Aesthetics and Rejuvenation of the Temple.

The temples are an often overlooked, but important element of facial rejuvenation. The anatomy of the temple should be understood prior to any intervention in this location. Multimodal treatment to re-establish youthful convexity, proper hairline position, and correct actinic damage is recommended for optimal results. Important anatomy, aesthetic goals, and methods of rejuvenation are reviewed in detail.

Essential Grafting in the Traumatized Nose.

Corrective rhinoplasty after significant nasal trauma is a much different entity than elective rhinoplasty or rhinoplasty after minor trauma. The more significant the degree of trauma the patient is subjected to, the greater the deleterious effects will be on the soft tissue and skeletal elements of the patient's nose. With this disruption of the anatomic integrity and dynamics of the nose, the patient experiences deformity and dysfunction of the nose. This may be minor and transient or may be lifelong and disabling. In this article, the authors review some of the more long-term aspects of nasal trauma and provide the reader with insights to the use of cartilage grafting techniques that are useful in the management of posttraumatic nasal deformity and airway obstruction.

Embryonal rhabdomyosarcoma of the auricle in a child.

We describe the diagnosis and management of a child with embryonal rhabdomyosarcoma of the auricle and emphasize both clinical and radiological findings of this rare condition. A nine-year-old boy presented for evaluation of a slowly enlarging left auricle mass. The mass was nodular, violaceous, semi-translucent, and hyperpigmented with an overlying pseudo-vesicular plaque. The mass appeared to involve the left cavum concha, root of the helix, superior aspect of the external auditory canal, the tragus and extend to a deep preauricular component. MR imaging documented a lobulated soft tissue mass surrounding the external auditory canal with superficial involvement of the pinna. Incisional biopsy of the mass suggested embryonal rhabdomyosarcoma. The tumor was completely removed by total auriculectomy and lateral temporal bone resection. The final diagnosis was embryonal rhabdomyosarcoma. Although rare, otolaryngologists, pediatricians, and radiologists need to consider rhabdomyosarcoma in the differential diagnosis of auricle mass in children.

Life in an Academic Practice Versus a Solo Private Practice: How Different Are They?

Facial plastic surgery has thrived in both academic and private settings. In this article, 3 surgeons comment on a variety of selected topics that are pertinent to their lives as academic and private practice surgeons.

Microfat and Nanofat: When and Where These Treatments Work.

Facial fat transfer has evolved from simple grafting techniques to smaller lobule (microfat) and adipose-derived stem cell (nanofat) injection techniques. These new methods look to overcome the early limitations of facial fat transfer while meeting increased demand and understanding of the role of volume loss in facial aging. The purpose of this article is to review basic principles of microfat and nanofat and demonstrate one technique for their application.

Hearing Outcomes after Surgical Drainage of Petrous Apex Cholesterol Granuloma.

Objective This study aims to assess the hearing outcomes of patients undergoing surgical management of petrous apex cholesterol granuloma and to discuss the role of otic capsule-sparing approaches in drainage of petrous apex cholesterol granulomas. Design Retrospective case series. Setting Tertiary care medical center. Participants Eight patients underwent surgery for presumed or definitive cholesterol granuloma between 2002 and 2011 and met the inclusion criteria for this study. Main Outcome Measures Pre- and postoperative audiogram results as measured by pure tone thresholds and word recognition scores. Results Four patients (50%) demonstrated improvement in speech discrimination. One patient had an increase from 0 to 67% in word recognition scores. Four patients (50%) demonstrated worsening of pure tone thresholds, including two patients with anacusis. Conclusion Perilabyrinthine drainage of petrous apex cholesterol granulomas may result in hearing preservation or hearing improvement, even in the setting of otic capsule erosion. Patients should be counseled about the potential risk of significant hearing loss.

Secondary onlay free flap reconstruction of glossectomy defects following initial successful flap restoration.

Patients who undergo tongue reconstruction over time may develop gradual worsening of dysarthria and dysphagia secondary to flap atrophy. At our institution, these patients undergo a secondary flap onlay procedure for augmentation of the neotongue. We review a total of 11 patients with total glossectomy defect who underwent secondary tongue augmentation with secondary onlay free flap consisting of radial forearm free flap (n = 6) and rectus free flap (n = 5). There was improvement in swallowing in 7 of 11 patients. Five (45.4%) patients achieved gastric tube independence. Seven (63.6%) patients achieved a varying degree of oral intake. All patients achieved tracheostomy independence. Dysarthria was improved in all patients. There were no flap failures. Therefore, a secondary onlay flap technique is feasible and may improve dysphagia and dysarthria to achieve gastric tube and tracheostomy independence in total glossectomy patients with delayed tongue atrophy.

Flap selection and functional outcomes in total glossectomy with laryngeal preservation.

OBJECTIVE: Reconstruction of total glossectomy defects has been revolutionized by the popularity of free flap use in the head and neck. Challenging defects can be addressed with a variety of different free and pedicled flaps. The purpose of this study is to review our method of flap selection in cases of total glossectomy defects with laryngeal preservation, with an emphasis on the variations of these defects and patient body habitus. STUDY DESIGN: Case series with chart review. SETTING: Tertiary care referral center. SUBJECTS AND METHODS: All patients undergoing total glossectomy with laryngeal preservation (TGLP) by the senior author (YD) from September 1997 to May 2012. Objective data regarding patient demographics, existing defect, method of reconstruction, adjuvant treatment, operative details, outcomes, and complications were recorded. Both means and frequency of prolonged tracheostomy or gastrostomy tube were used to assess outcomes. RESULTS: One hundred and three patients were identified. Ninety-four met inclusion criteria. All patients were T3 or T4 stage tumors. Mean follow-up was 3.4 years. Fifty-nine patients (62%) underwent free flap reconstruction while the remaining 35 (37%) were treated with a pedicled pectoralis myocutaneous flap. Tracheostomy decannulation and gastrostomy tube removal rates were 84% and 29%, respectively. No patients were converted to total laryngectomy. CONCLUSION: Optimal reconstruction of TGLP defects may be accomplished with either pedicled or free-tissue flap reconstruction. Selecting an ideal flap for reconstruction of total glossectomy defects should be patient specific and based on matching donor flap bulk. This treatment approach demonstrates high tracheostomy and gastric tube independence.

Paranasal sinus and skull base fibro-osseous lesions: when is biopsy indicated for diagnosis?

BACKGROUND: Paranasal sinus fibro-osseous (FO) lesions represent a heterogeneous group, often sharing overlapping radiographic and pathologic features posing a dilemma in accurate diagnosis. The objective of this study was to correlate preoperative radiologic and postoperative histologic diagnosis to help guide a diagnostic algorithm. METHODS: Retrospective analysis of 60 FO lesions between 1994 and 2010. RESULTS: The mean age was 42.3 years with average follow-up of 12.5 months. The preliminary radiologic diagnosis was osteoma in 22 (36.7%), fibrous dysplasia (FD) in 9 (15%), ossifying fibroma (OF) vs FD in 5 (8.3%), and OF in 3 (5%) cases. The diagnosis was indeterminate in 21 (35%) cases. Management consisted of excision in 29 (48.3%), observation in 17 (28.3%), and biopsy in 14 (23.3%) patients. For patients undergoing resection or biopsy, positive predictive value of preoperative radiology was 100% (10/10) for osteoma, 85.7% (6/7) for FD, and 33.3% (1/3) for OF cases. For the indeterminate lesions, most common pathologic diagnoses for 21 patients included osteoma in 4 (17.4%), arrested pneumatization in 3 (14.3%), OF in 3 (14.3%), and FD in 2 (9.5%). For FD vs OF cases, 3 underwent surgery, revealing osteoma, FD, and OF in 1 patient each. CONCLUSION: In this series, radiologic-histopathologic correlation was high for osteoma and FD and low for OF and OF vs FD. This data suggests that patients with classic radiologic characteristics of osteoma and FD may be observed, unless resection is warranted based on clinical symptomatology. Preoperative diagnosis of OF, OF vs FD, or indeterminate lesions may warrant a biopsy to establish firm diagnosis to guide definitive management, especially if preoperative computed tomography (CT) imaging is concerning for an aggressive FO neoplasm.

Outcomes of Direct Facial-to-Hypoglossal Neurorrhaphy with Parotid Release.

Lesions of the temporal bone and cerebellopontine angle and their management can result in facial nerve paralysis. When the nerve deficit is not amenable to primary end-to-end repair or interpositional grafting, nerve transposition can be used to accomplish the goals of restoring facial tone, symmetry, and voluntary movement. The most widely used nerve transposition is the hypoglossal-facial nerve anastamosis, of which there are several technical variations. Previously we described a technique of single end-to-side anastamosis using intratemporal facial nerve mobilization and parotid release. This study further characterizes the results of this technique with a larger patient cohort and longer-term follow-up. The design of this study is a retrospective chart review and the setting is an academic tertiary care referral center. Twenty-one patients with facial nerve paralysis from proximal nerve injury at the cerebellopontine angle underwent facial-hypoglossal neurorraphy with parotid release. Outcomes were assessed using the Repaired Facial Nerve Recovery Scale, questionnaires, and patient photographs. Of the 21 patients, 18 were successfully reinnervated to a score of a B or C on the recovery scale, which equates to good oral and ocular sphincter closure with minimal mass movement. The mean duration of paralysis between injury and repair was 12.1 months (range 0 to 36 months) with a mean follow-up of 55 months. There were no cases of hemiglossal atrophy, paralysis, or subjective dysfunction. Direct facial-hypoglossal neurorrhaphy with parotid release achieved a functional reinnervation and good clinical outcome in the majority of patients, with minimal lingual morbidity. This technique is a viable option for facial reanimation and should be strongly considered as a surgical option for the paralyzed face.

Chondromyxoid fibroma of sphenoid sinus with unusual calcifications: case report with literature review.

Chondromyxoid fibroma (CMF) is a rare benign primary tumor which usually affects the metaphyses of the long bone of the lower extremities in childhood and young adults. Rarely, CMF occurs in the skull base and parasinuses, which may be difficult to distinguish from chondrosarcoma or chordoma and other tumors in the head. It is composed of chondroid, myxoid, and fibrous tissue growth in a lobular pattern, infrequently with calcifications. We report one case of CMF involving the sphenoid sinus mimicking a chondrosarcoma. The tumor mass showed calcifications on images and histology.