Nasal Valve Reconstruction Using a Titanium Implant: An Outcomes Study.

Septoplasty alone is not always sufficient to correct nasal obstruction. Various techniques have been employed to repair nasal valve collapse and improve airflow. This article aimed to evaluate outcomes and quality of life following nasal valve reconstruction using a titanium implant in patients with nasal valve collapse. This is a single-center retrospective study that consisted of a telephone questionnaire of 37 quality-of-life measures and questions related to the surgical procedure and recovery process to evaluate postsurgical outcomes. Fifteen patients completed the survey. There was a significant improvement in nasal blockage/obstruction, breathing through the nose, sleeping, breathing through nose during exercise, the need to blow nose, sneezing, facial pain/pressure, fatigue, productivity, and restlessness/irritability after surgery. Overall, 100% of patients were satisfied with the results and would recommend this procedure. The most common postoperative complaints were pain (33%) and difficulty breathing (33%). Patients noticed no increase (20%) or a slight increase (73%) in the size of their nose. Sixty percent of patients cannot see the implant and 13% report the implant is barely noticeable. Nasal valve repair with a titanium implant was successful at improving symptoms of nasal obstruction and other quality-of-life issues. Satisfaction was high among all patients. The implants are palpable, thought to be visible by some patients, yet accepted by the majority of patients. This approach may be especially important in patients with prior nasal surgery but continue to experience refractory symptoms.

Comparison of photographic methods.

BACKGROUND: Photo documentation has become increasing important in medicine, especially given the demand for cosmetic procedures. Standard photography is not always adequate; newer techniques exploring the use of polarized, cross and ultraviolet photography can give detailed information on subtle skin lesions including skin pigmentation and skin surface characteristics. OBJECTIVE: To use various methods of photography including standard photography, cross polarized light, parallel polarized light and ultraviolet passing photography to assess which method most effectively captures skin features such as texture, pigment, and/ or vascularity. METHODS: A prospective analysis comparing advanced photographic techniques including standard photography, polarized light photography, cross-polarized light photography and ultraviolet light passing photography. The photos were then evaluated and scored by two experts and a blinded observer to characterize the differences visualized in each type of photography compared to standard photography in terms of subsurface skin features, hypopigmentation, hyperpigmentation, and rhytids. RESULTS: 9 subjects completed the study. Overall, of the 3 photographic methods compared to standard photography, UV passing most enhanced the visualization of subsurface features and hypopigmentation, with increased hyperpigmentation as well. Enhancement of these features made UV passing best for capturing photodamage. Cross-polarized photography was best for visualizing hyperpigmentation, but also heightened visualization of hypopigmentation and subsurface features such as vascularity. Parallel-polarized photography enhanced visualization of skin texture. CONCLUSIONS: These methods of photography show a quantifiable and reproducible selective ability to evaluate and document elements such as skin texture, vascularity, and pigmentation. Each of these techniques has unique properties that can add to the precision of the clinical evaluation and can be of particular value to providers of cosmetic procedures where photo documentation has become increasingly important in providing an objective means of evaluating outcomes.

Evaluation of headache relief with cosmetic onabotulinumtoxinA injections.

Chronic headaches are common and can have a significant effect on quality of life. Approved treatment options are vast and include the use botulinum toxin injections. The objective of this study is to evaluate the effects of purely cosmetic onabotulinumtoxinA (BOTOX) injections on the frequency and severity of chronic headaches. Patients seeking treatment of hyperfunctional facial lines were enrolled to complete pre- and posttreatment questionnaires assessing headache symptoms. Quantitative data was compared using paired two-tailed student t-tests between groups of patients who received onabotulinumtoxinA injections, both onabotulinumtoxinA and hyaluronic acid (Restylane) injections, and hyaluronic acid injections. One hundred and ten patients were enrolled; 73 completed the study. Of the 45 patients with pretreatment headaches, 76% (22/29) that received cosmetic onabotulinumtoxinA injections alone and 69% (27/39) that received onabotulinumtoxinA with or without hyaluronic acid injections reported overall improvement in headaches. Patients who received only onabotulinumtoxinA reported a significant decrease in the frequency (P = 0.0016) and severity (P = 0.0002) of headaches, and the number of days over-the-counter medications were taken (P = 0.0238). It took an average 9.5 days for headache improvement vs. 4.4 days for an appearance change. In patients who received only hyaluronic acid injections (n = 6), no significant improvement in headaches was reported. Overall satisfaction was high and unaffected by whether patients experienced headache relief. The majority of patients (93%) reported that they would "definitely" or "likely" receive onabotulinumtoxinA injections again in the future. Purely cosmetic onabotulinumtoxinA injections of doses between 15-50 units can significantly decrease the severity and frequency of headaches.

Recognition and treatment of non-infectious hyaluronic acid reactions.

OBJECTIVE: To differentiate a non-infectious inflammatory reaction following hyaluronic acid injection for facial rejuvenation from other reported complications, and describe appropriate treatment. METHODS: Using a review of the literature and information available from the manufacturer, recommendations for management of non-infectious hyaluronic acid reactions are made. RESULTS: Patients who are afebrile with a normal white blood cell count and negative cultures, who appear to have an infectious process following hyaluronic acid injection are in fact having an inflammatory response. The inflammation may worsen with antibiotic therapy. Treatment should be systemic and/or local steroids, which may need to be for up to 6 months. CONCLUSION: After reviewing the literature, non-infectious inflammatory reaction following hyaluronic acid injection is exceedingly rare with only one other reported case. Erythematous skin in the week following injection without other infectious markers, such as fever or elevated serum white blood cell count, is an inflammatory reaction and should be treated with steroid therapy.

Patient outcomes, satisfaction, and improvement in headaches after endoscopic brow-lift.

IMPORTANCE: To improve preoperative counseling for patients considering endoscopic brow-lift (EBL). OBJECTIVES: To understand patient-reported outcomes, satisfaction, and recovery after EBL surgery to improve preoperative counseling. DESIGN, SETTING, AND PARTICIPANTS: A retrospective telephone survey of 57 patients who had EBL or EBL with concurrent rhytidectomy to assess cosmetic and functional outcomes using 47 questions. MAIN OUTCOME AND MEASURE: Questions evaluated outcomes, satisfaction, and recovery. RESULTS: Fifty-three patients (93%) reported the procedure was successful, and 55 patients (96%) would recommend undergoing this procedure. Forty-two (74%) were incidentally told they looked younger; 37 patients (65%) were told they looked less tired. Forty-two patients (74%) reported increased confidence. Fifty-one patients (89%) required analgesics for less than 1 week, 44 patients (77%) reported scars as unnoticeable, 54 patients (95%) reported postoperative edema lasting less than 2 weeks, 16 patients (28%) reported alopecia at an incision site, and 36 patients (63%) had some numbness. In the 16 patients who reported headaches before surgery, 8 patients (50%) reported an improvement in either frequency or intensity. Patients who underwent rhytidectomy were significantly more likely to take 2 weeks or longer to return to normal activities. No differences were noted between rhytidectomy with EBL compared with EBL alone in analgesic use, edema, numbness, alopecia, and satisfaction. CONCLUSIONS AND RELEVANCE: Endoscopic brow-lift is well tolerated and most patients are happy with the outcome. Relying on patient-reported information helps us to better understand the surgical experience and to improve preoperative counseling. LEVEL OF EVIDENCE: 4.

Nonmelanoma skin cancer treatment training varies across different medical specialists.

BACKGROUND: Physicians from various specialties treat patients with nonmelanoma skin cancer (NMSC). The isolation of specialties from each other may result in different approaches to skin cancer training. PURPOSE: Our purpose was to determine the type and amount of NMSC surgical training that is received during dermatology, general surgery, internal medicine, otolaryngology, and plastic surgery residencies. METHODS: E-mail contact information for residency program directors of all accredited programs in each specialty was compiled through the American Medical Association's online residency database. A total of 920 residency program directors were emailed surveys concerning the training of residents in the treatment of NMSC. RESULTS: Forty-two of 920 surveys were returned. All surveyed specialty groups, except internal medicine, had training in NMSC treatment including simple excision, split thickness skin grafts, and tissue rearrangement. A majority of the dermatology and plastic surgery programs instruct their residents in Mohs micrographic surgery and full thickness skin grafts. Electrodessication and curettage was most often instructed in dermatology, general surgery, and plastic surgery programs. CONCLUSION: Greater consistency in NMSC treatment training may be beneficial. Because different approaches may be best suited to particular clinical situations, NMSC treatment training should include adequate exposure to all NMSC treatment techniques.

Microtia reconstruction.

Success in microtia surgery requires meticulous patient education, planning, technique, and follow-through. When these principles are followed, excellent results as well as tremendous satisfaction are achievable for both the patient and surgeon.

Nonmelanoma skin cancer: an episode of care management approach.

BACKGROUND: The incidence of nonmelanoma skin cancers (NMSCs) was estimated at 1.3-million cases for the year 2000 and is on the rise. It is the most common form of cancer in the United States, more common than all other cancers combined. To determine the contributors to the cost of NMSC care, an episode of care of NMSC needed to be defined. OBJECTIVE: To define and validate an episode of NMSC care. DESIGN: Using survey and Medicare part A and part B claims data of the Medicare Current Beneficiary Survey (MCBS), 1992 to 1995, an algorithm was created to define an episode of care for the diagnosis and treatment of an NMSC. MCBS estimates of the number of episodes occurring in three service settings (physician's office, outpatient/ambulatory surgical center, or hospital) and demographics were compared to data from independent datasets, including the National Ambulatory Medical Care Survey (NAMCS, 1995), the National Survey of Ambulatory Surgery (NSAS, 1994 to 1996), and the National Hospital Discharge Survey (NHDS, 1992 to 1997). RESULTS: Pathology claims for NMSC diagnosis served as the indicator of NMSC episodes. The procedures, office visits, and tests that resulted in and from the pathology specimen were identified. The sum of the associated charges to Medicare or Medicare payments for all identified claims equaled the total cost of the episode of NMSC care. For example, these preliminary results demonstrated significant differences between medical and surgical subspecialties. CONCLUSION: This study defined and validated a model of an episode of NMSC care. This model's initial results serve as preliminary data for the design of further studies addressing the differences between specialties and settings. The use of this model will allow identification of factors that determine the cost of NMSC treatment and that are associated with higher cost of care.

Skin cancer is among the most costly of all cancers to treat for the Medicare population.

BACKGROUND: Compared with other malignancies, nonmelanoma skin cancer (NMSC) is associated with much less morbidity and mortality. NMSC is, however, far more common than other malignancies. The cost of managing NMSC has not been assessed. OBJECTIVE: The purpose of our study was to determine where the cost of NMSC management ranks among other cancers in the Medicare population. DESIGN: Representative Medicare part A and B claims data were obtained from the Medicare current beneficiary survey, 1992 to 1995. Claims associated with cancer costs were identified using the International Classification of Diseases, Ninth Revision, Clinical Modification codes. Weights were applied to obtain nationally representative estimates. RESULTS: Average Medicare expenditure on cancer management was $13 billion per year. The 5 most costly cancers to Medicare were lung and bronchus, prostate, colon and rectum, breast, and NMSC. The mean annual cost per patient using Medicare for all cancers was $17,094. Malignancies of lung and bronchus, colon and rectum, breast, and prostate were 11 to 19 times more costly per affected patient than NMSC. CONCLUSION: In addition to classifying cancers by number of cases and number of deaths, the financial impact of treatment can also be used to prioritize different malignancies. Such a scheme ranks NMSC far higher than would death statistics. In light of its already high and rising incidence, the cost of NMSC care to Medicare is likely to increase. However, to maintain the cost-effective management of NMSC, it is essential to preserve the current low per-patient cost of its management.