Microtia Reconstruction.

Microtia reconstruction is a challenging endeavor that has seen significant technique evolution. It is important to educate patients and their families to determine the best hearing rehabilitation and ear reconstructive options. Microtia is often associated with aural atresia, hearing loss, and craniofacial syndromes. Optimal care is provided by multiple disciplines, including a reconstructive surgeon, an otologic surgeon, an audiologist, and a craniofacial pediatrician. Microtia management includes observation, prosthetic ear, autologous cartilage reconstruction, or alloplastic implant placement. Hearing management options are observation, bone conduction sound processor, or atresiaplasty with and without hearing aids. Appropriate counseling should be done to manage expectations.

Complication Rates in Delayed Reconstruction of the Head and Neck After Mohs Micrographic Surgery.

IMPORTANCE: Same-day Mohs reconstructive surgery is not always possible owing to patient factors, scheduling, and complexity of defect, but there is hesitancy in delaying closure of such defects. OBJECTIVE: To describe the frequency of and predictors of complications in patients undergoing delayed facial reconstruction after Mohs micrographic surgery (MMS). DESIGN, SETTING, AND PARTICIPANTS: This was a retrospective, multi-institutional cohort study from February 1, 1989, to December 31, 2012. Data were pooled from 2 institutions: University of Washington Medical Center and Virginia Mason Medical Center. All patients who underwent MMS for facial carcinomas with delayed (non-same-day) reconstruction were included. We excluded those with incomplete medical records and no follow-up. The analysis was performed from June 2014 to March 2016. MAIN OUTCOMES AND MEASURES: Our main outcome measure was postoperative complication, classified as immediate (≤24 hours after surgery) or delayed (>24 hours after surgery). RESULTS: A total of 415 cases in 342 patients were identified. Reconstruction occurred from 1 to 11 days after excision, with 95.4% of repairs occurring within 2 days of MMS. The overall complication rate was 8.2%. The total delayed complication rate was 7.7% (32 of 415 cases). The overall infection rate was 2.4%. In terms of patient characteristics, reconstruction delayed more than 2 days, bone or cartilage exposure, and large defects were associated with complications. In terms of defect location and reconstruction type, complications were associated with composite defects (those that included >1 facial subunit) and use of interpolated flaps with cartilage grafting. We used these variables in a multivariable logistic regression model and found that composite location, use of interpolated flap with cartilage grafting, and reconstruction delayed more than 2 days were associated with postoperative complications. Among the variables in the model, composite location of defects, interpolated flap with cartilage grafting, and delayed reconstruction greater than 2 days were found to have a statistically significant association with a complication (OR, 3.48 [95% CI, 1.16-10.56]; OR, 4.93 [95% CI, 1.44-16.95]; OR, 4.26 [95% CI, 1.24-14.60], respectively). CONCLUSIONS AND RELEVANCE: To our knowledge, this is the largest study to report complication rates in delayed reconstruction of MMS defects in the head and neck, noting a rate that is similar to what has been reported in the literature. We noted a statistically significant increased risk of complications when reconstruction is performed for composite defects, if an interpolated flap with cartilage is performed, and if reconstruction is performed after more than 2 days. LEVEL OF EVIDENCE: 3.

Autologous Costochondral Microtia Reconstruction.

Reconstruction with autologous costochondral cartilage is one of the mainstays of surgical management of congenital microtia. We review the literature, present our current technique for microtia reconstruction with autologous costochondral graft, and discuss the evolution of our technique over the past 20 years. We aim to minimize donor site morbidity and create the most durable and natural appearing ear possible using a stacked framework to augment the antihelical fold and antitragal-tragal complex. Assessment of outcomes is challenging due to the paucity of available objective measures with which to evaluate aesthetic outcomes. Various instruments are used to assess outcomes, but none is universally accepted as the standard. The challenges we continue to face are humbling, but ongoing work on tissue engineering, application of 3D models, and use of validated questionnaires can help us get closer to achieving a maximal aesthetic outcome.

Facial flap complications.

Knowledge of fundamental concepts can help decrease the chance of complications in plastic surgery. Local flap reconstruction for facial defects has many pitfalls. This article describes common complications in local flap reconstruction of the face and describes strategies that prevent problems.

Intraoperative suction-assisted evaluation of the nasal valve in rhinoplasty.

OBJECTIVE: To introduce and analyze suction-assisted analysis of nasal valve strength in functional septorhinoplasty. This is a novel method for helping the surgeon analyze the integrity of a patient's airway during surgery. METHODS: In this prospective study, 20 patients who underwent functional septorhinoplasty were analyzed. Negative pressure using suction tubing was placed at the nasal sill, and measurements of the amount of maximal depression of the nasal valve were performed in the operating room immediately before incision and immediately after closure of the incisions. RESULTS: All 20 patients had an immediate decrease in the deviation of the weakest point of the valve, with a mean change of 2.14 mm. The change on both sides was statistically significant (paired t test, P < .001). This novel method helped the surgeons decide which grafts provided the most immediate structural benefit. CONCLUSIONS: Structure-based septorhinoplasty can immediately improve the strength of the nasal valve. Suction-assisted analysis of the nasal valve can be a useful "real-time" tool for determining which maneuvers improve the strength of the nasal valve.

Tissue conservation using circular defect with dog-ear deformities excision technique.

OBJECTIVES: Compare circular defect with dog-ear deformities excision (CDDE) technique to 3:1 fusiform excision technique when removing facial lesions to analyze which technique provides superior wound closure. METHODS: Identical 1-cm circular skin defects were created on bilateral cheek, forehead, and parietal scalp on three fresh cadavers. Similarly, using four fresh cadavers, identical 2-cm circular skin defects were created on bilateral cheek, forehead, and scalp. In both the 1-cm and 2-cm circular defects (n = 19), a 3:1 fusiform excision and closure was performed on one side of the cadaver head for control. On the opposite side, CDDE excision technique was performed. The following measurements were recorded: circumferential incision length after tissue excision, average of wound widening widths after an approximation suture was placed at the halfway point, and the final incision length after primary closure. Final incision length upon closure was divided by the original defect size to obtain a final incision length to defect ratio. A paired t-test was performed on all variables for analysis. RESULTS: When using the CDDE excision technique, there were statistically significant decreases in circumference, average wound widening, final incision length in both 1-cm and 2-cm circular defects (P < .01). The final incision length upon closure to defect ratio in CDDE excision was approximately 2.5:1, whereas 3:1 fusiform excision resulted in the final incision length to defect ratio of approximately 3.5:1. CONCLUSIONS: When compared to fusiform excision technique, CDDE excision technique appears to minimize tissue excision, decrease wound widening and the final incision length.

Pediatric nasal injuries and management.

Although serious trauma injuries are uncommon in the pediatric population, nasal injuries are a more common problem. In this population, many physicians are uncomfortable managing these injuries. The evaluation and treatment of nasal trauma differ considerably in children compared with adult nasal fractures. Poor patient cooperation during the physical exam coupled with significant anatomic differences can present the nasal surgeon with a difficult diagnostic dilemma. The surgical management of pediatric nasoseptal injuries is not without controversy, as disturbing the nasal growth centers can have significant effect on future nasal and midfacial development. This article reviews the diagnostic and therapeutic challenges presented by these injuries for children and provides recommendations to successfully manage nasal injuries in this population.

Preserving structural integrity of the alar cartilage in aesthetic rhinoplasty using a cephalic turn-in flap.

Resection of the alar cartilage has long been a mainstay of aesthetic rhinoplasty. One drawback of this technique is the destabilization of the ala/lateral nasal wall complex. Herein we describe the cephalic turn-in flap, a technique for reinforcement of the alar cartilage after removal of its cephalic portion.

Treatment of the posttraumatic and postrhinoplasty crooked nose.

Successful management of the persistently crooked nose after a previous trauma or surgery is best achieved through careful analysis of the problem and clear communication with the patient regarding his or her goals of revision surgery. To address the nose in a systematic fashion, the surgeon should divide the crooked nose into horizontal thirds with appropriate management directed toward the structural abnormality in each third. A review of the treatment of the postrhinoplasty and posttraumatic crooked nose is presented with an emphasis on re-establishing structural support and improving appearance while preserving or creating a functional nasal airway.

Childhood nasal trauma with previous rhinoplasty and persistent deformity.

This article reviews a case of a young woman with a history of childhood trauma resulting in nasal deformity along with chronic nasal obstruction. Discussion for correction of these problems includes septoplasty, tip shield graft, cap graft, alar batten graft, an crushed cartilage graft. Pre- and postoperative photographs are provided with corresponding preoperative diagrams and schematics.

Nasal trauma, two prior rhinoplasties.

This article reviews a case of a woman presenting with nasal deformity following childhood nasal trauma and two subsequent rhinoplasties. Discussion for correction of these problems includes tip dome graft, shield and cap graft, superior and inferior cartilage onlay grafts, spreader graft, columellar strut, and lateral osteotomies. Pre- and postoperative photographs are provided with corresponding preoperative diagrams and schematics.

Wound healing and physiology of skin flaps.

This article focuses on the dynamic process of wound healing, including the three phases of wound healing and the different types of wound healing. The physiology of skin flaps is described, with a focus on the vascular supply and biomechanics of skin flaps. The article reviews older and newer concepts of skin flap design.

A modern approach to nasal osteotomies.

A thorough understanding of the anatomy of the nose is paramount in rhinoplasty. Correction of deformities of the nasal vault presents a challenge to the facial plastic surgeon. Suboptimal aesthetic results may occur when either inadequate or excessive mobilization of the nasal bony-cartilaginous framework is performed. Furthermore, postoperative complications such as collapse of the nasal airway may occur. A number of techniques are available to appropriately mobilize and reposition the bony nasal vault. In this article, we will review pertinent anatomy, technical considerations and clinical perspectives on mobilization of the nasal bones.