Laryngeal lipotransfer: review of a 14-year experience.

OBJECTIVE: To determine the efficacy of lipotransfer for treatment of various vocal fold (VF) pathologies. STUDY TYPE: Retrospective review. METHODS: We reviewed retrospectively the indications for and techniques of laryngeal lipotransfer and its effect on glottic closure and mucosal wave. One hundred four patients treated with lipotransfer between 1997 and 2010 were screened for inclusion in this study. Fifteen patients were excluded. Strobovideolaryngoscopic examinations for the 89 included subjects were reviewed to determine the change in glottic closure and mucosal wave. The degree of improvement, if any, was graded as mild, moderate, or substantial. The population was divided into the following four groups for analysis: (1) single lateral lipoinjection, (2) combination of lipoinjection and thyroplasty, (3) multiple lipoinjections with or without other injection medialization procedures, and (4) lipoimplantation for treatment of VF scar. RESULTS: Lipotransfer was used alone and as an adjunct procedure to treat glottic insufficiency (GI) secondary to VF motion abnormality or vibratory margin pathology. Augmentation was accomplished either by lateral injection or by medial implantation through an access tunnel. Most patients showed a statistically significant improvement in glottic closure because of lipoinjection and in mucosal wave because of lipoimplantation. Few minor and no serious complications occurred. CONCLUSION: Laryngeal lipotransfer is safe and effective for treatment of GI and VF scar.

Midface lifting: current standards.

The most significant factor contributing to the overall change in the appearance of an individual's facial features over time is age. This process of gradual structural weakening of the face begins during the third decade and continues to worsen during the remainder of an individual's lifetime. Here, we discuss how the approach to midface rejuvenation has evolved over time owing to our increased understanding of the aging process. In addition, we discuss specific techniques that we use that have helped us achieve more natural and lasting results.

Thread-lift for facial rejuvenation: assessment of long-term results.

OBJECTIVE: To evaluate the long-term success of the thread-lift procedure for facial rejuvenation. METHODS: Thirty-three patients underwent a thread-lift procedure alone or in combination with other facial rejuvenation procedures to the brow, midface, jowl, and neck. Ten patients underwent thread-lifts only, and 23 had thread-lifts with other procedures. Ten additional patients having had non-thread-lift rejuvenation procedures, including lipotransfer, chemical peels, and rhytidectomies, were randomly designated as controls. The mean follow-up period was 21 months (range, 12-31 months). Photodocumentation was obtained at each visit. Long-term aesthetic results were evaluated by 4 independent, blinded, and board-certified facial plastic surgeons. Each result was graded on a scale of 0 to 3, with 0 indicating no change; 1, minimal improvement; 2, moderate improvement; and 3, considerable improvement. The population was divided into 3 groups for comparison. Two-tailed t test (P = .05) was used for statistical analysis of aesthetic outcomes. RESULTS: Although aesthetic improvement was noted in all groups at 1 month, measurable results persisted to the end of the study for all but the group that underwent the thread-lift procedure only. Aesthetic improvement scores of the non-thread-lift control group were better than the group that underwent thread-lift only. Similarly, when the thread-lift was combined with other procedures, scores were better than when thread-lift was used alone. Statistical significance was demonstrated in both of these comparisons (P < .01). CONCLUSIONS: The thread-lift provides only limited short-term improvement that may be largely attributed to postprocedural edema and inflammation. Our results objectively demonstrate the poor long-term sustainability of the thread-lift procedure. Given these findings, as well as the measurable risk of adverse events and patient discomfort, we cannot justify further use of this procedure for facial rejuvenation.

Pulsed-dye laser for treating ecchymoses after facial cosmetic procedures.

OBJECTIVE: To assess the safety and efficacy of a 595-nm pulsed-dye laser in the treatment of ecchymoses after facial cosmetic procedures. METHODS: Twenty consecutive patients with ecchymoses after facial cosmetic procedures underwent treatment with the pulsed-dye laser. A 10-mm spot size was used, with pulse duration of 6 milliseconds, fluence of 6 J/cm(2), and cryogen spray for 30 milliseconds with a 20-millisecond delay. The ecchymotic area was outlined; the lateral half was treated on postoperative day 5 or 6 and the medial half on postoperative day 7 to 10. Clinical photographs were obtained before and after each treatment. Three blinded independent observers evaluated the photographs and graded the ecchymoses on a scale of 0 to 3, with 3 indicating severe ecchymosis. RESULTS: The most common procedures associated with ecchymoses are cervicofacial rhytidectomy, facial lipocontouring, thread lift, and minimally invasive subperiosteal midface-lift. Pulsed-dye laser treatment resulted in a 63% mean improvement in ecchymosis scores within 48 to 72 hours. The only adverse effects were mild edema and discomfort. Maximal efficacy of the laser treatment was observed when it was performed between 5 and 10 days postoperatively. Patient satisfaction was universally high. CONCLUSIONS: Treatment with the pulsed-dye laser is safe and effective for expeditious resolution of postoperative ecchymoses after facial cosmetic procedures. It has the potential for wider application in treating postoperative ecchymoses on other areas of the body and after trauma.

Evolution of midface rejuvenation.

Age is the most significant factor contributing to the overall change in the appearance of an individual's facial features over time. This gradual process of structural weakening of the face begins during the third decade and continues to worsen during the remainder of an individual's lifetime. In this article we discuss how the approach to midface rejuvenation has evolved over time owing to our increased understanding of the aging process. In addition, we discuss specific techniques that we employ that have helped us achieve more natural and lasting results.

Fat transfer in conjunction with facial rejuvenation procedures.

Age is the most significant factor contributing to the overall change in the appearance of an individual's facial features over time. The purpose of any cosmetic procedure is to reverse the aging process that has occurred in an individual. During the last 5 years, volume restoration through lipotransfer combined with lifting procedures has been instrumental in elevating these procedures to a new level of excellence in comprehensive facial rejuvenation. The authors believe that restoration of facial volume can be achieved safely, precisely and reliably by lipotransfer. In this article they describe their techniques of lipotransfer.

The decision process in choosing costal cartilage for use in revision rhinoplasty.

The aims of rhinoplasty reconstruction include maintaining or augmenting long-term tip projection, restoring rigid dorsal stability, and restoring optimum respiratory function. The methods set forth to obtain these objectives are inherently based on the intrinsic nasal principles at the time of the rhinoplasty. Because of the excellent and consistent results autologous costal cartilage grafts provide when faced with problems such as the traumatic saddle deformity, defects after neoplastic resection, congenital nasal deformities, severe tip weakness or underprojection, rhinoplasty in the ethnic patient, and revision rhinoplasty, they are an invaluable resource to the rhinoplasty surgeon. Once the surgeon becomes comfortable and proficient at harvesting this graft, it inevitably will become the graft of choice when substantial amounts of cartilage are required.

Current concepts in the postoperative care of the rhinoplasty patient.

This is a systematic review of the available literature and our own personal experience regarding the optimal management of the rhinoplasty patient. The routine utilization of nasal splinting, casting and perioperative antibiotics is supported. The management of a number of common early complications is also discussed. Meticulous technique based on sound structural principles and coupled with preoperative planning and attention to wound care will result in a favorable outcome in most individuals undergoing rhinoplasty.

Objective assessment of the accuracy of computer-simulated imaging in rhinoplasty.

OBJECTIVE: The objective of the study was to evaluate the accuracy by which computer-simulated rhinoplasty images reflect surgical results in 6-month postoperative photographs. METHODS: We performed a retrospective, objective evaluation of 5 features of the facial profile in the computer-simulated images and in the 6-month postoperative photographs of 36 rhinoplasty patients. Data recorded for the nasolabial angle, nasofrontal angle, columella tip angle, columella/infratip lobule ratio, and an established method of assessing tip projection were subjected to statistical analysis by 2-tailed t test and analysis of variance testing. RESULTS: Simulated and actual measurements of columella tip angle were found to be significantly different (P = .021). The set of measurements taken from computer-simulated images at the nasolabial angle (P = .301), nasofrontal angle (P = .471), columellar/infratip lobule ratio (P = .402), and tip projection ratio (P = .547) were not statistically different from the respective measurements recorded from the 6-month follow-up images. CONCLUSIONS: No significant difference was found between the measurements recorded from computer-simulated images and those recorded from 6-month postoperative photographs in 4 of the 5 features of the facial profile studied. The accuracy and predictive value of computer-simulated images is demonstrated and quantified for the first time.

Free tissue transfer reconstruction of the head and neck at a Veterans Affairs hospital.

BACKGROUND: The Veterans Affairs (VA) population is considered to have generally poorer health than its non-VA counterpart. METHODS: We reviewed our experience with 55 consecutive patients undergoing free tissue transfers for head and neck reconstruction at the Dallas VA Hospital between July 2000 and September 2006, with 6 months' follow-up. RESULTS: The overall success rate was 93% (51 of 55 flaps). Factors affecting flap survival were fasciocutaneous flap versus others (p = .01) and minimal versus excessive intraoperative crystalloid administration (p = .03). Nine different flaps were used. Major and minor complications occurred in 33% (n = 18) and 31% (n = 17) patients, respectively. Average intensive care unit and hospital stays were 7.4 and 16.0 days, respectively. CONCLUSIONS: Free flaps for head and neck reconstructions in the VA population can be performed with excellent success rates. Complication rates and hospital days in this population are similar to those of the non-VA populations. Flap selection and administration of minimal intraoperative fluids are important.

Tragal cartilage grafts in rhinoplasty: a viable alternative in the graft-depleted patient.

OBJECTIVE: To describe a simple technique for harvesting tragal cartilage and describe its use in rhinoplasty. STUDY DESIGN: Retrospective review. SUBJECTS AND METHODS: Rhinoplasties performed between January 2005 and June 2007 in which tragal cartilage grafts were utilized by the senior author (CSC) were reviewed to assess type of graft, preservation of tragal contour, and donor-site morbidity. RESULTS: Tragal cartilage grafts were used in three primary and three secondary rhinoplasty patients. Postoperative follow-up ranged from six months to 12 months. Tragal cartilage was used as five alar contour grafts, one lateral crural onlay graft, one dorsal onlay graft, and one infratip lobule graft. Tragal cartilage was used to close the septal perforation of one patient. Tragal contour was preserved in all patients, and there were no complications noted with this procedure. CONCLUSION: The tragus provides a simple, convenient alternative source of cartilage for rhinoplasty in graft-depleted patients.

Comparison of closed reduction alone versus primary open repair of acute nasoseptal fractures.

OBJECTIVE: Nasoseptal injuries have traditionally been treated via closed reduction. Historically, the high incidence of postreduction deformities has led some surgeons to consider alternative approaches to obtain superior results. Here we compare simple closed reduction versus primary open repair of the nasoseptal fracture. STUDY DESIGN: This was a prospective study of 40 consecutive patients treated with simple closed reduction of their combined nasal bone and septal fracture versus 40 patients treated with closed reduction of their nasal bone fracture and open treatment of the septum. Group outcomes were then compared. RESULTS: In the closed reduction group, 60% had significant postoperative septal deviation, whereas only 12.5% suffered from residual septal deformity in the open group. This resulted in a statistically significant reduction (p < .01) of patients requiring a second operation to formally address the septum. CONCLUSION: By addressing the septum through an open approach, a statistically significant reduction in the number of patients requiring revision rhinoplasty was achieved.

External auditory canal hemangioma: case report.

A patient with a hemangioma completely within the external auditory canal is reported.

Restorative rhinoplasty in the aging patient.

OBJECTIVE: The objective of this study is to review our favorable experience in performing rhinoplasty in aging patients. METHODS: All patients aged 65 years or greater who underwent rhinoplasty, either esthetic or functional, by the senior author (Y.D.) from August 1997 to July 2005 with a minimum follow up of 1 year were retrospectively reviewed. RESULTS: A total of 51 patients met the inclusion criteria and had complete records available for review. The average age was 69.5 years (range, 65-82 years) with 24 female and 27 male patients. All but two patients underwent open rhinoplasty. Eighteen procedures represented secondary rhinoplasties. Seven patients required auricular cartilage grafts, and 11 patients required costal cartilage grafts. One costal cartilage graft was aborted as a result of excessive calcification. All patients underwent columellar strut placement, 92% underwent internal valve grafts, and 80.4% underwent grafting of the external nasal valves. Nasal osteotomies were performed in only 23.5% of patients, all with the percutaneous technique. Revision surgery was necessary in only three (5.8%) patients, all of whom required grafting of the external valve (not performed primarily). In each of these cases, no significant external valve collapse was noted preoperatively. Premaxillary augmentation with diced or crushed cartilage grafts was performed in 81.8% (n = 18) of patients with an edentulous maxillary arch. CONCLUSIONS: Aging patients present unique technical challenges in rhinoplasty that warrant a comprehensive approach to restore internal and external valve competency and tip support. Consideration of prophylactic external valve grafts in addition to the routine use of internal valve grafts and columellar struts may help decrease the need for revision surgery in this patient population. Reasonable functional and esthetic outcomes can be expected in the aging patient.

Integrity of craniofacial plating systems after multiple sterilization procedures.

PURPOSE: To determine the effect of multiple autoclave sterilization cycles on the integrity of titanium plates and screws used in craniofacial reconstruction. MATERIALS AND METHODS: Torque to fracture was evaluated for 36 titanium 6AL-4V (Ti 6/4) screws divided evenly into 3 groups and tested as machined (control), after 10 cycles of autoclaving or after 50 cycles of autoclaving. Sterilization was carried out by autoclaving for 15 minutes followed by 8 minutes of drying at 270 degrees to 272 degrees F. The maximum torque attained before fracture was recorded. Rotating beam specimens were crafted from single lots of Ti 6/4, commercially pure titanium grade 4 (CP4) and commercially pure titanium grade 2 (CP2), and then subjected to testing in a standard rotating beam device as machined (control), after 10 cycles of autoclaving or after 50 cycles of autoclaving. The cycles required to fracture the specimen at a given applied stress were recorded for each material and for the number of autoclavings carried out before testing. RESULTS: Although there was a trend toward decreased strength and increased ability to fracture with increased number of autoclave cycles, this did not reach statistical significance. Torque to fracture testing for 7 mm Ti 6/4 screws showed no significant difference in the maximum torque reached before fracture between controls, those screws that had been autoclaved 10 times (P < .500 +/- 5.70) and those that had been autoclaved 50 times (P < .398 +/- 4.08). Rotating beam specimens of Ti 6/4, CP4, and CP2 showed no significant difference in cycles to fracture regardless of the number of sterilization cycles to which the material was subjected. CONCLUSIONS: Repeated cycles of autoclaving had no significant effect on the integrity of titanium plates and screws routinely used in craniofacial surgery.

Rethinking nasal osteotomies: an anatomic approach.

OBJECTIVES: To review our experience with our anatomic (medial, transverse, and lateral) nasal osteotomy technique for correcting the asymmetric bony nasal vault in esthetic and functional rhinoplasty. METHODS: All patients undergoing anatomic nasal osteotomy technique by the senior author (y.d.) from August 1997 to August 2005 with a minimum follow-up of 6 months were reviewed. Preoperative and postoperative photographs and clinical examination were analyzed to determine restoration of a symmetric bony nasal vault configuration. RESULTS: A total of 322 patients met the inclusion criteria. Percent of patients who had favorable results with restoration of a symmetric bony nasal vault configuration was 98.1%. Six (1.9%) patients required revision surgery at the level of the nasal bones with repeat osteotomies or dorsal rasping. All six of these patients had favorable outcomes after revision surgery. CONCLUSIONS: The anatomic nasal osteotomy technique represents an effective, simple, and logical approach for correcting asymmetric bony nasal vault.

Nodular hidradenocarcinoma over the parotid gland: a pathologic presentation.

BACKGROUND: Nodular hidradenocarcinoma (NHAC), an eccrine carcinoma, has been reported in the dermatology and pathology literature, but few references have been made in the otolaryngology literature even though the head and neck is a common site of occurrence. METHODS: A case report of a 37-year-old Hispanic man with a right-sided neck mass diagnosed preoperatively as a parotid mass by imaging and fine-needle aspiration is presented. After presentation at our multidisciplinary tumor board, excision of the mass was undertaken. RESULTS: Final pathology revealed a NHAC, which is presented in our report. CONCLUSION: NHAC is an aggressive malignant tumor that is often misdiagnosed preoperatively and that must be treated with aggressive multimodality therapy for increased survival.

T-cell lymphoma of the upper eyelid: a case report and review of the literature.

We present the case report of a 95-year-old white female with a cutaneous T-cell lymphoma (CTCL) of the upper eyelid. Due to her comorbid medical problems, multidisciplinary tumor board recommendation for treatment was surgical excision. She underwent excision with frontalis muscle flap and contralateral eyelid full thickness skin graft reconstruction. The patient has been symptom free for 3.5 years. A literature review of cutaneous CTCL isolated to the eyelid is included.

Liposarcoma of the tongue: case report and review of the literature.

Liposarcoma is the most common soft-tissue malignancy in adults, but the appearance of a liposarcoma in the head and neck region is distinctly unusual. Intraoral liposarcomas represent a particularly interesting subset of this tumor in that (1) they are exceedingly rare and (2) affected patients tend to have a better prognosis than do patients with a similar lesion located elsewhere in the head and neck. An understanding of the histologic subtypes and corresponding clinical behavior of liposarcomas will assist physicians in appropriately managing these patients. Most of these tumors can be effectively treated with conservative surgery. We report the rare case of a well-differentiated liposarcoma arising in the tongue of a 55-year-old man. We also discuss the typical pathologic findings in these malignancies and review the diagnosis, associated controversies, management, and prognosis.

Sialoblastoma: a rare submandibular gland neoplasm.

A sialoblastoma is a rare congenital epithelial tumor that arises in a major salivary gland. To our knowledge, only 24 cases of sialoblastoma have been previously reported in the English-language literature. We report a new case, that of a 15-month-old boy who presented with a submandibular mass. Surgical excision of the mass was undertaken. Intraoperatively, the mass appeared to be adjacent to the submandibular gland, but it had not invaded it. The mass was excised, and the submandibular gland was left in place. Pathology identified the tumor as a sialoblastoma. However, pathology also revealed that residual tumor was present at the surgical margin. The patient was returned to the operating room for excision of the left submandibular gland and the level I lymph nodes. Following revision surgery, the surgical margins were negative. The patient remained disease-free at the 1-year follow-up. Despite the need for revision surgery, this case provides support for the idea that surgery alone is sufficient for curative treatment.