: A total of 1001 patients were included. Most patients were Black (n = 665; 66%) and/or male individuals (n = 813; 57%) with an average age of 37 years (range 15 -110). The most common etiologies were assault (n = 471; 44%), motor vehicle collision (n = 238; 22%), and fall (n = 117; 11%). The mechanism of injury was a determinant of fracture type (P = 0.045). The most common CMF injuries were mandibular fracture (n = 953; 95%), maxillary fracture (n = 815; 81%), and orbital fracture (n = 206; 21%). Male sex predicted panfacial fractures (P = 0.045). Black patients experienced more severe CMF trauma compared with other races (P < 0.001). ORIF was the most common treatment for mandibular (n = 481; 73%) and maxillary (n = 62; 66%) fractures. Conclusions: Etiology and patterns of CMF trauma differ globally, with assault and motor vehicle collisions being the leading causative factors in our patient population. Patient demographics are relatively consistent worldwide, with most injuries occurring in 30- to 40-year-old men. This study offers insight into at-risk populations and guidance on their management.

Evidence of Hematoma Prevention After Facelift.

Hematoma is a common complication after facelift procedures. Multiple factors have been shown to increase the risk of hematoma formation, such as male gender, anticoagulant medication use, perioperative hypertension, increased intrathoracic pressure, and operative technique. The purpose of this manuscript is to provide an overview of existing literature to provide surgeons with evidence-based recommendations on how to minimize hematoma risk during facelift surgery. A literature search for hematoma and facelift surgery was performed that identified 478 unique manuscripts. Abstracts were reviewed, excluding articles not describing facelift surgery, those written before 1970, studies with a sample size of fewer than 5 patients, non-English studies, and those that did not provide postoperative hematoma rates. Forty-five articles were included in this text, with their recommendations. Measures such as the prophylactic management of pain, nausea, and hypertension, the use of fibrin glue tissue sealants, the use of local anesthesia rather than general anesthesia, and strict blood pressure control of at least <140 mmHg were found to significantly reduce hematoma formation. Quilting sutures has shown benefit in some high-risk patients. Measures such as drains, compression dressings, perioperative use of selective serotonin reuptake inhibitors, and perioperative steroids had no significant effect on hematoma formation. In addition to appropriate patient selection and careful intraoperative hemostasis, many adjunct measures have been shown to reduce postoperative hematoma formation in facelift procedures.

Natural language processing with machine learning methods to analyze unstructured patient-reported outcomes derived from electronic health records: A systematic review.

OBJECTIVE: Natural language processing (NLP) combined with machine learning (ML) techniques are increasingly used to process unstructured/free-text patient-reported outcome (PRO) data available in electronic health records (EHRs). This systematic review summarizes the literature reporting NLP/ML systems/toolkits for analyzing PROs in clinical narratives of EHRs and discusses the future directions for the application of this modality in clinical care. METHODS: We searched PubMed, Scopus, and Web of Science for studies written in English between 1/1/2000 and 12/31/2020. Seventy-nine studies meeting the eligibility criteria were included. We abstracted and summarized information related to the study purpose, patient population, type/source/amount of unstructured PRO data, linguistic features, and NLP systems/toolkits for processing unstructured PROs in EHRs. RESULTS: Most of the studies used NLP/ML techniques to extract PROs from clinical narratives (n = 74) and mapped the extracted PROs into specific PRO domains for phenotyping or clustering purposes (n = 26). Some studies used NLP/ML to process PROs for predicting disease progression or onset of adverse events (n = 22) or developing/validating NLP/ML pipelines for analyzing unstructured PROs (n = 19). Studies used different linguistic features, including lexical, syntactic, semantic, and contextual features, to process unstructured PROs. Among the 25 NLP systems/toolkits we identified, 15 used rule-based NLP, 6 used hybrid NLP, and 4 used non-neural ML algorithms embedded in NLP. CONCLUSIONS: This study supports the potential utility of different NLP/ML techniques in processing unstructured PROs available in EHRs for clinical care. Though using annotation rules for NLP/ML to analyze unstructured PROs is dominant, deploying novel neural ML-based methods is warranted.

Upper-Extremity Peripheral Nerve Stimulators.

Chronic pain conditions are some of the most challenging problems upper-extremity surgeons face and often require a multimodal approach including neuromodulation. Peripheral nerve stimulation (PNS) is one of these modalities, delivering electrical stimulation to peripheral axons to modulate the spinal cord and block out nociceptive signals from the extremity. This blockade leads to long-lasting effects in both the peripheral and central nervous systems. Not only does PNS decrease peripheral pain signals but it also decreases the peripheral inflammatory response and assists with central nervous system plasticity for long-term pain control. Although PNS was initially developed in the 1960s, it has been underrepresented in the literature largely due to the advent of spinal cord stimulation and the lack of Food and Drug Administration-approved hardware for PNS. However, for upper-extremity pain, PNS provides notable benefits over spinal cord stimulation devices, as PNS allows for safer, more specific, and often more effective pain control. As clinicians attempt to limit narcotic use, therapies such as PNS have been revisited and are gaining popularity. We present a narrative review of PNS; discuss its mechanism of action, indications, and surgical technique; and provide a summary of the available literature for the upper-extremity surgeon. Peripheral nerve stimulation offers a solution for chronic, debilitating pain recalcitrant to other treatment modalities.

Upper Extremity Crotalid Envenomation: A Review of Incidence and Recent Trends in Management of Snakebites.

PURPOSE: The goal of this study was to evaluate the recent trends in the management of upper extremity Crotalid envenomation in the state of Georgia, United States. METHODS: A retrospective review of the Georgia Poison Center database looking at the reported snakebites to the upper extremity between 2015 and 2020 was performed. Patient demographics, timing and location of injury, severity of envenomation, treatment, including use of antivenin and surgical intervention, and reported complications related to the use of antivenin was extracted. RESULTS: A retrospective review of snakebites between 2015 and 2020 showed 2408 snakebite cases with a mean patient age of 37.4 years. Males incurred 62.8% of all bites. The highest incidence was in summer 52.5%, and between the hours of 5 PM to midnight 57.2%. Overall, 1010 (41.9%) of all bites were categorized as venomous snakebites (55.6% copperhead, 20% rattlesnake, 2.4% cottonmouth, and 22% miscellaneous [including 3 Elapid envenomations] or unidentified. The total number of venomous bites to the upper extremity was 575 (56.9%) and 567 patients received antivenin. Envenomation severity was mild in 29%, moderate in 45%, severe in 10%, and undetermined in 16% of cases. Crotalidae polyvalent immune Fab (Ovine) was the main antivenin used, with overall mean initial therapy dose of 6.2 vials and 59% of patients receiving maintenance therapy. Three patients (0.5%) had a severe anaphylactic reaction to antivenin requiring cessation of therapy. Seven patients had acute compartment syndrome of the upper extremity requiring fasciotomy (3 copperhead, 2 rattlesnake, and 2 unidentified). There was no reported mortality during this period. CONCLUSIONS: Hand surgeons should be familiar with the management of upper extremity Crotalid envenomation. Antivenin remains the main treatment for symptomatic patients. Crotalid snakebites rarely require operative intervention. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic IV.

Systematic Review of Syndrome of the Trephined and Reconstructive Implications.

Syndrome of the trephined (SoT) is a severe complication following decompressive craniectomy resulting in neurological decline which can progress to aphasia, catatonia, and even death. While cranioplasty can reverse neurological symptoms of SoT, awareness of SoT is poor outside of the neurosurgery community. The authors performed a systematic review of the literature on SoT with a focus on reconstructive implications. Search terms "syndrome of the trephined" and "sunken flap syndrome" were applied to PubMed to identify primary studies through October 2021. Full-text review yielded 11 articles discussing SoT and reconstructive techniques or implications with 56 patients undergoing cranial reconstruction. Average age of the patients was 41.8±9.5 years. Sixty-three percent of the patients were male. The most common indication for craniectomy was traumatic brain injury (43%), followed by tumor resection (23%), intracerebral hemorrhage (11%), and aneurysmal subarachnoid hemorrhage (2%). Patients most commonly suffered from motor deficits (52%), decreased wakefulness (30%), depression or anxiety (21%), speech deficits (16%), headache (16%), and cognitive difficulties (2%). Time until presentation of symptoms following decompression was 4.4±8.9 months. Patients typically underwent cranioplasty with polyetheretherketone (48%), titanium mesh (21%), split thickness calvarial bone (16%), full thickness calvarial bone (14%), or split thickness rib graft (4%). Eight percent of patients required free tissue transfer for soft tissue coverage. Traumatic Brain Injury (TBI) was a risk factor for development of SoT when adjusting for age and sex (odds ratio: 8.2, 95% confidence interval: 1.2-8.9). No difference significant difference was observed between length until initial improvement of neurological symptoms following autologous versus allograft reconstruction (P=0.47). SoT can be a neurologically devastating complication of decompressive craniectomy which can resolve following urgent cranioplasty. Familiarity with this syndrome and its reconstructive implications is critical for the plastic surgery provider, who may be called upon to assist with these urgent cases.

Preventing Infection in Implant-based Breast Reconstruction: Evaluating the Evidence for Common Practices and Standardized Protocols.

Infection following implant-based breast reconstruction (IBBR) results in increased rates of hospital readmission, reoperation, patient and hospital expenses, and reconstructive failure. IBBR is a complex, multistep procedure, and there is a relative lack of high-quality plastic surgery evidence regarding "best practices" in the prevention of implant infections. In the absence of strong data, standardizing procedures based on available evidence can reduce error and improve efficacy and outcomes. Methods: We performed a focused literature review of the available evidence supporting specific interventions for infection prevention in the preoperative, intraoperative, and postoperative phases of care that are applicable to IBBR. In addition, we examined previously published standardized perioperative protocols for implant reconstruction. Results: Preoperative, intraoperative, and postoperative planning and organization is crucial in IBBR. Preoperative planning involves skin decolonization in advance of surgery with either chlorhexidine gluconate or mupirocin. Intraoperative methods that have shown potential benefit include double-gloving, breast pocket irrigation, separate closing instruments, and the utilization of "no-touch" techniques. In the postoperative period, the duration of drain removal and postoperative antibiotic administration play an important role in the prevention of surgical site infection. Conclusions: There is a crucial need to establish an evidence-based set of "best practices" for IBBR, and there exists a paucity of evidence in the breast literature. These data can be utilized to develop a standardized protocol as part of a rigorous quality improvement methodology.

Evaluating Outcomes and Weight Loss After Panniculectomy.

OBJECTIVE: The objective of this study was to evaluate long-term outcomes and weight loss after panniculectomy. METHODS: A retrospective chart review study was performed on 225 consecutive patients who had undergone panniculectomy from 2002 and 2020. Demographic variables including smoking status, medical comorbidities, and prior history of weight loss/bariatric surgery were collected for 173 patients. Preoperative and postoperative body mass index (BMI) were calculated in addition to postoperative outcomes. RESULTS: The study population was 85% female with a mean age of 57 years and an average follow-up of 3.9 years. Relevant comorbidities included obesity (88%), hypertension (65%), diabetes (37%), and smoking (8%), and the majority (53%) of patients had undergone prior bariatric surgery. The overall complication rate was 40%. Twenty percent of patients required reoperation or readmission, and 20% had minor complications addressed in an outpatient setting. Patients who had higher preoperative BMI experienced a significant long-term reduction in BMI. In addition, patients who did not undergo prior bariatric surgery tended to lose weight more often and by larger amounts than patients who had prior bariatric surgery (71.6% vs 57.6, P = 0.023). Complications were not uncommon and included infection (17%), delayed wound healing (16%), seroma (8%), and hematoma (3%). Patients who had prior bariatric surgery were at reduced risk of any complication (P = 0.012). Smoking increased the incidence of infection (38.5% of smokers vs 15.6% of nonsmokers, P = 0.039). Concomitant hernia repair increased the risk of overall complications (64.3% vs 35.9%, P = 0.003) and delayed wound healing (39.2% vs 11.7%, P < 0.001). In the subgroup of patients who did not lose weight, a panniculus weight greater than 5 kg was associated with an increased complication rate (61.5% vs 27%, P = 0.03). CONCLUSIONS: Patients who underwent a panniculectomy tended to lose weight postoperatively, particularly those who had not undergone previous bariatric surgery. Complications were not uncommon, especially in patients with a smoking history. Prior bariatric surgery patients had a significant decrease in postoperative complications but tended to lose less weight after panniculectomy than those without prior bariatric surgery. Concomitant hernia repair put patients at an increased risk of complications.

Syndrome of the Trephined Related to Inflation of a Scalp Tissue Expander.

ABSTRACT: Syndrome of the Trephined (SoT) is a severe complication following decompressive craniectomy. Urgent cranioplasty fully reverses the neurologic symptoms of SoT. This article presents a recent case of SoT following inflation of a scalp tissue expander.A review of the literature was performed and case details obtained from the electronic medical record. Our patient had a large craniectomy defect following traumatic brain injury. A scalp tissue expander was used before secondary cranioplasty. The patient suffered severe neurologic decline temporally related to tissue expander inflation, which was fully reversed following expander removal and urgent cranioplasty.SoT can be a neurologically devastating complication which can resolve following urgent cranioplasty. To our knowledge, this is the first description of SoT resulting from inflation of a scalp tissue expander. Familiarity with this syndrome is critical for the plastic surgery provider, who may be called upon to assist with these urgent cases.

In Vivo Randomized Controlled Study of the Bone Response of All-Suture Anchors and Biocomposite Anchors.

BACKGROUND: Suture anchors are widely used for labral reconstruction surgery. However, there has been some concern over the development of osteolysis around the anchor. This has been reported for both biocomposite and all-suture anchors, but they have not been compared directly in vivo. PURPOSE: To compare the bone response to 2 common suture anchors: a traditional biocomposite push-fit anchor and an all-suture anchor. STUDY DESIGN: Randomized controlled trial; Level of evidence, 2. METHODS: Included in this study were 17 patients with a total of 37 unique suture anchors. Magnetic resonance imaging scans were performed at 3 weeks and 6 months postoperatively. A total of 38 senior radiologists and shoulder surgeons evaluated the images using a previously validated system for grading the bone response around suture anchors. The mean difference in grading at 3 weeks and 6 months was calculated using unpaired t tests, and the interrater reliability was evaluated with an intraclass correlation coefficient (ICC). RESULTS: At 3 weeks, there was no statistically significant difference in the degree of osteolysis surrounding each suture anchor type (P = .258), with little bone response. However, on the 6-month scans, there was a significantly lower level of osteolysis seen in the all-suture anchors compared with the biocomposite anchors (P = .040). Interrater reliability was excellent, with an ICC value of 0.975 (95% CI, 0.962-0.985). CONCLUSION: All-suture anchors cause significantly less osteolysis in glenoid bone at 6 months compared with biocomposite anchors.

Epibulbar Osseous Choristoma: A Rare Find in the Superior Conjunctival Tarsal Plate of the Upper Eyelid.

A 37-year-old male was found to have a firm yellowy-white palpable mass embedded within the conjunctival surface of the tarsal plate of the left upper eyelid. This was asymptomatic and noted on a routine examination for contralateral epiphora. An excisional biopsy was performed and a "rock-like nodule" was removed with histopathology confirming the presence of mature bone. While the literature describes these lesions located in other aspects of the orbit, this is the first described case of an epibulbar osseous choristoma located in the tarsal plate of the upper eyelid.

Nasal and Lacrimal Sac Histopathology in Patients With Granulomatous Polyangiitis Undergoing Lacrimal Drainage Surgery.

PURPOSE: To examine histological changes within nasal and lacrimal sac mucosa harvested from patients with granulomatous polyangiitis (GPA) who required lacrimal drainage surgery. As these patients were considered quiescent on clinical and serological grounds, particular attention was paid to the presence of active vasculitis. DESIGN: Retrospective noncomparative case series. PARTICIPANTS: Patients with GPA who had open lacrimal drainage surgery under the care of a single surgeon between 1991 and 2017. All patients had paired biopsies of both nasal and ipsilateral lacrimal sac mucosa. METHODS: Biopsies of the nasal and lacrimal sac mucosa, taken from the operative site during either primary or revisional open dacryocystorhinostomy, were reported by experienced ophthalmic histopathologists. Outcome measures were the surgical appearance of the tissues and the proportion of each tissue showing histological evidence of active vasculitis, chronic inflammation with or without fibrosis, marked fibrosis without inflammation, or acute-on-chronic inflammatory changes. RESULTS: Paired tissues were available from 47 patients (25 females; 53%) who had undergone 64 procedures (57 primary, 7 revisional). All patients had systemic disease, this being known prior to surgery in 43 patients (with 41/43 on long-established systemic immunosuppression) and suspected clinically after the initial lacrimal examination in 4/47. Most lacrimal sacs and nasal spaces showed a variety of abnormalities, this commonly being extensive scarring. Despite most patients being considered to have inactive systemic GPA, active vasculitis was evident in 23/64 (36%) lacrimal sac biopsies and 32/64 (50%) nasal mucosal biopsies-suggesting that serological markers may not be reliable guide to disease activity where disease is of limited volume (as, for example, with limited sino-nasal disease). Chronic lymphocytic inflammation was present in a further 35/64 (55%) sacs-associated with marked fibrosis in 5-and a further 25/64 (41%) nasal biopsies (with fibrosis in 2). CONCLUSIONS: The lacrimal sac and nasal space are highly abnormal in most patients with GPA undergoing lacrimal drainage surgery. Despite having clinically and serologically inactive disease on established systemic immunotherapy, histological examination often shows unrecognized active vasculitis, which might indicate inadequate systemic immunosuppression for the underlying condition.Lacrimal sac and nasal mucosa from patients with granulomatous polyangiitis undergoing dacryocystorhinostomy usually show chronic lymphocytic inflammation with marked fibrosis, but up to half reveal active vasculitis despite long-established systemic immunosuppression and apparently "quiescent" disease.

External dacryocystorhinostomy in patients with granulomatous polyangiitis.

AIM: To review the outcome for primary or revisional external dacryocystorhinostomy in patients with granulomatous polyangiitis. PATIENTS AND METHODS: Retrospective case-note review to include age at presentation, duration of prior GPA, immunosuppression at time of surgery, nature of first lacrimal surgery, and symptomatic control. RESULTS: Forty-eight patients (25 female; 52%) presented at an average age of 50.5 years and 7 (15%) had prior lacrimal surgery on one (5/7; 71%) or both sides. The duration of systemic GPA varied, with 40% having disease for up to 3 years prior to lacrimal referral, and 41/48 (85%) being on systemic immunosuppression. Forty-eight patients had 71 affected drainage pathways-having symptoms for an average of 22 months (range <1 month to 7 years). Surgery was undertaken on 70/71 systems-62/70 primary DCRs (20 unilateral; 8 simultaneous bilateral; 13 sequential bilateral). Of nine systems with persistent symptoms after prior surgery, eight underwent revisional surgery (six unilateral; one sequential bilateral). With a follow-up of 2.5 years (range 3 months to 14 years), volume symptoms were cured in all 70 cases. Flow symptoms were controlled in 58/62 (94%) systems after primary DCR, and all eight after revisional surgery. Of four sides with persistent epiphora, one was cured with revisional DCR and three with placement of Jones' canalicular bypass tubes. CONCLUSION: Mucoid discharge, dacryocystitis and recurrent conjunctivitis were cured in all patients with GPA after either primary and revisional surgery. Continued epiphora was controlled in most patients with additional closed procedures.

Nasal and Lacrimal Sac Histopathology in Patients With Systemic Sarcoidosis Undergoing External Lacrimal Drainage Surgery.

PURPOSE: To review the histological findings in the lacrimal sac and nasal mucosa from patients with sarcoidosis undergoing external lacrimal drainage surgery. METHODS: All patients undergoing external dacryocystorhinostomy at Moorfields Eye Hospital with a known history of sarcoidosis had biopsies taken from the lacrimal sac and/or nasal mucosa during surgery. These patients were identified from databases at Moorfields Eye Hospital and the Institute of Ophthalmology, and their clinical notes were reviewed retrospectively for intraoperative findings with a view to identifying common trends. The histological findings of each biopsy were reviewed and classified as showing granulomas, nongranulomatous inflammation, or nonspecific fibrosis. RESULTS: Forty patients (29 females; 72%) were known to have systemic sarcoidosis prior to surgery, and they underwent 60 external dacryocystorhinostomies. Paired histological samples were available from 49/60 (82%) procedures, nasal biopsies alone in 3 dacryocystorhinostomies (5%), and solely lacrimal sac biopsies in 8 (13%). The main site of systemic sarcoidosis was pulmonary involvement (19 patients; 48%). Recorded operative findings included 9 large lacrimal sac mucoceles (29%), a "thick" (26%) or "inflamed" (9.7%) lacrimal sac mucosa, and "thick" (36%) or "friable" (32%) nasal mucosa. Noncaseating granulomas were identified in 34/57 (60%) sacs, and 45/52 (87%) nasal tissues-this being in 31/49 (63%) of paired tissues. Chronic inflammation, without granulomas, was present in 20/57 (35%) lacrimal sacs but only in 5/52 (9.6%) of nasal biopsies. CONCLUSIONS: In patients with sarcoidosis undergoing external dacryocystorhinostomy, the characteristic histological feature-noncaseating granulomas-is present in most patients' lacrimal sac mucosa and in almost all of their nasal mucosae. The lacrimal sac and nasal mucosa often appears abnormal-thickened or friable-during surgery.

Reconstruction of extensive medial canthal defects using a single V-Y, island pedicle flap.

The medial canthus represents one of the most challenging regions of the face to reconstruct due to the anatomical structures present, the concavity of the area, and the differences in skin texture. We present a case series of 11 patients whose defects were reconstructed with a single V-Y island pedicle flap running along the nasofacial sulcus. Our single-stage flap which modified and simplified a previously described technique achieves similar cosmetic and postoperative outcomes along with a high level of patient satisfaction in an area which can be reconstructed in a variety of ways, often with suboptimal results.