Gender-Affirmation Hair Transplantation Techniques.

Hair restoration can play an important role for transgender patients seeking gender-affirmation procedures. In our clinic, we have seen an increase in transgender patients seeking hair restoration. The most common hair restoration procedures performed in our clinic for the transgender patient are hairline lowering procedures, facial hair restoration procedures including eyebrow and beard transplantation, and body hair transplantation.

Facial Hair Transplantation for Transgender Patients: A Literature Review and Guidelines for Practice.

BACKGROUND: Facial hair transplantation has become an increasingly popular modality to create a more masculine appearance for transmasculine patients. OBJECTIVES: This aim of this study was to review the current literature regarding facial hair transplantation and provide recommendations and best practices for transgender patients. METHODS: A comprehensive literature search of the PubMed, MEDLINE, and Embase databases was conducted for studies published through April 2020 for publications discussing facial hair transplant in transmasculine patients, in addition to the nontransgender population. Data extracted include patient demographics, techniques, outcomes, complications, and patient satisfaction. RESULTS: We identified 2 articles discussing facial hair transplantation in transmasculine patients. Due to the paucity of publications describing facial hair transplantation in transmasculine patients, data regarding facial hair transplant from the cisgender population were utilized to augment our review and recommendations. CONCLUSIONS: Facial hair transplant is a safe and effective means of promoting a masculine appearance for transgender patients. Nevertheless, facial hair transplantation should be deferred until at least 1 year after the initiation of testosterone therapy to allow surgeons to more accurately identify regions that would benefit the most from transplantation. Additionally, providers should engage patients in discussions about any plans to undergo facial masculinization surgery because this can alter the position of transplanted hairs. Currently, follicular unit extraction from the occipital scalp is the preferred technique, with use of the temporal scalp if additional grafts are needed. Patients should be advised that a secondary grafting procedure may be needed a year after initial transplant to achieve desired density.

Beard Hair Transplantation.

In the field of hair restoration, there has been a significant increase in demand with patients for facial hair transplantation procedures. Modern techniques in hair transplantation allow for facial hair transplantation and for the attainment of natural-appearing results. Facial hair transplantation is a subspecialty within hair restoration with many gratifying benefits for the patients as well as for the hair restoration surgeon. Adapting these advanced techniques into a hair restoration practice allows a surgeon to offer their patients these procedures and provides an expanded artistic element to a hair restoration surgeon's practice.

What's New in Facial Hair Transplantation?: Effective Techniques for Beard and Eyebrow Transplantation.

Natural results in facial hair restoration are made possible with modern refinements in hair transplantation. There has been a large increase in the demand for facial hair restoration in men and women. Women mostly seek to thicken and restore eyebrow density, whereas men seek to have a fuller beard. This article describes the techniques refined in facial hair transplantation.

Hair Transplantation Techniques for the Transgender Patient.

Hair transplantation can play a complementary role in the spectrum of gender transformation procedures sought by transgender patients undergoing gender transformation surgery. The authors' clinic has seen an increase in the demand for hair restoration in transgender patients. Hairline lowering, eyebrow transplantation, and pubic hair transplantation can play roles for male-to-female transgender patients whereas beard hair transplantation and body hair transplantation can play integral roles for female-to-male patients seeking gender transformation surgery. This article delineates an experience in the role hair restoration plays for transgender patients and outlines a surgical approach for these hair restoration procedures.

Introducing Hair Transplantation into a Facial Plastic Surgery Practice.

Hair restoration can be an integral addition to the facial plastic surgery practice. As surgeons dedicated to reconstructive and aesthetic surgery of the head and neck, hair restoration is a natural complement to a facial plastic surgeon's practice. This article presents the keys to adding and starting hair restoration to one's facial plastic surgery practice.

Ethnic considerations in hair restoration surgery.

Patients of different ethnicities have specific characteristics that are essential for hair transplant surgeons to understand so that aesthetic results can be achieved. In this article, the approaches of follicular unit extraction and follicular unit grafting or strip hair transplants for pattern hair loss are reviewed, along with the procedures of eyebrow and beard transplants and surgical hairline advancement/forehead reduction surgeries, within various ethnic groups.

Lower lateral cartilage repositioning: objective analysis using 3-dimensional imaging.

IMPORTANCE: In recent years, with the advent of 3-dimensional (3D) imaging techniques, it has become possible to objectively measure rhinoplasty results. However, few studies have used 3D imaging software to assess postoperative rhinoplasty results of the nasal tip. OBJECTIVE: To analyze nasal tip volumes of patients with bulbous tips and measure postoperative nasal tip volume changes in patients who have undergone lower lateral cartilage (LLC) repositioning. DESIGN, SETTING, AND PARTICIPANTS: A prospective study of patients with a preoperative diagnosis of bulbous nasal tip and cephalically oriented LLC as measured intraoperatively (with angles less than 30 degrees from the midline) who underwent rhinoplasty by a single surgeon and preoperative and postoperative 3dMD imaging at a university hospital. INTERVENTIONS: Rhinoplasty with LLC repositioning and preoperative and postoperative 3dMD system imaging. We also used 3dMD Vultus software for the analysis of nasal tip volume changes. MAIN OUTCOMES AND MEASURES: Changes in nasal tip volume and LLC angle. RESULTS: Thirty-one patients met the inclusion criteria (25 women and 6 men; mean age, 33 years). Among these, there were 16 primary and 15 revision cases with a follow-up range of 1 to 19 months. Statistical tests included a paired t test on volume and angle changes as well as correlative and exploratory analyses to gain further insight into the analysis population over time. The change in the LLC angle after repositioning was found to be statistically significant. The mean decrease in volume on the right was 0.0254 mL, and the mean decrease on the left was 0.0249 mL. The mean total volume change was a decrease of 0.0503 mL. An exploratory analysis suggested that subjects with longer follow-up displayed a greater reduction in volume. Using 5 months as a cutoff, we found that the subgroup with longer follow-up displayed a mean total bilateral volume change of -0.07 mL compared with -0.03 mL in the subgroup with shorter follow-up. CONCLUSIONS AND RELEVANCE: We found that LLC repositioning when used to address bulbous nasal tips and cephalically oriented LLCs leads to significant increase (preoperative to postoperative) in the angle of the LLC (to a more caudal orientation). We also found an overall trend of decreasing nasal tip volume throughout follow-up. Although not statistically significant, the overall decrease in volume is clinically meaningful when paired with favorable positioning of the LLC. Exploratory analyses suggest that treatment effect is consistent across sexes and that greater decrease in total volume might be found with longer follow-up. LEVEL OF EVIDENCE: 4.

Audioprofiles and antioxidant enzyme genotypes in presbycusis.

OBJECTIVES/HYPOTHESIS: Audiometric patterns have been shown to indirectly provide information regarding the pathophysiology of presbycusis and be useful in the phenotyping of hereditary deafness. STUDY DESIGN AND METHODS: Hospital-based cohort study of adults with presbycusis, comparing the association of audiometric patterns and polymorphisms of antioxidant enzymes that have been linked to presbycusis: GSTT1, GSTM1 and NAT2. All subjects underwent a clinical evaluation and completed questionnaires regarding ototoxicity and noise exposure. Pure-tone threshold audiometry was obtained and subjects' audiograms were classified into specific patterns. DNA was extracted from blood and the polymorphisms of GSTT1, GSTM1, and the NAT2 variants (NAT2* 5A; NAT2* 6A,B) were analyzed by PCR. RESULTS: The audiometric patterns that were more prevalent in our cohort were "High-Frequency Steeply Sloping" or HFSS (33%), "High-Frequency Gently Sloping" or HFGS (31%), and "Flat" (27%), with other patterns being rare. We did not find a statistical significant effect of gender, age, hearing level, and ear side on the audiometric pattern. Subjects with mutant alleles for GSTT1 were more likely to have a HFSS audiogram than subjects with the wild type genotype. CONCLUSIONS: In this cohort, there was a similar prevalence for the three audiometric configurations HFSS, HFGS, and Flat, with other configurations being rare. Subjects with mutant alleles for GSTT1 were more likely to have a HFSS audiogram than subjects with the wild type genotype, suggesting that the basal turn of the cochlea is susceptible to GSTT1 regulated oxidative stress. However, further studies of audioprofiles with larger sample sizes may be needed to establish phenotype-genotype correlations in presbycusis.

Revision of the surgically overshortened nose.

The short nose deformity may arise from multiple etiologies including iatrogenic following rhinoplasty. The weakening of the cartilaginous support and the contractile forces imposed by the healing soft tissue envelope may result in the short nose deformity. The focus of this article is to present the senior author's approach to this nasal deformity.

Correction of the retracted alar base.

Alar base retraction is a common yet difficult problem faced by the rhinoplasty surgeon. It may be caused by weakened, overresected lateral crura, vestibular lining deficiencies, or congenital alar malpositioning. Methods of correction include soft tissue manipulation, auricular composite grafting, and cartilage grafting. We present the senior author's graded approach to alar retraction using auricular composite grafting, alar rim grafting, and lateral crural strut graft placement with caudal lateral crural repositioning.

Antioxidant enzymes, presbycusis, and ethnic variability.

OBJECTIVE: A proposed mechanism for presbycusis is a significant increase in oxidative stress in the cochlea. The enzymes glutathione S-transferase (GST) and N-acetyltransferase (NAT) are two classes of antioxidant enzymes active in the cochlea. In this work, we sought to investigate the association of different polymorphisms of GSTM1, GSTT1, and NAT2 and presbycusis and analyze whether ethnicity has an effect in the genotype-phenotype associations. STUDY DESIGN: Case-control study of 134 DNA samples. SETTING: University-based tertiary care center. SUBJECTS AND METHODS: Clinical, audiometric, and DNA testing of 55 adults with presbycusis and 79 control patients with normal hearing. RESULTS: The GSTM1 null genotype was present in 77 percent of white Hispanics and 51 percent of white non-Hispanics (Fisher's exact test, 2-tail, P = 0.0262). The GSTT1 null genotype was present in 34 percent of control patients and in 60 percent of white presbycusis subjects (P = 0.0067, odds ratio [OR] = 2.843, 95% confidence interval [95% CI] = 1.379-5.860). The GSTM1 null genotype was more frequent in presbycusis subjects, i.e., 48 percent of control patients and 69 percent of white subjects carried this deletion (P = 0.0198, OR = 2.43, 95% CI = 1.163-5.067). The NAT2*6A mutant genotype was more frequent among subjects with presbycusis (60%) than in control patients (34%; P = 0.0086, OR = 2.88, 95% CI = 1.355-6.141). CONCLUSION: We showed an increased risk of presbycusis among white subjects carrying the GSTM1 and the GSTT1 null genotype and the NAT*6A mutant allele. Subjects with the GSTT1 null genotypes are almost three times more likely to develop presbycusis than those with the wild type. The GSTM1 null genotype was more prevalent in white Hispanics than in white non-Hispanics, but the GSTT1 and NAT2 polymorphisms were equally represented in the two groups.

Single-stage total endoscopic resection of a plexiform neurofibroma of the maxillary sinus in a child with type 1 neurofibromatosis.

Plexiform neurofibromas are peripheral nerve sheath tumors associated with neurofibromatosis type 1. The maxillary sinus is an extremely rare location of the plexiform neurofibroma and only two adult cases have been previously reported. We report the first case of plexiform neurofibroma of the maxillary sinus occurring in a child with neurofibromatosis type 1. This unusual location presents a management challenge considering the infiltrative nature and the potential malignant degeneration of this type of tumor. MRI is highly valuable to diagnose and plan the surgical approach of the plexiform neurofibroma of the maxillary sinus. Due to the location of the tumor and the patient's age, conservative surgery is highly recommended. We performed an endoscopic total en-bloc resection of the tumor with no recurrence after nine months of follow-up.

Malleus handle: determinant of success in ossiculoplasty.

OBJECTIVE: The purpose of this study is to identify prognostic factors affecting outcome in ossicular chain reconstruction (OCR). STUDY DESIGN AND SETTING: This study is a retrospective case series of electronic database at an academic institution. MATERIALS AND METHODS: We reviewed 209 cases of chronic supportive otitis media performed from January 2000 through December 2007 and collected demographic, clinical, audiologic, and outcome information. Univariate analyses of group differences in terms of postoperative air-bone gap (ABG) changes were evaluated by analysis of variance. Multiple regression analyses were used to examine the relationship between postoperative ABG and the independent variables. RESULTS: There were 105 cases of OCR the met the inclusion criteria (44 primary and 61 revision tympanoplasties), with an average follow-up of 19 months. The diagnoses were chronic suppurative otitis media without cholesteatoma in 36 cases and cholesteatoma in 69 cases. The mean preoperative ABG was 34 +/- 15 dB, and the mean postoperative ABG was 20 +/- 14 dB (P < 0.001). Of the independent variables analyzed, the type of procedure (ie, OCR performed during second-look tympanoplasty vs canal wall up vs canal wall down), preoperative ABG, and status of malleus handle were predictive of the success of OCR. CONCLUSIONS: Favorable prognostic factors in OCR include smaller preoperative ABG and the presence of an intact malleus handle.

Management of the neck in Merkel cell carcinoma of the head and neck: University of Miami experience.

BACKGROUND: We reviewed management of the cervical lymph nodes in patients with Merkel cell carcinoma (MCC) of the head and neck. METHODS: Records of 15 patients with MCC of the head and neck area were evaluated for the type of surgical treatment, including wide local excision, sentinel lymph node (SLN) biopsy, neck dissection, postoperative radiation therapy, and clinical outcomes. RESULTS: Median follow-up was 24 months (range, 5-84 months). Ten patients were treated with wide local excision plus SLN, with or without neck dissection. Five patients were treated with wide local excision only or wide local excision plus neck dissection. One patient died of distant metastases (7%), and 14 patients remain alive (93%), over a mean follow-up of 24 months. CONCLUSION: Wide excision and SLN biopsy for primary MCC with N0 neck is feasible for early-stage, previously untreated lesions. SLN biopsy was helpful in determining the nodal levels to be dissected or irradiated.

Sentinel node biopsy for squamous cell carcinoma of the head and neck.

The clinical utility of sentinel node biopsy for melanoma has led multiple investigators to apply this approach to other cutaneous malignancies as well as to early cancers of the upper aerodigestive tract. Data are most extensive for oral cancer. A multi-institutional pathologic validation trial for selected oral cancers provided negative predictive values of 96%. Subsequent trials should document clinical follow-up. This technique may ultimately play a wider role in the management of mucosal cancers.

Sentinel node biopsy in oral squamous cell carcinoma.

The clinical utility of sentinel node biopsy techniques for cutaneous melanoma has led multiple investigators to study the applicability of this approach to other solid tumors, including cancers of the upper aerodigestive tract, and especially the oral cavity. Preliminary data indicate that it may be useful for early oral cancers, with the exception of floor of mouth tumors, where technical challenges related to the proximity of the lymphatic basin remain a problem. A multi-institutional pathologic validation trial, involving sentinel node biopsy followed by completion selective neck dissection, has completed accrual. While central step sectioning and immunohistochemistry remain to be completed and analyzed, routine pathologic techniques provided negative predictive values of 96% for oral cancer excluding floor of mouth lesions. Subsequent trials need to involve clinical follow-up and evaluation for recurrence in the neck. We believe this technique may ultimately play a role in the management of early oral cancer.

Surgical outcomes and safety of transnasal endoscopic resection for anterior skull tumors.

OBJECTIVE: To report the surgical outcomes and safety of transnasal endoscopic resection (TER) for anterior skull base (ASB) tumors. STUDY DESIGN AND SETTING: A retrospective chart review to identify patients undergoing TER for ASB tumors at a tertiary care medical center between September 1997 and June 2006. RESULTS: Nineteen patients underwent TER for ASB tumors without open craniotomy. There were 17 malignant and two benign lesions. Olfactory neuroblastoma was the most common pathology, occurring in 53 percent of patients. One patient recurred locally, resulting in an overall local control rate of 94.7 percent for all neoplasms and 94.1 percent for malignant disease. It should be noted that the tumor control rate may be premature given the small sample size and limited follow-up. Overall, there were 16 complications, but only two of these, an orbital hematoma and a frontal lobe abscess, were considered major complications directly attributable to surgery. CONCLUSIONS: TER for ASB tumors appears to be safe in properly selected patients. In light of the small sample size and limited follow-up, the major complication rate directly attributable to surgery was 11 percent, and the overall local control rate was 95 percent. A larger multi-institutional series with longer follow-up is warranted.

Mucoepidermoid carcinoma of the external auditory canal (EAC).

We present the third case of mucoepidermoid carcinoma of the external auditory canal (EAC) in the English literature, and discuss the management of this lesion. The patient underwent a wide local resection, superficial parotidectomy, and selective neck dissection. Although intraoperative frozen section margins were negative, permanent histopathologic examination demonstrated tumor in the medial margin, and the tumor was upgraded to a high-grade mucoepidermoid carcinoma. The patient returned to the operating room for a wider local resection, and EAC reconstruction with a temporoparietal pedicled flap and split thickness skin graft. All margins were negative on final histopathologic examination. Radiotherapy was deferred in the event of a recurrence. The patient is currently disease-free 29 months after the final excision. Most authors advocate an aggressive surgical approach, which includes a form of a temporal bone resection, for the treatment of EAC carcinoma. Although this may be warranted in cases of squamous cell carcinoma, mucoepidermoid carcinoma of the EAC may be amenable to a conservative step-by-step approach for local control with less postoperative morbidity. Given the difficulty in detecting mucoepidermoid carcinoma in surgical margins by frozen section analysis, patients should be informed of the possibility of further surgery (re-resection) when a conservative approach is used.