Surgical Adjuncts to Rhinoplasty: An Algorithmic Approach.

BACKGROUND: Nasal aesthetics can be significantly affected by the interdependence of the surrounding bone and soft tissues of the face. These include the maxilla, septum, frontal bone, mandible, and the soft tissues and cartilage surrounding the nose. Therefore, it is pertinent to analyze and address these critical relationships of the nose in order to achieve a successful rhinoplasty. This work seeks to describe the battery of adjunct procedures available to supplement a rhinoplasty. Furthermore, each preoperative finding or indication for the adjunct is described in an algorithmic fashion. METHODS: A literature search using PubMed, Google Scholar, and a university library database was performed to locate papers describing adjunctive procedures to rhinoplasty. Indications and preoperative analysis were extracted from each paper. If the indication or finding was unclear, supplementary literature describing rhinoplasty and adjunctive analysis were sought in order to supplement our findings. RESULTS: Sixteen papers in total described adjunctive procedures for rhinoplasty. Each work highlighted a procedure or set of procedures on a surrounding facial feature including the forehead, brow, cheeks, lips, and chin, and neck. In total, 13 adjunct procedures for rhinoplasty are described with their respective indications. Additional literature and techniques were researched to clarify indicated procedures. CONCLUSION: The ability to correctly understand the critical relationships of the nose can help the surgeon correctly recognize the indication for a rhinoplasty adjunct procedure, leading to better aesthetic balance and surgical outcomes. LEVEL OF EVIDENCE II: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Management of Facial Scars.

Scarring is a natural process of healing after damage to the skin that extends to the reticular dermis. While some scars may be socially acceptable, even admirable, scars of the face can be viewed as disfiguring or ugly. Minimizing the appearance of facial scars and optimizing their cosmetic outcome ideally begin before surgery or, in the cause of trauma, at the initial reconstruction. Even when there has been poor initial healing, a scar's appearance can be improved. Herein, we review conservative, medical, and surgical therapies to improve the appearance of facial scars.

Epidemiological Trends of Head and Neck Cancer in the United States: A SEER Population Study.

PURPOSE: This study represents the most recent epidemiologic trends of head and neck cancer (HNC) in the United States. It provides an important discussion on oropharyngeal cancer and cancers related to the human papillomavirus. The objective was to identify trends in HNC (2002 to 2012) within the United States. MATERIALS AND METHODS: This study is a retrospective analysis of the US National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) submission. Using the November 2014 submission of the SEER database and SEER-18 data files, data from 2002 to 2012 were analyzed to determine the most recent epidemiologic trends. HNCs of all subtypes were analyzed together. Laryngeal cancers were further analyzed separately. Oropharyngeal cancers of the base of tongue and tonsil were analyzed independently to attempt to trend HPV-related cancers. RESULTS: From 2002 to 2012, there were 149,301 cases of HNC recorded in the SEER database. The HNC rate decreased by 0.22% per year (P = .0549) and the rate of laryngeal cancer decreased by 1.9% per year (P < .0001). The rate of oropharyngeal (HPV-related) cancer increased by 2.5% per year (P < .0001). HNC rates increased significantly in Kentucky and Connecticut and decreased in California (P < .05). HPV-related cancers increased significantly in all states except Georgia, Hawaii, and Michigan (P < .05). Laryngeal cancer rates decreased in California, Georgia, New Jersey, and New Mexico (P < .05). CONCLUSIONS: The overall incidence of HNC is decreasing in the United States. There is an increasing incidence of HPV-related cancers of the oropharynx. Meaningful differences in cancer incidence and rate of change exist between men and women. Furthermore, younger groups have a greater decrease of overall HNC, with an overall increase in HPV-related cancer in patients older than 50 years.

Surgical management of temporal bone osteoradionecrosis: Single surgeon experience of 47 cases.

PURPOSE: To report the outcomes of 47 patients with temporal bone osteoradionecrosis treated primarily with surgical resection in order to analyze whether flap type and hyperbaric oxygen use affect wound breakdown. MATERIALS AND METHODS: Between January 1998 and January 2016, 47 patients were treated for temporal bone osteoradionecrosis with surgery. Some patients were also treated with hyperbaric oxygen. Resection of grossly necrotic temporal bone was followed by immediate reconstruction with local, regional, or free flaps. Minimum follow-up was 6months. If patients had breakdown of their initial reconstructions, secondary reconstruction was performed with either a regional or free flap. During the post-operative period, wound breakdown, flap complications, and patient survival were noted. RESULTS: 30 patients developed ORN from primary radiotherapy while 17 had post-operative radiation. It was found that wound breakdown was significantly associated with type of flap reconstruction (p=0.02) with local flap reconstruction portending a poorer prognosis. Hyperbaric oxygen was not associated with decreased wound breakdown (p=0.5). CONCLUSIONS: Surgical treatment can be an effective treatment for temporal bone osteoradionecrosis, without hyperbaric oxygen providing any additional benefit. Reconstruction with regional or free flaps may be a more reliable method to resurface defects compared to local flaps.

The role of intraoperative nerve monitoring in tracheal surgery: 20-year experience with 110 cases.

PURPOSE: To determine the utility of intraoperative nerve monitoring (IONM) during tracheal resection or slide tracheoplasty to prevent recurrent laryngeal nerve injury. METHODS: 110 patients underwent tracheal resection or tracheoplasty between 1997 and 2016. During the first 10-year period, IONM was not used while during the second 10-year period, IONM was used. 49 patients had surgery without IONM while 61 had surgery with IONM. During the post-operative period, patients with nerve injury were compared to determine if significant difference existed between the two modalities. RESULTS: In patients who had surgery without IONM, 7 (14.2%) patients were found to have compromised nerve function whereas 8 (13.1%) patients in the group with IONM had nerve injury. 3 patients regained function in the first group while four regained function in the second. A Fisher's exact test was run on the entire cohort and the difference in vocal fold injury was not found to be statistically significant (p > 0.05). CONCLUSION: Based on this single surgeon experience, there may be no protective benefit with the use of IONM during tracheal surgery.

Supraclavicular Flap Reconstruction of Cutaneous Defects Has Lower Complication Rate than Mucosal Defects.

Background The objective of this study was to determine whether there was a difference in complication rate between cutaneous and mucosal defects reconstructed with the supraclavicular artery flap. Methods Retrospective review of postoperative complications in 63 patients from 2008 to 2015 with cutaneous and mucosal head and neck defects following oncologic ablation reconstructed with the supraclavicular flap, with a minimum follow-up duration of 6 months. Of the 63 patients, 38 patients had cutaneous defects, whereas 25 had mucosal defects. Patients were followed up postoperatively to determine the presence of wound infection, partial flap necrosis, complete flap necrosis, and fistula formation. Complications in both defect groups as well as a statistical comparison of total complications were analyzed. Results Patients with cutaneous defects reconstructed with the supraclavicular flap had significantly lower postoperative complications than those with mucosal defects (p = 0.002). Flap necrosis, both partial and complete, was also lower in this same group (p = 0.0052). Conclusion The supraclavicular artery flap may be a more suitable option for patients with cutaneous defects, given the reliability and lower propensity for postoperative complications Level of Evidence The level of evidence is 4.

Colonic Perforation: A Medical Complication.

Hypothyroidism is a common comorbidity that on acute presentation is often overlooked. It can be an easily managed condition; however non-compliance can have severe consequences. In the presented case it was requirement for emergency surgery that resulted in stoma formation. This case is a first example of the need to include patient's decision making process with regards to medication adherence in the setting of chronic disease.

Accepting multiple simultaneous liver offers does not negatively impact transplant outcomes.

Impact of performing multiple liver transplants (LT) in a short period of time is unknown. Consecutively performed LT potentially increase complication rates through team fatigue and overutilization of resources and increase ischemia time. We analyzed the impact of undertaking consecutive LT (Consecutive liver transplant, CLT; LT preceded by another transplant performed not more than 12 h before, both transplants grouped together) on outcomes. Of 1702 LT performed, 314 (18.4%) were CLT. Outcome data was compared with solitary LT (SLT; not more than one LT in 12-h period). Recipient, donor, and graft characteristics were evenly matched between SLT and CLT; second LT of CLT group utilized younger donors grafts with longer cold ischemic times (P = 0.015). Implantation and operative time were significantly lower in CLT recipients on intergroup analysis (P = 0.0001 and 0.002, respectively). Early hepatic artery thrombosis (E-HAT) was higher in CLT versus SLT (P = 0.038), despite absolute number of E-HAT being low in all groups. Intragroup analysis demonstrated a trend toward more frequent E-HAT in first LT, compared to subsequent transplants; however, difference did not reach statistical significance (P = 0.135). In era of organ scarcity, CLT performed at high-volume center is safe and allows pragmatic utilization of organs, potentially reducing number of discarded grafts and reducing waiting list mortality.

Surgical Management of Extracranial Meningiomas Arising in the Head and Neck.

PURPOSE: To determine outcomes in the management of extracranial meningiomas of the head and neck. PATIENTS AND METHODS: This is a retrospective single-surgeon series performed at a tertiary-care referral center. In all, 23 patients met the inclusion criteria, consisting of 12 men and 11 women. The mean age of patients treated was 60.5 years (range, 32 to 71 years). Subsite involvement included the infratemporal fossa (n = 8), greater wing of the sphenoid and orbit (n = 7), clivus (n = 2), and parapharyngeal space (n = 6). RESULTS: In all, recurrence occurred in 21% of patients (n = 5) who underwent gross tumor resection. Two patients underwent subtotal resection because of the tumor's location within the clivus with adjuvant CyberKnife therapy (Accuray, Sunnyvale, CA). Both patients had persistent disease with no new neurologic symptoms. Examination showed that 100% of patients (N = 23) had dural involvement. Post-ablative complications occurred in 43% of patients (n = 10). CONCLUSIONS: We presently report the largest series of surgical treatment for extracranial meningiomas. Gross tumor resection should be the mainstay of therapy, except in anatomically restricted regions such as the petrous apex and clivus. Adjuvant therapy including CyberKnife therapy may be used in such lesions. All lesions showed dural involvement. A more unified nomenclature is required for the characterization of these lesions.

Worldwide 10-Year Systematic Review of Treatment Trends in Fibula Free Flap for Mandibular Reconstruction.

PURPOSE: The purpose of this study was to describe the trends pertaining to the use of the fibula free flap for mandibular reconstruction during the past 10 years. MATERIALS AND METHODS: A systematic review for publications on the fibula free flap in mandibular reconstruction in the PubMed and Scopus databases was performed from January 1, 2005 until December 31, 2014. Publications were classified by topic, number of patients, and country of origin. The study period was split into 2 periods. The first 5-year period was compared with the second 5-year period. RESULTS: Eighty-five publications were identified. There was an increase in publications regarding restorative decision making (11 vs 9), surgical techniques (13 vs 6), outcomes (20 vs 10), and computer-aided design and computer-aided manufacturing (CAD-CAM; 8 vs 2) in the second 5-year period. The number of patients reported also increased in publications on surgical techniques (1,085 vs 59), outcomes (777 vs 254), bisphosphonate-related osteonecrosis of the jaw and osteoradionecrosis (165 vs 28), and CAD-CAM (65 vs 15) in the second 5-year period. The United States, India, China, and Europe produced most of the publications. CONCLUSIONS: In the past 10 years, there was a surge in publications on the use of the fibula free flap for mandibular reconstruction. There was a 1.8-fold increase in the number of publications and a 3.4-fold increase in the number of patients undergoing this method of mandibular reconstruction in the second 5-year period. Publications from the United States, India, and China contributed to a large increase in the number of patients in the second 5-year period. More interest in CAD-CAM technology was seen in the second 5-year period that was not seen in the first 5-year period.

What Are the Optimal Monitoring Techniques in Head and Neck Microvascular Reconstruction?

PURPOSE: We evaluated the outcomes for widely used systems in terms of accuracy, salvage rates, and added cost compared to conventional monitoring. METHODS: We performed a narrative review of the literature (high-impact report). RESULTS: The overall free flap success for head and neck reconstruction is at least 95% using any type of monitoring. Salvage rates in decreasing frequency of monitoring techniques are 85% with near-infrared spectroscopy (NIRS), 81% with implantable Doppler, and 61.5% with conventional monitoring. False-positive rates in increasing frequency are 0% for NIRS, 0.4% for conventional monitoring, and <10% for implantable Doppler. Current data show implantable Doppler to be potentially cost-effective for institutions with a failure rate of at least 6%. Buried flaps may be monitored with conventional monitoring using an exteriorized paddle, or using implantable Doppler. CONCLUSIONS: The cost-effectiveness of advanced flap monitoring systems beyond conventional monitoring is related to the success rate of each institution. Cost-effectiveness studies are necessary to determine at what point NIRS becomes advantageous.

Use of Giant Bilobed Flap for Advanced Head and Neck Defects.

This article aims to review the use of giant bilobed flaps in the reconstruction of various large defects within the head and neck. A single case series study with chart review was performed. Various facial, neck, and mentum defects were documented, and closure was accomplished through a variety of medially and laterally based giant bilobed flaps. Preoperative and postoperative photography, as well as intraoperative planning, was performed. A total of 23 patients were able to achieve closure of facial, head, and neck defects with single-stage closure through the use of a giant bilobed flap. No tissue expanders, free tissue transfers, or skin grafts were required to achieve final closure, with acceptable cosmetic and functional results. Bilobed-shaped flaps allow for local tissue transfer in regions of otherwise limited tissue laxity and mobility, classically designed and utilized in the region of the nose. We describe its applicability to closure of large head and neck defects that may otherwise require free tissue transfer or the use of tissue expanders.

Vasculobiliary complications following adult right lobe split liver transplantation from the perspective of reconstruction techniques.

Split liver transplantation (SLT) compensates for the organ shortage and provides an alternative solution for recipients disadvantaged by a smaller body size. Variations in the hepatic arterial anatomy and reconstructive techniques may lead to more technical complications, and we sought to analyze the incidence and risk factors of vasculobiliary complications with respect to reconstructive techniques. We identified 171 adult right lobe SLT procedures and 1412 whole liver transplantation (WLT) procedures between January 2000 and June 2012 and compared the results of these 2 groups. In the SLT group, arterial reconstruction techniques were classified into 4 subgroups (I-IV), and biliary reconstruction was classified into 2 groups [duct-to-duct (DD) anastomosis and Roux-en-Y hepaticojejunostomy (RH)]. Specific surgical complications were analyzed against reconstruction techniques. The overall incidence of vascular and biliary complications in the SLT group was greater than that in the WLT group (P = 0.009 and P = 0.001, respectively). There was no difference in hepatic artery thrombosis (HAT), but we saw a tendency toward early HAT in the presence of multiple hepatic arteries supplying the right lobe graft (group IV; 20%) in comparison with the other arterial reconstruction groups (P = 0.052). No difference was noticed in the overall incidence of biliary complications in either DD or RH recipients across 4 arterial reconstruction groups. When the arterial reconstruction involved a right hepatic artery (groups II and III) combined with a DD biliary anastomosis, there was a significant preponderance of biliary complications (P = 0.04 and P = 0.01, respectively). There was no survival difference between SLT and WLT grafts. In conclusion, the complications of SLT are directly related to arterial and biliary reconstruction techniques, and this classification helps to identify high-risk reconstructive techniques.

Etiology and management of hepatic artery thrombosis after adult liver transplantation.

Hepatic artery thrombosis (HAT) represents a major cause of graft loss and mortality after liver transplantation. It occurs in up to 9% of adult recipients. The early diagnosis of HAT decreases septic complications, multiorgan failure, and graft loss, and there are better outcomes after treatment. In this study, we reviewed 102 episodes of HAT, which were classified as early hepatic artery thrombosis (E-HAT) when they were diagnosed within the first 21 days after transplantation. The overall incidence of HAT was 7%: 31 episodes (30.4%) were identified as E-HAT, and 71 episodes (69.6%) were identified as late hepatic artery thrombosis (L-HAT). Graft dysfunction was the commonest presentation (30 cases or 29%). Most E-HAT cases were managed with retransplantation (74%), whereas early revascularization was carried out for only 13% with a 75% success rate. The incidence of retransplantation for L-HAT was only 41%, whereas 32% were too ill for relisting and eventually died. Successful conservative management was noted for 13 of the 102 patients (13%) with collateralization and good hepatic perfusion, with biliary complications encountered in 7 cases (54%) subsequently. A multivariate analysis showed that previous episodes of HAT, the number of arterial anastomoses, and a low donor weight were independent risk factors for E-HAT, whereas a history of upper abdominal operations (non-HAT), a previous history of HAT, a low donor weight, and a recipient age < 50 years were independent risk factors for L-HAT. The graft survival rates for HAT patients were 52%, 36.6%, and 27.4% at 1, 3, and 5 years, whereas the corresponding rates were 81.4%, 81.2%, and 76.4% for non-HAT patients. In conclusion, prompt revascularization for E-HAT patients decreases the incidence of serious, irreversible septic complications and graft loss and improves overall outcomes. A significant number of L-HAT patients do not require further intervention despite the high incidence of ischemic cholangiopathy.

Patient with liver dysfunction while maintained on veno-venous extracorporeal membrane oxygenation should not be overlooked as a potential donor.

This report describes transplantation of liver allograft from a circulatory death donor who was supported by veno-venous extracorporeal membrane oxygenation (ECMO) for 14 days and presented with severely altered liver functions. Successful liver transplant was done in a patient with hepatocellular carcinoma (HCC) in the background of primary sclerosing cholangitis. There was immediate graft function and uneventful recovery with stable graft function at 1-year follow-up. This case illustrates the ability of veno-venous ECMO to resuscitate organs in the presence of severe dysfunction, and perhaps, lessons from this case may be incorporated to optimize the condition of organs rescued from these marginal donors and exemplify the use of ECMO in normothermic regional perfusion in donors after circulatory death.

A Retrospective Study on the Impact of COVID-19 on Emergency General Surgery.

Background The coronavirus pandemic has caused global disruption to all aspects of life. This disturbance has been most notable in the medical world. Political, societal, medical, and behavioral alterations have forced emergency surgical practices to adapt. This study investigated the impact of coronavirus 2019 (COVID-19) at a busy surgical center. Methodology This is a retrospective observational study. Three study periods were analyzed: pre-COVID, first wave, and second wave. Data were collected on referrals, diagnoses, investigations, management pathways, outcomes, patient behavior, and consultant practice. A one-way analysis of variance (ANOVA test) was used for the analysis of parametric data and the Mann-Whitney U test for non-parametric data. Results Declining numbers of patients presented across the three periods. There was a severe disruption in performing emergency general surgeries during the first wave, propagated by alterations in clinical decision-making, as well as fluctuations in societal and patient behavior. Despite the effects of the second wave being significantly more profound in terms of hospitalization and COVID-related mortality, a paradoxical, gradual return to the norm was noted, which was seen in referral pathways, imaging decisions, and management strategies. Conclusion Our data is suggestive of society, both within and outside the medical sphere, adjusting to life with COVID-19.

The impact of the COVID-19 pandemic on elective laparoscopic cholecystectomy: A retrospective Cohort study.

The coronavirus disease 2019 (COVID-19) pandemic had a significant impact on elective surgery for benign disease. We examined the effects of COVID-19 related delays on the outcomes of patients undergoing elective laparoscopic cholecystectomy (LC) in an upper gastrointestinal surgery unit in the UK. We have analysed data retrospectively of patients undergoing elective LC between 01/03/2019 to 01/05/2019 and 01/04/2021 to 11/06/2021. Demographics, waiting time to surgery, intra-operative details and outcome data were compared between the two cohorts. Indications for surgery were grouped as inflammatory (acute cholecystitis, gallstone pancreatitis, CBD stone with cholangitis) or non-inflammatory (biliary colic, gallbladder polyps, CBD stone without cholangitis). A p value of <0.05 was used for statistical significance. Out of the 159 patients included, 106 were operated pre-pandemic and 53 during the pandemic recovery phase. Both groups had similar age, gender, ASA-grades and BMI. In the pre-pandemic group, 68 (64.2%) were operated for a non-inflammatory pathology compared to 19 (35.8%) from the recovery phase cohort (p < 0.001). The waiting time to surgery was significantly higher amongst patients operated during the recovery phase (p = 0000.1). Less patients had complete cholecystectomy during the pandemic recovery phase (p = 0.04). There were no differences in intraoperative times and patient outcomes. These results demonstrate the impact of COVID-19 related delays to our cohort, however due to the retrospective nature of this study, the current results need to be backed up by higher evidence in order for strong recommendations to be made.

Safe autologous rib harvest in patients with breast implants; technique and review.

INTRODUCTION: Autologous rib harvest is a useful technique for rhinoplasty when septal cartilage is inadequate. For patients who have previously undergone augmentation mammoplasty, however, there is theoretical concern about the risk to breast implant integrity during costal cartilage harvest. The true risk to patients and their implants from autologous rib harvest is poorly studied. Herein, we review our technique and experience with autologous rib harvest after augmentation mammoplasty. METHOD: We performed a retrospective review of patients who underwent autologous rib harvest after augmentation mammoplasty between February 1998 and February 2017 at a tertiary care hospital and private practice. We identified basic demographics, implant type, approach to implantation, and any post-operative complications following rib harvest. Surgery was performed using an inframammary approach with a boat-technique for cartilage harvest. RESULTS: A total of 109 individuals, aged 19-64, were included in our study. There was a 2% rate of post-operative seroma development; no patients developed long-term complications. There was a 5% rate of incidental intraoperative discovery of implant dehiscence or implant entry, all of which were repaired primarily at the time of surgery, and none of which developed post-operative sequelae. There were no cases of pneumothorax, post-operative breast malposition, or other major complications. CONCLUSION: Herein, we present the largest cohort of patients to undergo autologous rib harvest after augmentation mammoplasty. Routine intra-operative drain placement and perioperative imaging is unnecessary. Our technique allows harvest of a suitable amount of cartilage, is very cosmetically acceptable to this cosmetically-conscious population, and is safe for patients and their implants.

Machine Learning and Feature Selection Applied to SEER Data to Reliably Assess Thyroid Cancer Prognosis.

Utilizing historical clinical datasets to guide future treatment choices is beneficial for patients and physicians. Machine learning and feature selection algorithms (namely, Fisher's discriminant ratio, Kruskal-Wallis' analysis, and Relief-F) have been combined in this research to analyse a SEER database containing clinical features from de-identified thyroid cancer patients. The data covered 34 unique clinical variables such as patients' age at diagnosis or information regarding lymph nodes, which were employed to build various novel classifiers to distinguish patients that lived for over 10 years since diagnosis, from those who did not survive at least five years. By properly optimizing supervised neural networks, specifically multilayer perceptrons, using data from large groups of thyroid cancer patients (between 6,756 and 20,344 for different models), we demonstrate that unspecialized and existing medical recording can be reliably turned into power of prediction to help doctors make informed and optimized treatment decisions, as distinguishing patients in terms of prognosis has been achieved with 94.5% accuracy. We also envisage the potential of applying our machine learning strategy to other diseases and purposes such as in designing clinical trials for unmasking the maximum benefits and minimizing risks associated with new drug candidates on given populations.