Benjamin C. Marcus

The utility of sentinel lymph node biopsy in head and neck melanoma in the pediatric population

Intraoperative lymph node mapping and sentinel lymph node biopsy have proven beneficial techniques in staging adult patients with melanoma of the head and neck, where there is great variability in lymphatic drainage. This technique has also been applied to pediatric patients with truncal cutaneous melanomas in an effort to determine nodal status without the morbidity associated with complete lymph node dissection. Nevertheless, the utility of sentinel lymph node biopsy in head and neck melanoma in the pediatric population has not been established. The objective of the authors’ study was to determine the clinical utility of intraoperative lymph node mapping and sentinel lymph node biopsy of head and neck melanoma in the pediatric population. The authors reviewed the records of seven pediatric patients with head and neck melanoma or borderline melanocytic proliferations of unknown biologic potential who underwent intraoperative lymph node mapping and sentinel lymph node biopsy between 1998 and 2001. All sentinel lymph node specimens were examined by a melanoma dermatopathologist for the presence of metastatic melanoma. The mean operative time for each case was 3 hours, 8 minutes (range, 2 hours, 15 minutes to 3 hours, 50 minutes). All seven pediatric patients who underwent extirpation of a primary head and neck melanoma and preoperative lymphoscintigraphy had unique and identifiable basins of drainage to regional nodal groups. Four of seven patients had at least one positive sentinel lymph node. Overall, five of 19 sentinel nodes (26 percent) resected had evidence of metastatic melanoma. Of the patients with positive sentinel lymph nodes, two of the primary lesions were diagnosed as melanoma while two were initially considered atypical melanocytic proliferations of uncertain biologic potential with melanoma in the differential diagnosis. Sentinel lymph nodes in pediatric patients with melanoma of the head and neck can be successfully mapped and biopsied, as in adult patients. In addition, this procedure can provide critical diagnostic information for those pediatric patients with diagnostically challenging, controversial, or borderline melanocytic lesions.

Correction of internal nasal valve stenosis: a single surgeon comparison of butterfly versus traditional spreader grafts.

Nasal obstruction due to internal nasal valve (INV) collapse is relatively common. This article evaluates 2 different methods repairing the INV.Our subject population is a single-surgeon group of 82 patients who underwent a septorhinoplasty for nasal airway obstruction. Patients received either a spreader graft or butterfly graft. There are 30 patients who received spreader grafts and 52 patients who received a butterfly graft. All patients had a minimum of 3 months follow-up. All patients were evaluated with standardized questionnaire. Participants were asked to evaluate improvement in their nasal airway on an analog scale of 1 to 5. Participants were also asked to comment on changes in pre and postoperative snoring and sleep habits. Lastly, participants were queried regarding the ear cartilage harvest and if this bothered them.Patients undergoing both procedures demonstrated an overall improvement in their nasal breathing. Significant differences in improvement were observed for patients in the categories of postoperative snoring, sleep, and continuous positive airway pressure use. Patients were not bothered by the ear cartilage harvest.In select patients, the butterfly graft is a useful solution for INV collapse correction.

National interdisciplinary rhinoplasty.

BACKGROUND Rhinoplasty is a complex and multifaceted operation. There are great differences in methodologies between practitioners. Examining the preoperative, operative, and postoperative techniques employed by different practitioners will provide rhinoplasty surgeons with benchmarks by which they can evaluate their own practice. OBJECTIVE To assess current trends in rhinoplasty surgery. METHODS A comprehensive questionnaire was sent to 7368 members of the following societies: the American Society of Plastic Surgeons (ASPS), the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS), and the American Academy of Facial Plastic and Reconstructive Surgery (AAFPRS). Subgroup statistical analysis was performed. RESULTS The overall response rate was 26%. Plastic surgeons accounted for 68% of the response rate and ear, nose, and throat-affiliated physicians accounted for 28%, with a small minority (4%) being members of both groups. Sixty-five percent of respondents have been in practice 11 or more years. Fifty-two percent of respondents are in private practice, 19% are in academic practice, and the rest are in single- or multispecialty practices. The number of rhinoplasties performed per year is spread fairly evenly up to 50 per year; however, only 9% of respondents perform 50 to 100 rhinoplasties per year, and only 5% perform more than 100 rhinoplasties per year. Most prefer the open approach over the closed approach, with 33% performing open only and 42% using both approaches, but primarily open. CONCLUSIONS There is no uniform consensus regarding general rhinoplasty trends. Subanalysis shows that, overall, there are statistically significant similarities and differences amongst different specialties.

Perioperative Arnica montana for Reduction of Ecchymosis in Rhinoplasty Surgery.

Background Studies of homeopathic therapies to decrease postrhinoplasty ecchymosis have previously used subjective measurements, limiting their clinical significance. Recently, Arnica montana was shown to decrease postoperative ecchymosis after rhytidectomy, using an objective measuring tool. We believe that oral A. montana, given perioperatively, can be objectively shown to reduce extent and intensity of postoperative ecchymosis in rhinoplasty surgery. Methods Subjects scheduled for rhinoplasty surgery with nasal bone osteotomies by a single surgeon were prospectively randomized to receive either oral perioperative A. montana (Alpine Pharmaceuticals, San Rafael, Calif) or placebo in a double-blinded fashion. Ecchymosis was measured in digital “three-quarter”–view photographs at 3 postoperative time points. Each bruise was outlined with Adobe Photoshop (Adobe Systems Incorporated, San Jose, Calif), and the extent was scaled to a standardized reference card. Cyan, magenta, yellow, black, and luminosity were analyzed in the bruised and control areas to calculate change in intensity. P value of <0.1 was set as a meaningful difference with statistical significance. Results Compared with 13 subjects receiving placebo, 9 taking A. montana had 16.2%, 32.9%, and 20.4% less extent on postoperative days 2/3, 7, and 9/10, a statistically significant difference on day 7 (P = 0.097). Color change initially showed 13.1% increase in intensity with A. montana but 10.9% and 36.3% decreases on days 7 and 9/10, a statistically significant difference on day 9/10 (P = 0.074). One subject experienced mild itching and rash with the study drug that resolved during the study period. Conclusions Arnica montana seems to accelerate postoperative healing, with quicker resolution of the extent and the intensity of ecchymosis after osteotomies in rhinoplasty surgery, which may dramatically affect patient satisfaction.

International interdisciplinary rhytidectomy survey.

Facial rhytidectomy is a complex and multi-faceted operation performed by different methodologies between practitioners. This study elucidates current international trends in facelift surgery, including patient selection, operative technique, and postoperative care. A 43-item questionnaire was sent electronically to 7247 members of the following societies: ASPS, ISAPS, CSPS, IFFPS, and the AAFPRS. The survey focused on 3 main areas: (a) background information, (b) intraoperative technique, and (c) postoperative care. The response rate was 11.4%. The majority of our population was from the United States (US) (73%). Most (85%) of the respondents have practices where over 50% of their procedures are considered aesthetic surgery. Statistical differences between the uses of minimally invasive adjuvant treatments (thread lifts, endotine mid-face devices, superficial and deep skin resurfacing procedures) were found between plastic surgeons (PS) and facial plastic surgeons (FPS), as well as between US, Canadian, and international surgeons. Suture imbrication (42%) was the most common way of handling the submuscular aponeurotic system. International surgeons were more likely (49.6% vs. 37.7%, P < 0.05) to use this technique than US or Canadian surgeons. Difference in handling patients who smoke and postoperative management differences were also found between the groups queried. No differences were found between FPS and PS in the handling of the submuscular aponeurotic system, treatment of platysmal bands, treatment of ptotic submandibular glands, or treatment of submental fat deposits (P > 0.05). Differences exist between FPS and PS, and between US, Canadian, and international surgeons with regard to facelift techniques and perioperative management. These differences need to be addressed in order to measure outcomes across specialties and between techniques. This data will additionally be helpful for less experienced and younger surgeons who wish to define best practice patterns.

Facial Resurfacing of the Male Patient

Cosmetic facial plastic procedures, surgical and nonsurgical alike, continue to increase in number. Recent statistics from the American Society of Aesthetic Plastic Surgery indicate that approximately 78% of the nearly 8.3 million cosmetic procedures performed in the United States each year are nonsurgical. Similar statistics have been demonstrated by the American Academy of Facial Plastic and Reconstructive Surgery who report that over the past 5 years there has been a 47% increase in nonsurgical procedures compared with a 19% increase in surgical procedures. The demographic of those seeking cosmetic procedures is dramatically changing also. Although cosmetic surgery was once predominantly sought by females, more and more male patients are now seeking treatment.

Energy-Based Facial Rejuvenation: Advances in Diagnosis and Treatment

Importance The market for nonsurgical, energy-based facial rejuvenation techniques has increased exponentially since lasers were first used for skin rejuvenation in 1983. Advances in this area have led to a wide range of products that require the modern facial plastic surgeon to have a large repertoire of knowledge. Objective To serve as a guide for current trends in the development of technology, applications, and outcomes of laser and laser-related technology over the past 5 years. Evidence Review We performed a review of PubMed from January 1, 2011, to March 1, 2016, and focused on randomized clinical trials, meta-analyses, systematic reviews, and clinical practice guidelines including case control, case studies and case reports when necessary, and included 14 articles we deemed landmark articles before 2011. Findings Three broad categories of technology are leading non–energy-based rejuvenation technology: lasers, light therapy, and non–laser-based thermal tightening devices. Laser light therapy has continued to diversify with the use of ablative and nonablative resurfacing technologies, fractionated lasers, and their combined use. Light therapy has developed for use in combination with other technologies or stand alone. Finally, thermally based nonlaser skin-tightening devices, such as radiofrequency (RF) and intense focused ultrasonography (IFUS), are evolving technologies that have changed rapidly over the past 5 years. Conclusions and Relevance Improvements in safety and efficacy for energy-based treatment have expanded the patient base considering these therapies viable options. With a wide variety of options, the modern facial plastic surgeon can have a frank discussion with the patient regarding nonsurgical techniques that were never before available. Many of these patients can now derive benefit from treatments requiring significantly less downtime than before while the clinician can augment the treatment to maximize benefit to fit the patient’s time schedule.

The Use of Autologous Fat for Facial Rejuvenation

Adding volume to the aging face is a notion that has come into vogue as of late but is, however, not a new idea. With the advent of miro-liposuction techniques, there is renewed interest in the use of aspirated fat. Commercial fillers have a valuable place in the cosmetic surgeons armamentarium and offer immediate volume correction with a more modest financial commitment. Nevertheless, the standardization of fat grafting techniques marks an exciting shift in facial aesthetics with the ability to correct all aspects of the aging face with safe, natural, and lasting results.

The Revision Rhinoplasty Consult: The Art of Managing Expectations.

Rhinoplasty is widely acknowledged to be a challenging operation. The success of the operation has long been measured in anecdotal ways. As the surgeon-do I think the outcome is good? Does the patient tell me they are happy? At hand is an obvious issue with patients sometimes not returning to their original doctor. Other times they may have minor concerns that take minimal effort to correct. Does that constitute a revision? In most circles, the ultimate definition of revision rhinoplasty is a return to surgery with the intent to correct a functional or aesthetic concern that arose after the original procedure.

Revisiting the Labial-Buccal Sulcus Flap for Septal Perforation Closure: Review at a Single Institution

changes to the degree of septal rotation. In addition, this is the first to examine the effect of differing types of septal release on the degree of rotation. The septum bends at a hinge point that is the bony cartilaginous junction, and the ULCs are fixed. As one moves farther caudally on the septum and farther cranially on the ULC, tension increases and pulls the septum toward the fixed point laterally and cranially. We have shown that the bending of the septum increases with increased septal release, which decreases septal attachments and increases the potential for mobility. In this study, each procedure was performed sequentially to the cadavers from least to most deforming. While it is possible that microfracture or cartilage memory contributed to further deformation with each maneuver, we think this unlikely. The ASR procedure is a modified extracorporeal septoplasty wherein the entire septum is removed excepting a variable portion of the dorsal cartilage, which remains attached at the keystone. We have previously reported on 77 patients treated with ASR reporting a 0% dorsal irregularity rate.3,6 One drawback of the ASR has been the residual dorsal septal deviation. The clocking suture should further increase the efficacy of the ASR procedure because the dorsal deviation can be addressed without the need to fully dissociate the quadrangular cartilage (as in a full extracorporeal septoplasty). The benefits of the clocking suture are adaptability because sutures may be varied according to the desired effect, do not widen the midvault, and do not prevent other techniques from being used. This technique is a useful addition to the rhinoplasty surgeon’s armamentarium.