Three-Dimensional Printed Facial Models in Rhinoplasty.

Digital patient photography and morphing software have become an important part of rhinoplasty over the past few decades. Presented is a novel technology incorporating 3D photography and printing to produce life-size models for use in patient evaluation and treatment. Surveys were conducted to assess patient response and were universally positive. Early surgeon experience also indicates benefit for intraoperative use. Three-dimensional printing and modeling is a new technology that has exciting applications for rhinoplasty and facial plastic surgery.

The Management of Vascular Malformations of the Airway: Natural History, Investigations, Medical, Surgical and Radiological Management.

Vascular malformations may affect nearly all aspects of the upper airway. Each type of malformation has a characteristic pattern of disease. These lesions may be focal or diffuse, and require directed management strategies. Physicians treating these entities should have a high level of suspicion to consider airway evaluation even in the absence of overt symptoms. However, cutaneous head and neck venous malformations or other lesions affecting the lips, oral cavity, or tongue can herald the presence of coexisting airway lesions. A multidisciplinary approach is critical in achieving comprehensive treatment.

Modified Facial Translocation Approach in a One-Month Old With a Skullbase Tumor.

The authors present a patient of a neonate with a skull base extragonadal germ cell tumor requiring a modified facial translocation approach for resection. A 1-week-old female presented with right proptosis, eyelid edema, and nasal obstruction. Imaging revealed a 3-cm right-sided skull base mass involving the right maxillary, ethmoid, sphenoid sinuses, orbit, infratemporal fossa, and cavernous sinus via skull base erosion. The lesion was refractory to chemotherapy and required surgical excision. A modified facial translocation approach with preservation of anterior maxillary bone vascularization was used to remove the tumor, which was found to be teratoma with yolk-sac features. The patient tolerated surgery well and was noted to have minimally affected facial skeleton growth at 2-year follow-up. This modified facial translocation approach allowed safe access to this anterior skull base tumor with acceptable morbidity and mild facial growth effects so far.

Combined Transzygomatic and Pterional Approach for Resection of a Dermoid Cyst of the Foreman Ovale.

Dermoid cysts are rare, benign intracranial lesions commonly located in the posterior fossa. We describe a uniquely located dermoid cyst in the foreman ovale resected via a combined pterional and transzygomatic approach.

Current surgical management of macroglossia.

PURPOSE OF REVIEW: To discuss the current surgical management of macroglossia. RECENT FINDINGS: Traditional surgical management of severe macroglossia has been with anterior wedge or keyhole resection. Long-term follow-up has been limited, and only recently have assessments been done regarding functional and aesthetic outcomes. New methods including double stellate and combination approaches have shown promise, though with limited case size reports. Addressing macroglossia in three dimensions may be the most effective way of achieving positive positional, speech and aesthetic outcomes, but comparative studies are lacking. Other causes of macroglossia, such as vascular malformations, can be managed with less aggressive measures such as laser and radio-frequency ablation. SUMMARY: The aggressiveness of the management should match the severity of the symptoms. The anterior wedge resection and modified keyhole incisions are the most well studied operative strategies. Short and long-term outcome data are limited, and neither method is definitively superior. Less aggressive measures are options for less severe macroglossia. Surgical management of macroglossia should be tailored to each individual patient and in accordance to surgeon experience and expertise.

Free flap reconstruction experience and outcomes at a low-volume institution over 20 years.

OBJECTIVE: Assess the efficacy of free flap reconstruction performed at a low-volume program and evaluate how volume and outcomes have changed over 20 years. STUDY DESIGN: Case series with chart review. SETTING: Tertiary academic medical center. SUBJECTS AND METHODS: A retrospective chart review was performed at a tertiary care academic program on all free tissue flaps from the primary reconstructive surgeon over 20 years (1993-2013). In total, 136 procedures were obtained from operative notes, billing codes, and chart databases. Outcome variables included procedure success and complications. Patients stayed in general intensive care unit and hospital floor units. RESULTS: Flap success was 92.6% of all cases. In the past 13 years, 70 flaps were performed with 3 failures (96% success rate). Take-back rate was 16% of total cases with a flap recovery rate of 60%. Postoperative failure occurred after 72 hours in 60% of cases. Nearly 60% of patients experienced a complication of any type or severity. Twenty percent had a flap complication while maintaining viability, with half of these being partial dehiscence. Systemic complications affected 20% of all cases. The average hospital stay for noncomplicated patients was 13 days. There was 1 postoperative mortality. Fibula and radial forearm were the most common flaps at 44% and 26%, respectively. CONCLUSION: Free flap reconstruction of the head and neck can be performed by appropriately skilled surgeons with acceptable outcomes in low-volume settings. Success rate appears to increase as clinical experience is gained.

Efficacy of the CHADS2 scoring system to assess left atrial thrombogenic milieu risk before cardioversion of non-valvular atrial fibrillation.

The CHADS2 scoring system was found to be a good predictor for risk stratification of stroke in patients with atrial fibrillation. The effectiveness of this scoring system in assessing thrombogenic milieu before direct-current cardioversion has not yet fully been established on a large scale. In this study, data from 2,369 consecutive patients in whom transesophageal echocardiography was performed for screening before direct-current cardioversion from 1999 to 2008 were analyzed. Left atrial (LA) or LA appendage (LAA) thrombogenic milieu (spontaneous echo contrast, sludge, and thrombus) was investigated. The results were correlated with CHADS2 score findings. The mean age was 66 ± 13 years, and the ratio of men to women was 2.2:1. CHADS2 scores of 0, 1, 2, 3, 4, 5 and 6 were present in 11%, 25%, 30%, 22%, 8%, 3%, and 1% of the studies, respectively. The prevalence of LA or LAA sludge or thrombus increased with increasing CHADS2 scores (2.3%, 7%, 8.5%, 9.9%, 12.3%, and 14.1% for scores of 0, 1, 2, 3, 4, and 5 or 6, respectively, p = 0.01). In a multivariate model, an ejection fraction ≤20% was the best predictor of LA or LAA sludge or thrombus (odds ratio 2.99, p <0.001). In conclusion, transesophageal echocardiographic markers of thrombogenic milieu were highly correlated with increasing CHADS2 scores in patients who underwent transesophageal echocardiography-guided cardioversion. Giving more value to echocardiographic findings, such as the left ventricular ejection fraction, and its different levels (especially an ejection fraction ≤20%) might improve the precision of the CHADS2 scoring scheme to predict thrombogenic milieu in the left atrium or LAA as a surrogate to cardioembolic risk in patients with atrial fibrillation.

Transesophageal echocardiography and cardioversion trends in patients with atrial fibrillation: a 10-year survey.

BACKGROUND: Transesophageal echocardiography (TEE) has long been used to assess for left atrial thrombus (LAT) in patients undergoing direct-current cardioversion (DCC) for atrial fibrillation or flutter. However, little is known about its recent trends and current applications. METHODS: In this retrospective study, 3,191 serial transesophageal echocardiographic studies in 2,705 unique patients (mean age, 66 ± 13 years; 68% men) with atrial fibrillation or atrial flutter who underwent TEE before DCC from 1999 to 2008 were identified using the Cleveland Clinic echocardiography database. Clinical data and information on the presence of spontaneous echocardiographic contrast, sludge, or LAT before DCC were obtained as well as the total number of transesophageal echocardiographic studies and DCC procedures performed in outpatient or inpatient settings. RESULTS: Increasing trends of TEE-guided DCC were observed over the past 10 years (25% in 1999, 34% in 2008). TEE-guided DCC was also performed more often in the outpatient setting (21% in 1999, 37% in 2008). There was no yearly difference for the prevalence of LAT or sludge (8% overall; P = .12). CONCLUSIONS: Over the past 10 years, trends have suggested that the application of TEE-guided DCC compared with the conventional approach have consistently grown and that more DCC procedures are done in the outpatient setting. Given the high LAT or sludge detection rate of 8%, TEE-guided DCC has continued to be an important part of atrial fibrillation management.

Indications for TEE before cardioversion for atrial fibrillation: implications for appropriateness criteria.

The purpose of this study was to evaluate appropriateness of transesophageal echocardiography (TEE) before direct current cardioversion (DCC), investigate indications for TEE, and analyze if indications are predictive of outcome. According to American College of Cardiology Foundation/American Society of Echocardiography 2011 Appropriateness Criteria, TEE is appropriate in the evaluation of patients with atrial fibrillation (AF) to facilitate clinical decision making with regards to anticoagulation and/or DCC. However, it is unclear in which instances physicians utilize TEE. We reviewed 671 TEE studies in 604 AF patients (age 66 ± 13 years, 67% male) in which TEE was performed before DCC for left atrial thrombus (LAT)/sludge. Studies were divided by the main indication for TEE into the following 8 categories: 1) congestive heart failure (CHF)/hemodynamic compromise; 2) symptomatic; 3) new onset AF; 4) hospitalized and symptomatic; 5) high stroke risk; 6) subtherapeutic anticoagulation; 7) miscellaneous; and 8) inappropriate for TEE. The main indications for TEE before DCC were symptomatic (26.4%) and CHF/hemodynamic compromise (26.1%). We deemed 2.7% of the studies as inappropriate. LAT/sludge was found in 8.2% of studies. Incidence of LAT/sludge differed significantly between indications (p = 0.0021) and the highest incidences occurred in the high stroke risk (17.6%) and hospitalized and symptomatic (14.1%) categories. No LAT/sludge was found in the miscellaneous or inappropriate groups. Stroke occurred in 2.5% (n = 15) of all patients and in all groups except for miscellaneous and inappropriate (p = 0.3). TEE is appropriately used prior to DCC for patients with the main indications of symptomatic and CHF/hemodynamic compromise. In a minority of studies, TEE utilization was inappropriate. Incidence of LAT/sludge differed between indications.