Nasal tip refinement: analysis of surgical technique, efficacy, and secondary effect of skin thickness.

BACKGROUND: Effective control and refinement of the nasal tip is an integral component of the rhinoplasty operation. A multitude of techniques exist to complement the rhinoplasty surgeon's approach, but attaining consistent and long-lasting results is still challenging due to the complex interplay between nasal anatomy and surgical technique. OBJECTIVES: The authors sought to determine whether the degree of tip narrowing with rhinoplasty is associated with the narrowing technique selected by the surgeon and whether there is an association between skin thickness and tip narrowing. METHODS: A retrospective chart review was conducted of all patients undergoing rhinoplasty in a single-surgeon practice between April 2004 and November 2006. Demographic information and specific operative techniques were recorded. Standard basal views of pre- and postoperative photographs were examined by two blinded observers, who measured nasal tip width relative to interpupillary distance with imaging software. Skin thickness was assessed and categorized by a surgical expert according to Fitzpatrick classification. RESULTS: Forty patients were identified with adequate follow-up and complete data sets. A statistically significant reduction in tip width pre- and postoperatively was seen (P = .041). No significant difference in tip narrowing between various techniques was found (P = .309), and no significant association between tip narrowing and skin thickness was identified (P = .186). CONCLUSIONS: Although tip-narrowing techniques are effective in rhinoplasty, the specific technique employed may not be clinically relevant. Furthermore, skin thickness may not be as significant a factor in tip narrowing as is commonly believed.

The Canadian experience with fillers.

The number of commercially available injectable soft tissue fillers has increased dramatically over the past decade. In the United States, a variety of temporary fillers have received Food and Drug Administration (FDA) approval. However, at the present time, there are no permanent soft tissue injectable fillers available. This article will discuss the authors' experience with some of the more popular soft tissue fillers on the market in Canada that are not currently available in the United States.

Insular carcinoma of the thyroid.

Thyroid surgeons are becoming increasingly more aware of a histologically distinct subset of thyroid carcinoma whose classification falls between well-differentiated and anaplastic carcinomas with respect to both cell differentiation and clinical behavior. This subtype of tumors has been categorized as poorly differentiated or insular carcinoma, based on its characteristic cell groupings. Although the differentiation of insular carcinoma from other thyroid carcinomas has important prognostic and therapeutic significance, relatively little about insular carcinoma has been published in the otolaryngology literature. In this article, we describe a new case of insular carcinoma and we discuss the findings of our review of the literature. We conclude that insular thyroid carcinoma warrants aggressive management with total thyroidectomy followed by radioactive iodine ablation of any remaining thyroid tissue.

Intraoperative ultrasound reduces ECMO catheter malposition requiring surgical correction.

BACKGROUND/PURPOSE: One hundred ninety-three cannulation procedures for extracorporeal membrane oxygenation (ECMO) have been performed at the authors' institution from 1994 to now. Before 1996, their practice had been to position these catheters exclusively by clinical assessment and chest radiograph. Since then, the authors have utilized intraoperative ultrasound guidance during cannulation procedures to confirm proper tip position. This retrospective analysis was undertaken to establish whether this practice has reduced the rate of surgical repositioning of ECMO catheters in these patients. METHODS: A retrospective chart review was performed for all infants who underwent ECMO cannulation procedures at the authors' institution. Numbers of infants requiring surgery to readjust ECMO catheter position were totaled. Cases were categorized according to the presence or absence of intraoperative ultrasound scan. Statistical significance was determined using X(2) analysis, Student's t test, or analysis of variance where appropriate. RESULTS: There were 193 ECMO cannulations performed. Of the 101 procedures done without ultrasound scan, 18 necessitated surgical repositioning. In contrast, only 3 of the 92 catheters placed with ultrasound assistance required reoperation. This represents a reduction the rate of repositioning from 17.8% to 3.3% of cannulations (P =.003). CONCLUSIONS: Based on these findings, the authors advocate the use of intraoperative ultrasound imaging to optimize the position of ECMO catheters. This high rate of initial success helps avoid the potential morbidity of ECMO circuit malfunction, repeat neck dissection, and catheter manipulation in these critically ill, anticoagulated patients.