Sonic Rhinoplasty: Review and Updated Uses.

The ultrasonic bone aspirator (UBA) allows for precision and provides ease of use in multiple steps of cosmetic and functional rhinoplasties. Its use has previously been described; however, since the publication of many studies the UBA has been improved and its applications for rhinoplasty have been modified and expanded. Both bony and cartilaginous modifications to the nose can be aided with the use of the UBA. From our experience, patient results have subjectively been found to be more acceptable, if not better, than with the use of other rhinoplasty instruments.

Functional outcomes of temporomandibular joint reconstruction with vascularized tissue.

OBJECTIVE: To determine how current temporomandibular joint (TMJ) reconstruction methods affect functional outcomes. METHODS: Retrospective review from January 2006 to July 2017 at a single tertiary care center. All patients who underwent mandibulectomy with subsequent reconstruction with vascularized free tissue were included in the study. Condylar segments were reconstructed with vascularized free tissue flap in conjunction with autologous tissue or allograft in the joint space. Preoperative, 3 month, 1 year, and 2 year postoperative records were assessed for trismus, need for tube feeds, and Functional Oral Intake Scale (FOIS). RESULTS: Joint space was reconstructed with autologous tissue (n = 10), allograft (n = 15) or both (n = 9). At three months, FOIS scores significantly decreased from 5.4 preoperatively to 4.8 post operatively (P = .024) and need for tube feeds significantly increased from 15.8% preoperatively to 35.1% (P ≤0.027). Trismus significantly decreased from 63.2% to 27% (P = .006). At one-year, there were no significant changes in functional status compared to pre-operative state. Patients who had previous RT had significantly worse FOIS scores preoperatively (p = .002), at three months (p < .001), one year (p < .001), and two years (p = .008). There was no significant difference in postoperative functional status of patients based on the method of TMJ reconstruction. CONCLUSION: Reconstruction of the TMJ with vascularized free tissue is a viable option and yields acceptable long-term outcomes. While functional status may improve or worsen in the immediate postoperative period, long term results mirror preoperative function. Preoperative trismus will likely improve. LEVEL OF EVIDENCE: Level 3; Retrospective Comparative Study.

Safety of Concurrent Endoscopic Browlift and Blepharoplasty.

The objective of the study was to evaluate the clinical safety of endoscopic browlift alone or in combination with blepharoplasty as a treatment for the aging face. This is a retrospective comparative study from 2007 to 2016 at a single tertiary care center. A consecutive sample of patients undergoing surgery for aging of the upper face was included in the study. Surgeries deemed to be inclusive were endoscopic browlift, upper blepharoplasty, and lower blepharoplasty. In total, 46 patients undergoing endoscopic browlift with concurrent blepharoplasty were included. Patient demographics, past medical history, follow-up, and any complications related to their surgery were studied up to 90 months postoperatively. Combination of endoscopic browlift with blepharoplasty did not increase the risk of complications on univariate analysis (p = 0.735). There were no differences in complication rates on univariate analysis of patients with a smoking history, diabetes, or autoimmune disease (p = 0.111, p = 0.575, p > 0.999, respectively). Furthermore, there was no difference between groups in complication rates, smoking history, diabetes, or autoimmune disease (p = 0.735, p = 0.181, p = 0.310, p = 0.218, respectively). Smoking had an insignificant increased risk of complication as compared with nonsmokers on multivariate analysis (odds ratio [OR] = 4.526; p = 0.073). Increasing age was slightly associated with fewer complications on multivariate analysis in this patient cohort (OR = 0.939; p = 0.048). By combining endoscopic browlift with a concomitant blepharoplasty, the goals of the patient and the standards of the surgeon can be effectively and safely achieved. Analysis of complications from 46 combined cases at our institution asserts that this is a safe operation. Smoking status was the only observed predictor for postoperative complications. This was a level of evidence 3, retrospective comparative study.

Modified Selective Neurectomy: A New Paradigm in the Management of Facial Palsy with Synkinesis.

All patients with postparalytic facial paralysis are at risk of developing synkinesis due to aberrant nerve regeneration. Synkinesis can result in smile dysfunction, tension, and eyelid aperture narrowing due to overactive and uncoordinated muscle activity. When the synkinesis causes an asymmetric smile, there are several treatment modalities including neurotoxin, neuromuscular retraining, and surgery. Modified selective neurectomy of the facial nerve is a treatment option that potentially can improve the smile mechanism by reducing the activity of counterproductive facial muscles while preserving the natural neural pathway.

Modified Selective Neurectomy with Symmetrical Facial Repositioning.

Importance: There are no surgical techniques described to treat synkinesis and concurrent facial asymmetry. We describe our innovative and effective approach and technique. Objective: To improve the spontaneous smile mechanism as well as facial symmetry in patients with synkinesis not only during the smile mechanism but also at rest. Design: Surgical pearls-surgical technique description. Setting: Private practice. Participants: Patients who underwent the operation.

Thermistor-controlled subdermal skin tightening for the aging face: Clinical outcomes and efficacy.

OBJECTIVE: Patients are increasingly seeking nonsurgical treatment for the aging face. The purpose of this study was to evaluate the clinical efficacy and outcomes of a thermistor-controlled subdermal skin tightening device (ThermiTight) as a treatment modality for the aging face. METHODS: A retrospective analysis of 12 patients was completed on patients having undergone ThermiTight for midface and neck skin tightening. Only five patients had a greater than 1 year follow-up and were included in the study. Two blinded reviewers assessed photographs taken pre-procedure and 1 year post-procedure using a standardized skin laxity scale. Patient charts were reviewed to assess for complications up to 12 months post-treatment. RESULTS: The mean age of included patients was 57 years, and all five patients were female. One (20%) patient treated with ThermiTight was also treated with injectables (Botox, Juvéderm) simultaneously. One (20%) patient developed a wound complication. One (20%) patient complained of incisional site pain at her first postoperative visit that subsequently self-resolved. On a five-point scale to assess facial skin laxity, there was an average improved score of 0.85 per patient (P < .001) at one year post-procedure. Two blinded reviewers correctly categorized photographs as either being "baseline" or "post-procedure" 100% of the time. There was no significant difference between the skin laxity scores by the blinded reviewers (P = .05). CONCLUSION: ThermiTight is a new technology used for nonsurgical treatment of the aging face. Long-term outcomes demonstrate the safety and efficacy of the procedure. Complications are rare, but possible, in the use of ThermiTight. Level of Evidence: 3.

Thyroid Cancer Metabolism: A Review.

Metabolic dysregulation within the tumor microenvironment (TME) is critical to the process of tumorigenesis in various cancer types. Thyrocyte metabolism in papillary and anaplastic thyroid cancer, however, remains poorly characterized, and studies analyzing the role of multicompartment metabolism in thyrocyte oncogenesis are sparse. We present a review of the current knowledge on cellular metabolism in non-cancerous and cancerous thyroid tissues, focusing on the monocarboxylate transporters MCT1 and MCT4, and on a transporter of the outer mitochondrial membrane TOMM20. Understanding the metabolic phenotype of tumor cells and associated stromal cells in thyroid cancer can have profound implications on the use of biomarker staining in detecting subclinical cancer, imaging as it relates to expression of various transport proteins, and therapeutic interventions that manipulate this dysregulated tumor metabolism to halt tumorigenesis and eradicate the cancer. Future studies are required to confirm the prognostic significance of these biomarkers and their correlation with existing staging schemas such as the AGES, AMES, ATA and MACIS scoring systems.

Early outcome and predictors of early outcome in patients treated surgically for central cord syndrome.

OBJECT: The purpose of this study was to characterize changes in American Spinal Injury Association motor score (AMS) in the 1st week after traumatic central cord syndrome (CCS) to identify predictors of improved early outcome in patients treated with early versus delayed surgical intervention. METHODS: All patients presenting to a regional spinal cord injury center between January 2004 and June 2009 were queried for those with a diagnosis of CCS. Patients treated conservatively were excluded. A prospectively maintained spinal cord injury database was used to track AMS throughout each patient's hospitalization. Hospital records provided information regarding demographics, presenting neurological examination, imaging findings, comorbidities, timing and nature of surgical procedures, and length of stay (LOS) in the hospital and intensive care unit (ICU). Patients were separated into those who underwent early surgery, within 1 day of presentation (early group), and those who underwent surgery on a delayed basis (delayed group). Differences between groups were analyzed using the Student t-test and chi-square test. Predictors of outcome were identified using correlation analysis and multiple linear regression. RESULTS: Of 426 patients in the database, 80 (18.8%) were diagnosed as having CCS, and 68 of them ultimately underwent surgical decompression. Nineteen (28%) of 68 patients underwent surgery within 1 day of presentation (early group) while the remaining 49 patients (72%) underwent surgery on a delayed basis (delayed group). The mean age in the early group was significantly younger than that of the delayed group (52 vs 59 years, p = 0.049). Other characteristics were similar between groups including sex, proportion of patients with cord edema on MRI (44% early vs 55% delayed, p = 0.47), and proportion of patients with cervical fracture (26% early vs 28% delayed, p = 0.98). Patients in the early group presented with an AMS of 62.5 versus 70.0 for the delayed group (p = 0.36). No difference in the change in AMS was seen at 7 days between the early group (-2.9 points) and the delayed group (-4.2 points) (p = 0.34). Additionally, the number of patients who had early improvement was similar between the early and delayed groups (50% vs. 48%, respectively, p = 0.94). Neither time in the ICU (3.4 vs. 3.4 days, p = 0.84) nor the overall LOS (10.5 vs 12.5 days, p = 0.59) was different in the early versus delayed groups, respectively. Correlation analysis and multiple linear regression demonstrated early surgery was not associated with change in AMS or AMS at Day 7. Age was identified as the only significant predictor of change in AMS and had a negative effect (coefficient = -0.34, p = 0.025). CONCLUSIONS: Early treatment of patients with CCS remains controversial. Although some long-term neurological recovery is expected in patients with a CCS, surgeons and patients should not expect early neurological improvement with or without early operative intervention.