Patient complaints with primary versus revision rhinoplasty: analysis and practice implications.

BACKGROUND: Rhinoplasty patients often present with specific concerns and are frequently exacting in their demands and expectations of the surgical experience. OBJECTIVES: The authors assess the presenting complaints expressed during the rhinoplasty consultation process and compare the presentations of primary versus revision rhinoplasty patients. METHODS: A retrospective review of 400 consecutive rhinoplasty patients was performed. Demographic information and patient concerns regarding nasal appearance and function were recorded. Complaint frequencies (as well as rank order) were compared between primary and revision patients. Statistically significant associations were compared in more detail through logistic regression models. RESULTS: Primary rhinoplasty patients were significantly more likely to cite "too large" and "dorsal hump" as motivating concerns. Conversely, revision rhinoplasty patients were far more likely to cite concern regarding a "crooked nose," "tip asymmetry," "wide or large nostrils," "dorsal sloop," and "columellar show." Revision rhinoplasty patients also complained of issues such as "alar retraction," "pointy tip," and "nasal scarring," which were almost negligible in frequency in the primary rhinoplasty group. CONCLUSIONS: Patients presenting for primary rhinoplasty commonly seek a smaller, more refined nasal appearance. Patients with prior rhinoplasty operations are far more likely to raise concern regarding crookedness or asymmetries. By comparing the presentations of primary and revision rhinoplasty patients-and delineating the common indications for revision operations-novice rhinoplasty surgeons may be able to avoid certain pitfalls at the outset, thereby reducing their revision rates. The data may also assist surgeons in developing a more targeted approach to the consultation process in the revision setting.

Botulinum toxin type a for facial rejuvenation: treatment evolution and patient satisfaction.

BACKGROUND: Novel applications and injection sites for Botox are continually evolving. This study aimed to analyze Botox outcomes for various injection sites to differentiate treatments that consistently yield impressive results from those that produce less patient satisfaction. The change in the prevalence of Botox usage for each facial subsite over a 2-year period also was evaluated. METHODS: A retrospective chart review was performed for 60 patients who received Botox injections in a private cosmetic surgery practice. Patients were sampled from 24-month periods 2 years apart. The information collected included dosing and injection intervals and patterns. The outcomes analyzed included the prevalence of injections by subsite and the retention rate. RESULTS: The most frequently injected subsite was the glabellar region. The findings showed an impressive trend toward increasing numbers of patients receiving treatment of the superolateral orbicularis oculi (57-80%) and the depressor anguli oris (10-20%). CONCLUSIONS: Botox injection for facial rejuvenation has an excellent track record for patient satisfaction. The prevalence of treatment for the traditional injection sites was very stable over the measured period. The study findings support the use of Botox in certain more recently described regions such as the superolateral orbicularis oculi and the depressor anguli oris.

The Critical Role of Nutrition in Facial Plastic Surgery.

Nutrition plays a key role in optimizing healing following surgery. The increased catabolic state postoperatively, coupled with a propensity for patients to be suffering from marginal nutritional deficiencies at baseline preoperatively, necessitates that the surgeon be attuned to the need for optimal perioperative nutritional support. This ensures the smoothest recovery and best possible outcomes in facial plastic surgery. Key nutrients include vitamin A, vitamin C, zinc, bromelain, arnica montana, arginine, glutamine, hydrolyzed collagen, vitamin B complex, and protein. The ability for patients to obtain this optimal supplementation in a single product is the ideal solution for both surgeon and patient.

Long-term vertigo control in patients after intratympanic gentamicin instillation for Ménière's disease.

OBJECTIVES: To assess long-term vertigo symptom control in patients after intratympanic gentamicin instillation for incapacitating unilateral Ménière's disease. To analyze whether an absent caloric response, as analyzed using electronystagmography after gentamicin treatment, is a good predicator of long-term symptom control. Finally, to quantify the patient's perception of long-term posttreatment handicap. STUDY DESIGN: A retrospective study from a single institution. All patients underwent a similar fixed-dose and duration protocol of drug instillation. METHODS: Patients were enrolled in this study, and initial outcomes were assessed according to the American Academy of Otolaryngology-Head and Neck Surgery Committee on Hearing and Equilibrium Guidelines for Reporting Treatment Results in Ménière's Disease (1985 and 1995). In this study, only those patients treated more than 5 years previous were considered. One hundred thirty-two patients were eligible for inclusion. All patients underwent hearing testing and electronystagmography, including caloric testing before and after treatment. Posttreatment handicap and long-term vertigo control were assessed using the Dizziness Handicap Index questionnaire expanded with 5 questions specific for Ménière's disease. RESULTS: Analysis of results is based on the 63 patients who responded. Forty-four were vertigo-free, whereas 14 continued to experience some degree of vertigo. On average, they described 5 episodes in the immediate 24 months before the study. Of the 44 patients who were asymptomatic, 35 had an absent caloric response. Of the 14 patients who realized some vertigo, 12 had an absent caloric response posttreatment. Of the 63 responders, 44 filled in the Dizziness Handicap Index. Of the 19 who did not, 17 reported that they were vertigo-free. CONCLUSION: Our current protocol achieves complete or substantial vertigo control in most patients. A significant caloric response reduction has been a consequence in almost all patients, although an absent caloric response is not invariably a predictor of long-term symptom control. Finally, patient-perceived handicap in this long-term follow-up is consistent with that of others followed for a much shorter duration in that those who were vertigo-free volunteered a significantly lower score.

Quantifying fibrosis in head and neck cancer treatment: An overview.

BACKGROUND: Fibrosis is a common late complication of radiotherapy and/or surgical treatment for head and neck cancers. Fibrosis is difficult to quantify and formal methods of measure are not well recognized. The purpose of this review was to summarize the methods available to quantify neck fibrosis. METHODS: A PubMed search of articles was carried out using key words "neck" and "fibrosis." RESULTS: Many methods have been used to assess fibrosis, however, there is no preferred methodology. Specific to neck fibrosis, most studies have relied upon hand palpation rating scales. Indentation and suction techniques have been used to mechanically quantify neck fibrosis. There is scope to develop applications of ultrasound, dielectric, bioimpedance, and MRI techniques for use in the neck region. CONCLUSION: Quantitative assessment of neck fibrosis is sought after in order to compare treatment regimens and improve quality of life outcomes in patients with head and neck cancer.

Head and neck multidisciplinary team meetings: Effect on patient management.

BACKGROUND: The purpose of this study was for us to present our findings on the prospectively audited impact of head and neck multidisciplinary team meetings on patient management. METHODS: We collected clinical data, the pre-multidisciplinary team meeting treatment plan, the post-multidisciplinary team meeting treatment plans, and follow-up data from all patients discussed at a weekly multidisciplinary team meeting and we recorded the changes in management. RESULTS: One hundred seventy-two patients were discussed in 39 meetings. In 52 patients (30%), changes in management were documented of which 20 (67%) were major. Changes were statistically more likely when the referring physician was a medical or radiation oncologist, when the initial treatment plan did not include surgery, and when the histology was neither mucosal squamous cell cancer nor a skin malignancy. Compliance to the multidisciplinary team meeting treatment recommendation was 84% for all patients and 70% for patients with changes in their treatment recommendation. CONCLUSION: Head and neck multidisciplinary team meetings changed management in almost a third of the cases.

Alar retraction: etiology, treatment, and prevention.

IMPORTANCE: The effect of different rhinoplasty maneuvers on alar retraction remains to be elucidated. OBJECTIVE: To determine the etiology and treatment of alar retraction based on a series of specific rhinoplasty maneuvers. DESIGN: Retrospective review of a single surgeon's rhinoplasty digital photo database, examining preoperative alar retraction from January 1, 2002, to December 31, 2005, in 520 patients. Patients with more than 1 mm of alar retraction on preoperative photographs were identified. Postoperative photographs were examined to determine the effect of specific rhinoplasty maneuvers on the position of the alar margin; these maneuvers included cephalic trim, cephalic positioning of the lower lateral cartilage, composite grafts, alar rim grafts, alar batten grafts, and overlay of the lower lateral cartilage. SETTING: Tertiary care academic health center. PARTICIPANTS: Forty-five patients with alar retraction met inclusion criteria, resulting in 63 nasal halves with alar retraction. MAIN OUTCOMES AND MEASURES: Intraoperative findings, postoperative results. RESULTS: Forty-seven percent of the patients (n = 21) had prior surgery; 47% also had cephalically positioned lower lateral cartilages. Among patients with less than 4 mm of cartilage width at the outset, 46% of those who received supportive grafts achieved target correction vs only 7% for patients who did not undergo supportive cartilage grafting. In patients who underwent more than 4 mm of cephalic trim, those who received supportive grafts achieved 46% of target correction vs 11% among those who did not. Ninety-five percent of composite grafts, 69% of alar strut grafts, 47% of alar rim grafts, 43% of vertical lobule division, and 12% of alar batten grafts achieved their target correction values. CONCLUSIONS AND RELEVANCE: Alar retraction is a highly complex problem. It can be seen de novo and is associated with cephalically positioned lower lateral cartilages. Structurally supportive grafting-including composite grafts, alar strut grafts, alar rim grafts, vertical lobule division, and alar batten grafts-can improve alar retraction. LEVEL OF EVIDENCE: 4.

Detailed analysis of graft techniques for nasal reconstruction following Wegener granulomatosis.

BACKGROUND: Saddle nose deformity secondary to Wegener granulomatosis (WG) presents a significant challenge for the reconstructive surgeon. Various grafting options have been proposed, but achieving good outcomes can be difficult. METHODS: We conducted a retrospective analysis of 10 patients with WG who underwent reconstruction of saddle nose deformities by the senior author (A.G.) between 2005 and 2009. All patients were reconstructed using costal cartilage grafts. RESULTS: Primary surgery was functionally and cosmetically successful in 8 of 10 patients. Two patients experienced complications (graft resorption and columellar necrosis) requiring revision surgery; subsequently, they achieved good outcomes, with no further complications. There were no complications at the costal cartilage donor site. At the conclusion of the study, all patients were satisfied with their reconstructions. CONCLUSIONS: With a multidisciplinary team approach to pre- and postoperative patient management and careful surgical technique, reliable and excellent functional and cosmetic outcomes can be achieved with costal cartilage grafts.

The increasing prevalence of clindamycin resistance in Staphylococcus aureus isolates in children with head and neck abscesses.

OBJECTIVE: To retrospectively review trends in clindamycin resistance among Staphylococcus aureus head and neck abscesses between January 2000 and June 2008. METHODS: Between January 2000 and June 2008, inpatient and out-patient S aureus isolates were reviewed for antibiotic susceptibility. In particular, cultures from 153 abscesses in the head and neck region were assessed for clindamycin and methicillin resistance patterns. RESULTS: Annual clindamycin resistance rates for all S aureus isolates, and specifically for S aureus head and neck abscesses, revealed concerning levels of clindamycin and methicillin resistance. After 2002, the mean clindamycin resistance rate in head and neck abscesses was approximately 27%. The number of new cases of methicillin-resistant S aureus per year increased from four cases in 2000 to 44 cases in 2007. CONCLUSION: Antibiotic resistance should be considered following failed empirical therapy of head and neck abscesses with clindamycin.

From fragments to the whole: a comparison between cochlear implant users and normal-hearing listeners in music perception and enjoyment.

BACKGROUND: Cochlear implants (CIs) allow many profoundly deaf individuals to regain speech understanding. However, the ability to understand speech does not necessarily guarantee music enjoyment. Enabling a CI user to recover the ability to perceive and enjoy the complexity of music remains a challenge determined by many factors. OBJECTIVES: (1) To construct a novel, attention-based, diagnostic software tool (Music EAR) for the assessment of music enjoyment and perception and (2) to compare the results among three listener groups. METHODS: Thirty-six subjects completed the Music EAR assessment tool: 12 normal-hearing musicians (NHMs), 12 normal-hearing nonmusicians (NHnMs), and 12 CI listeners. Subjects were required to (1) rate enjoyment of musical excerpts at three complexity levels; (2) differentiate five instrumental timbres; (3) recognize pitch pattern variation; and (4) identify target musical patterns embedded holistically in a melody. RESULTS: Enjoyment scores for CI users were comparable to those for NHMs and superior to those for NHnMs and revealed that implantees enjoyed classical music most. CI users performed significantly poorer in all categories of music perception compared to normal-hearing listeners. Overall CI user scores were lowest in those tasks requiring increased attention. Two high-performing subjects matched or outperformed NHnMs in pitch and timbre perception tasks. CONCLUSIONS: The Music EAR assessment tool provides a unique approach to the measurement of music perception and enjoyment in CI users. Together with auditory training evidence, the results provide considerable hope for further recovery of music appreciation through methodical rehabilitation.

Novel outpatient approach to lower lip reanimation using a palmaris longus tendon sling.

OBJECTIVE: To report a new approach to lower lip reanimation, which can be performed in the outpatient clinic setting. STUDY DESIGN: Cross-sectional study. SETTING: Tertiary and quaternary care academic hospital, Toronto. SUBJECTS AND METHODS: An evaluation of nine patients with marginal mandibular nerve injury, who underwent harvest of the palmaris longus tendon and static suspension of the lower lip, was performed in the outpatient setting. Outcome measures included subjective self-evaluation of the functional and aesthetic results using the Lip Reanimation Outcomes Questionnaire and postoperative photographic grading of symmetry at rest and during three smile poses. Medical records were reviewed for demographics and complications. RESULTS: Seventy-eight percent of patients reported overall improvements in smiling, oral competence, and speech articulation following tendon transfer. Photographic grading by the judging panel found satisfactory smile symmetry postprocedure. CONCLUSIONS: The palmaris longus tendon sling procedure provides an effective, additional option for reanimation of the paralyzed lower lip.

Cephalic positioning of the lateral crura: implications for nasal tip-plasty.

OBJECTIVE: To apply a mathematical model to determine the relative effectiveness of various tip-plasty maneuvers while the lateral crura are in cephalic position compared with orthotopic position. METHODS: A Matlab (MathWorks, Natick, Massachusetts) computer program, called the Tip-Plasty Simulator, was developed to model the medial and lateral crura of the tripod concept in order to estimate the change in projection, rotation, and nasal length yielded by changes in crural length. The following rhinoplasty techniques were modeled in the software program: columellar strut graft/tongue-in-groove, lateral crural steal, lateral crural overlay, medial/intermediate crural overlay, hinge release with alar strut graft, and lateral crural repositioning. RESULTS: Using the Tip-Plasty Simulator, the directionality of the change in projection, rotation, and nasal length produced by the various tip-plasty maneuvers, as shown by our mathematical model, is largely the same as that expected and observed clinically. Notably, cephalically positioned lateral crura affected the results of the rhinoplasty maneuvers studied. CONCLUSIONS: By demonstrating a difference in the magnitude of change resulting from various rhinoplasty maneuvers, the results of this study enhance the ability of the rhinoplasty surgeon to predict the effects of various tip-plasty maneuvers, given the variable range in alar cartilage orientation that he or she is likely to encounter.

Arguing the ethics of facial transplantation.

While 7 face transplants have been performed around the world, to date, there remains debate regarding the validity of this procedure. We submit that performing a facial transplant-in the appropriately selected patient-is technically defensible and ethically sound. By outlining the technical and ethical boundaries of the debate, responding to the key arguments against the procedure, and describing its motivations and potential benefits, we state our justification of facial transplantation.

Development and preliminary validation of the lip reanimation outcomes questionnaire.

OBJECTIVE: Lip paralysis is associated with eating, speaking, and appearance impairments. The lip reanimation outcome questionnaire is designed to assess these functional impairments after lip reanimation. STUDY DESIGN: Cross-sectional validation study. SETTING: Tertiary care academic center. SUBJECTS AND METHODS: Patients who underwent lip reanimation and control subjects. A disease-specific instrument was created by systematic literature review and expert opinion. The 15-item patient completed subscale was administered to 20 lip reanimation patients. Photographs of 19 patients and three control subjects were taken in four poses and rated by six raters (2 surgeons, 2 residents, and 2 novices) by the use of a external rater subscale, and reliability was determined by the use of intraclass correlation coefficients (ICC). Content and construct validity were assessed. RESULTS: Internal consistency (ICC range 0.813-0.915 for each domain), test-retest reliability (ICC range 0.616-0.981 for each item) for the patient completed subscale, and interrater (ICC = 0.852) and interlevel reliability (ICC = 0.929) for the external rater subscale were substantial to excellent. The content validity index was 0.87. Construct validity was demonstrated by poorer scores in patients with transected nerves versus intact nerves for appearance (P = 0.04) and oral competence (P = 0.011). Photographs of control patients had lower asymmetry scores (P < 0.001), and the instrument detected greater asymmetry in patients with progressively more exaggerated smile (P < 0.001). CONCLUSION: The lip reanimation outcome questionnaire has promising reliability and validity in this preliminary study, but additional psychometric testing with larger samples is required before the survey can be recommended for clinical use.

The Sunnybrook experience: review of deep vein thrombosis and pulmonary embolism in otolaryngology.

OBJECTIVE: To determine the incidence of venous thromboembolism in otolaryngology patients at a Canadian tertiary care hospital. METHODS: This was a retrospective review of all otolaryngology operations at Sunnybrook Health Sciences Centre between January 1, 1989, and December 31, 2004. All patients who developed a deep vein thrombosis (DVT), a pulmonary embolism (PE), or both as in-patient postoperative complications were identified. RESULTS: Fourteen patients were identified in our study. Ten patients (71.4%) developed a DVT, five patients developed a PE (35.7%), and one patient (7.1%) developed both. The overall incidence of DVT and PE was 0.1% and 0.05%, respectively. The highest incidence occurred in patients undergoing major head and neck surgery. Patients who developed a PE had a statistically significantly longer hospital stay than patients who developed a DVT (p < .05). There were two deaths in the five patients who developed a PE. CONCLUSION: Venous thromboembolism is an infrequent but potentially devastating cause of morbidity and mortality in the otolaryngology patient population.

A multiphase disaster training exercise for emergency medicine residents: opportunity knocks.

BACKGROUND: Disaster planning is a core curriculum requirement for emergency medicine (EM) residency programs. Few comprehensive training opportunities in disaster planning incorporating the appropriate competencies have been reported. OBJECTIVES: To design, pilot, and evaluate a combination interactive Web-based disaster planning curriculum and real-time multidisciplinary full-scale disaster exercise. METHODS: Residents were assigned to groups led by a faculty mentor. Each group used an Internet-based platform to review the literature pertaining to their component of a disaster plan. The groups then used the platform to redesign an existing institutional disaster plan. Finally, they implemented their disaster plan for 80 simulated casualties resulting from a police, fire department, and emergency medical services multiple-casualty rescue exercise. All health professions then participated in a joint debriefing session. All aspects of the program were supervised by specialty EM faculty, and the exercise was evaluated using a five-point Likert scale with specific anchored descriptors. RESULTS: Sixteen residents and 17 faculty members participated in the exercise. Trained volunteers and high-fidelity simulations represented casualties varying in age from 6 months to 65 years, and in severity from ambulatory to moribund. Residents found the exercise enjoyable (4.9/5), relevant (4.6/5), and educational (4.8/5). CONCLUSIONS: Emergency medicine residency programs can benefit from participating in high-quality medical disaster exercises coordinated with local disaster response agencies. Residents report high satisfaction and learning from realistic simulations of disasters, and from collaboration with other community services.

Infection control for the otolaryngologist in the era of severe acute respiratory syndrome.

OBJECTIVES: Severe acute respiratory syndrome (SARS) has affected more than 8400 persons in 28 countries, with more than 800 deaths. The current SARS outbreak, especially in North American health care centers, has motivated a re-evaluation of infection control practices in the hospital and clinic environment. These considerations are particularly important to otolaryngology, in which examination and diagnostic procedures often bring the otolaryngologist in close--if not direct--contact with the patient's upper airway, mucosa, and secretions. The otolaryngologist is at increased risk of contracting a respiratory pathogen. METHOD: A joint effort by the Department of Otolaryngology at Queen's University and the Infection Control Services of the Hotel Dieu Hospital, Kingston, Ontario, was carried out to develop specific infection control guidelines for the otolaryngologists using strategies from the Centers for Disease Control and Prevention in the United States and the Laboratory Center for Disease Control, Health Canada. RESULTS: A set of specific recommendations was developed for the otolaryngologists to augment current infection control, including diligent use of personal protective equipment with every patient encounter. Moreover, this equipment should be removed according to specific protocol, to avoid contamination of self, others, and surroundings. Finally, a number of practice modifications are being adopted as prudent precautionary measures. CONCLUSION: It is essential to adhere to these recommendations in order to protect the health and safety of clinicians, colleagues, and patients.