Venous Flow Coupler in Head and Neck Free Flap Reconstruction.

OBJECTIVE: To describe the utility of venous flow couplers in monitoring free tissue flaps in the immediate postoperative setting. STUDY DESIGN: Retrospective case series. SETTING: Otolaryngology department at a single tertiary care institution. METHODS: A retrospective case series of free flap reconstructions in which venous flow couplers were employed to supplement flap monitoring. All free flap cases performed over the past 4 years were reviewed. Inclusion criteria were venous flow coupler and arterial flow Doppler monitored for 5 days postoperatively. RESULTS: From July 2014 through May 2018, the venous flow coupler was used with the arterial flow Doppler and clinical monitoring in 228 cases. Eleven cases did not meet criteria for inclusion; thus, 217 cases were analyzed. Twenty cases (9.2%) returned to the operating room with concern for flap compromise, and 16 were salvaged. The combination of venous flow coupler and arterial flow Doppler identified 19 of these flaps. Venous flow couplers identified 5 compromised flaps before there was an arterial signal change, and all were salvaged. Additionally, there was a 24.1% false-positive rate when 2 venous flow couplers were used in parallel. For the venous flow coupler, the positive predictive value was 64.3% and the negative predictive value, 98.9%. The false-positive rate in the series was 5.1%. The sensitivity was 90% and the specificity, 94.9%. CONCLUSION: The venous flow coupler is able to detect venous thrombosis in the absence of arterial thrombosis and may contribute to improved flap salvage rates.

Incorporating Midline Platysmaplasty with Lateral Superficial Muscular Aponeurotic System Facelifting.

Management of the platysma is key to achieving an ideal neck contour during rhytidectomy. This article reviews platysmal anatomy, indications for platysmaplasty, preoperative patient assessment, surgical technique for midline platysmaplasty, postoperative management, long-term outcomes, and the senior author's experience and philosophy on midline platysmaplasty in the setting of lateral superficial muscular aponeurotic system facelifting.

The Use of Spreader Grafts or Spreader Flaps-or Not-in Hump Reduction Rhinoplasty.

Hump reduction is one of the most common reasons patients seek cosmetic rhinoplasty. Spreader grafts or spreader flaps have become a key maneuver in supporting and reconstructing the nasal midvault after reductive profileplasty to prevent long-term functional and cosmetic sequelae. This article reviews the pertinent anatomy, describes indications for spreader graft or spreader flap placement, discusses surgical techniques and approaches for spreader graft placement, and describes complications of spreader graft use after hump reduction.

The Graduated Approach to Surgical Neck Contouring.

Achieving a more youthful neckline is one of the most common reasons why patients seek facial plastic surgery. A variety of treatment options are available to contour the neck, ranging from injectable medications to minimally invasive energy devices to surgery. A spectrum of surgical procedures can be offered to contour the neck, including liposuction, submentoplasty, necklift, and facelift, all with or without implants. The ideal neck aesthetic, pertinent anatomy, patient evaluation process, indications, and techniques for the aforementioned procedures are discussed in this article. A graduated approach to neck contouring based on the senior author's long-term experience is provided.

Nasal obstruction symptom evaluation (NOSE) score outcomes after septorhinoplasty.

OBJECTIVES/HYPOTHESIS: The time interval at which Nasal Obstruction Symptom Evaluation (NOSE) scores stabilize after functional septorhinoplasty has not been determined. Our goal was to characterize longitudinal trends of patient-reported outcomes of nasal obstruction using the NOSE survey instrument following functional septorhinoplasty. STUDY DESIGN: Prospective longitudinal cohort study. METHODS: Adult patients (≥18 years) with nasal obstruction who underwent functional septorhinoplasty by three different surgeons at a single academic, tertiary referral center were identified. NOSE scores were obtained preoperatively and prospectively during three postoperative intervals defined as early (1-3 months), middle (4-6 months), and late (≥10 months.) Longitudinal analysis included repeated measures analysis of variance and adjustments for multiple comparisons. RESULTS: A total of 49 patients met inclusion criteria. For the total cohort, mean NOSE scores significantly improved between preoperative and early postoperative evaluations (71.4, standard deviation [SD] ± 17.0 vs. 24.2, SD ± 19.5; P < .001) but did not significantly change between early and middle (20.6, SD ± 19.1; P = .543) or middle and late (23.1, SD ± 24.9; P > .999) time intervals. CONCLUSIONS: Patients with nasal obstruction who undergo functional septorhinoplasty can be expected to have significant improvement in self -reported nasal obstruction as early as 1 to 3 months postoperatively with a continued, durable, long-standing benefit lasting at least 10 months after surgery. Future studies can consider the 3-month time frame as a proxy for 1 year outcomes to help reduce survey burden. LEVEL OF EVIDENCE: 2c Laryngoscope, 129:841-846, 2019.

Technical Refinements and Outcomes of the Modified Anterior Septal Transplant.

IMPORTANCE: Severe anterior septal deviation and resultant nasal obstruction represent a difficult surgical task to correct. The goal of surgery is to straighten the anterior dorsal and caudal struts, while maintaining nasal tip and midvault support. This study presents a novel extracorporeal septoplasty technique to straighten the crooked anterior septum. OBJECTIVE: To describe the novel anterior septal transplant technique, which consists of complete resection of the caudal septum and reconstruction with extended spreader grafts and a columellar strut, without a separate caudal septal replacement graft. DESIGN, SETTING, AND PARTICIPANTS: This study was a retrospective case series at a tertiary academic referral center. Participants were sequential adult patients undergoing anterior septal transplant from January 1, 2008, to December 31, 2015. MAIN OUTCOMES AND MEASURES: Patient-reported nasal obstruction using Nasal Obstruction Symptom Evaluation (NOSE) scores and objective photographic analysis. Nasal tip deviation, projection, and rotation were measured. Preoperative and postoperative outcomes were compared. Complications are reported. RESULTS: Seventy-one patients (mean age, 46 years [age range, 16-72 years]; 48 [67.6%] female and 23 [32.4%] male) were included in the case series. Postoperative NOSE scores (mean [SD], 24.00 [24.58]) were significantly better than preoperative NOSE scores (mean [SD], 72.25 [14.55]) (P < .001). A separate cohort of 32 patients (mean age, 42 years [age range, 13-72 years]; 23 [71.9%] female and 9 [28.1%] male) had photographs available for analysis. In the frontal view, nasal deviation improved from a mean (SD) of 2.9 (2.0) degrees before surgery to a mean (SD) of 1.4 (1.7) degrees after surgery (P = .004). In the base view, the deviation was corrected from a mean (SD) of 4.9 (2.8) degrees to a mean (SD) of 1.7 (1.2) degrees (P < .001). Tip rotation and projection were unchanged after surgery. Four patients had mild dorsal irregularities after surgery. CONCLUSIONS AND RELEVANCE: Anterior septal transplant by the described technique is a safe and effective treatment option for severe anterior septal deviation. LEVEL OF EVIDENCE: 4.

Hemitransdomal versus Dome-Binding Suture.

The dome-binding suture (DBS) and hemitransdomal suture (HTS) are suture techniques used to narrow and define the nasal tip. The DBS can create a pinched, unnatural appearance, while the HTS puts the lateral crus in a more favorable orientation. This allows a natural contour between the nasal tip and alar lobule while maintaining alar margin support. Objective measurement of the rotational axis of the lateral crus between the DBS and the HTS has not been reported in the literature. To determine whether the DBS or HTS technique results in a more favorable rotational axis of the lateral crus as measured by the alar surface septal angle (ASSA). Open rhinoplasty with cephalic trim and placement of a DBS or HTS was performed in 6 cadaveric heads, for a total of 12 lower lateral cartilages at the VirtuOHSU Simulation and Surgical Training Center at Oregon Health and Science University (OHSU). ASSA measurements were taken at baseline and after placement of either a DBS or HTS. A total of 36 ASSA measurements were obtained. The median baseline ASSA prior to suture placement was 142 degrees (interquartile range [IQR]: 131.5-145 degrees), following DBS placement was 141 degrees (IQR: 33-150.5 degrees), and following HTS placement was 112 degrees (IQR: 108-117 degrees). There was no statistically significant difference of ASSA measurements between baseline and DBS placement (p = 0.24), but there was a statistically significant difference between baseline and HTS (p < 0.0001) and between DBS and HTS (p < 0.0001). The HTS technique creates a more favorable rotational axis of the lateral crus as compared with the DBS, as measured by the ASSA. This study provides objective data to support the use of the HTS for nasal tip contouring.

Objective Comparison of Nasal Tip Contours in the Basal View Between Dome Binding and Hemitransdomal Tip Suture Techniques in Rhinoplasty.

IMPORTANCE: The dome binding suture (DBS) used for nasal tip refinement creates the unwanted effects of nasal tip pinching owing to shadowing and loss of alar support. The hemitransdomal suture (HTS), however, refines the nasal tip while maintaining a natural contour between the nasal tip and the alar lobule. To our knowledge, no objective comparison between the DBS and HTS techniques has been described in the literature to date. OBJECTIVE: To determine whether the DBS or HTS technique results in an objectively satisfactory outcome in nasal tip contouring when assessed from the perspective of the basal view. DESIGN, SETTING, AND PARTICIPANTS: Postoperative basal view photographs of cosmetic rhinoplasty procedures performed on 112 Hispanic/Mestizo patients (85 [76%] women, and 27 [24%] men) in a facial plastic surgery practice in Chile, from May 2013 to May 2015 were reviewed. Only patients who underwent either DBS or HTS were included. Follow-up ranged from 6-24 months. Comparison of the nasal contour to the ideal tip-lobule line was performed and classified as satisfactory or unsatisfactory. MAIN OUTCOMES AND MEASURES: Satisfactory or unsatisfactory nasal tip contour in the basal view as analyzed by comparison with the ideal tip-lobule line. RESULTS: A total of 143 rhinoplasty procedures were performed over a 2-year period (May 2013-May 2015). A total of 112 patients met inclusion criteria. Of the 112 participants, mean (SD) age was 30 (9) years; 22 patients underwent DBS and 90 underwent HTS. Of the patients who underwent DBS, 5 of 22 (22.7%) had satisfactory contours. Of the patients who underwent HTS, 84 of 90 (93.3%) had satisfactory contours. CONCLUSIONS AND RELEVANCE: Comparison of nasal contour in the basal view with the ideal tip-lobule line demonstrates a statistically significant improvement in the rate of satisfactory outcomes using the HTS compared with the DBS technique. This study is the first, to our knowledge, to provide objective data to support the use of this technique when performing tip contouring in rhinoplasty. LEVEL OF EVIDENCE: 4.

Modifications to the Butterfly Graft Used to Treat Nasal Obstruction and Assessment of Visibility.

IMPORTANCE: Graft visibility in the supratip region has been the main criticism of the butterfly graft. Because of the graft location, slightly unfavorable supratip fullness can occur, resulting in patient dissatisfaction with the cosmetic result. OBJECTIVE: To describe the clinical outcomes and visibility of the butterfly graft after technique modifications. DESIGN, SETTING, AND PARTICIPANTS: In this retrospective review of adults who had undergone primary or secondary rhinoplasty with butterfly grafting from July 1, 2013, through July 31, 2014, at a tertiary care center at an academic institution, an operative log and photographs were reviewed in an effort to analyze outcomes of butterfly graft use in rhinoplasty. MAIN OUTCOMES AND MEASURES: Nasal obstruction and visibility of the butterfly graft. RESULTS: Thirty-four patients were included in the case series (mean [SD] age, 46 [19.4] years; 23 women and 11 men). The mean (SD) length of the graft was 3.4 (0.5) cm, and the mean (SD) width was 0.9 (0.2) cm. A significant decrease was found in the Nasal Obstruction Symptoms Evaluation score after surgery (mean [SD] preoperative score, 69 [17]; mean [SD] postoperative score, 23 [24]; P < .001). In regard to appearance, 25 patients (74%) rated their appearance as improved or no changes, 6 (18%) as minimally worse, and 1 (3%) as much worse. Fifty-nine observers participated in the masked survey for the study. When the graft was present, observers detected it 59.7% (282 of 472 answers) of the time. When the graft was not present, its presence was suspected 36.5% (237 of 649 answers) of the time. CONCLUSIONS AND RELEVANCE: The modified butterfly graft is a longer and thinner graft than the originally described butterfly graft. It is still an effective tool in the treatment of nasal obstruction with acceptable visibility. In most cases, it is difficult for health care professionals to identify the presence of the graft. LEVEL OF EVIDENCE: 4.

Facelift Controversies.

The primary purpose of the facelift is to restore the shape, volume, and contours of the youthful face. Facelift surgery has evolved over the years into multiple techniques to accomplish the same results. This article discusses the common controversies in facelift surgery and evaluates the best available evidence to guide surgical decision-making. In regard to the salient question of whether there is a "best" technique, the literature suggests that the options are generally equal in efficacy. This highlights the need for high-quality research with standardized preoperative assessment and evaluation of postoperative results to better assess outcomes.

The role of postoperative hematoma on free flap compromise.

OBJECTIVES/HYPOTHESIS: Hematomas may develop in the postoperative setting after free tissue transfer. When hematomas occur, they can exert pressure on surrounding tissues. Their effect on the vascular pedicle of a free flap is unknown. We describe our incidence of hematoma in free flaps and outcomes when the flap is compromised. STUDY DESIGN: Retrospective chart review of 1,883 free flaps performed between July 1998 and June 2014 at a tertiary referral center. METHODS: Patients with free flap compromise due to hematoma were identified. Etiology, demographic data, and outcomes were evaluated. RESULTS: Eighty-eight (4.7%) patients developed hematomas. Twenty (22.7%) of those had flap compromise. Twelve compromises (60%) showed evidence of pedicle thrombosis. The salvage rate was 75% versus 54% in 79 flaps with compromise from other causes (P = .12). Mean time to detection of the hematoma was 35.3 hours in salvaged flaps compared to 91.6 hours in unsalvageable flaps (P = .057). Time to operating room (OR) from detection was 2.8 hours in salvageable flaps compared to 12.4 hours in nonsalvageable flaps (P = .053). The salvage rate for flaps that returned to the OR in <5 hours was 93.3% compared to 20% (P = .0049) for those that did not. Vascular thrombosis reduced salvage rate to 58.3% from 100% (P = .002) when there was no thrombosis. CONCLUSIONS: In our series hematomas developed rarely. When they did, 23% went on to develop flap compromise. Prompt recognition and re-exploration allowed for a high salvage rate. Vessel thrombosis predicted inability to salvage the flap. LEVEL OF EVIDENCE: 4

Elevated intracranial pressure in patients with spontaneous cerebrospinal fluid otorrhea.

OBJECTIVES/HYPOTHESIS: To determine the prevalence of elevated intracranial hypertension in patients with spontaneous cerebrospinal fluid otorrhea (SCSFO). STUDY DESIGN: Case series with chart review at a tertiary care academic medical center following institutional review board approval. METHODS: A retrospective review was performed of patients undergoing operative repair of SCSFO between January 2007 and May 2012. RESULTS: Thirty-eight patients underwent operative repair of SCSFO. Of these, 22 underwent postoperative lumbar puncture with measurement of opening pressure. The opening pressure was elevated (> 20 cm/H2 0) in eight patients (36.4%). Preoperative magnetic resonance imaging was available for review by a neuroradiologist in 27 patients. Radiographic evidence of elevated intracranial pressure (ICP) was present in 48.1% of patients. CONCLUSION: Elevated ICP is common in patients with SCSFO. However, as only a minority of patients have elevated ICP, it is not the sole factor in the development of SCSFO.

Holmium laser endourethrotomy and litholapaxy of an occult prostatic utricle calculus.

Prostatic utricle (PU) stones are rare and the surgical treatment of such PU anomalies has proved challenging given their location adjacent to the posterior urethra and proximity to important fertility and continence structures. We report the case of a 58-year-old male with hypospadias, microphallus, and irritative lower urinary tract symptoms (LUTS) found to have a large PU stone. He underwent successful complete endoscopic removal of the stone via transurethral unroofing and holmium laser litholapaxy. We conclude that it is an effective alternative to other surgical techniques once size of the stone and the patient's individual anatomy are considered.