Corey C. Moore

The Effectiveness of Modified Cottle Maneuver in Predicting Outcomes in Functional Rhinoplasty

Objective. To assess the outcomes of functional rhinoplasty for nasal valve incompetence and to evaluate an in-office test used to select appropriate surgical techniques. Methods. Patients with nasal obstruction due to nasal valve incompetence were enrolled. The modified Cottle maneuver was used to assess the internal and external nasal valves to help select the appropriate surgical method. The rhinoplasty outcomes evaluation (ROE) form and a 10-point visual analog scale (VAS) of nasal breathing were used to compare preoperative and postoperative symptoms. Results. Forty-nine patients underwent functional rhinoplasty evaluation. Of those, 35 isolated batten or spreader grafts were inserted without additional procedures. Overall mean ROE score increased significantly (P < 0.0001) from 41.9 ± 2.4 to 81.7 ± 2.5 after surgery. Subjective improvement in nasal breathing was also observed with the VAS (mean improvement of 4.5 (95% CI 3.8–5.2) from baseline (P = 0.000)). Spearman rank correlation between predicted outcomes using the modified Cottle maneuver and postoperative outcomes was strong for the internal nasal valve (Rho = 0.80; P = 0.0029) and moderate for the external nasal valve (Rho = 0.50; P = 0.013). Conclusion. Functional rhinoplasty improved subjective nasal airflow in our population. The modified Cottle maneuver was effective in predicting positive surgical outcomes.

Quantitative and qualitative dermal change with microfat grafting of facial scars

Objective To evaluate changes in dermal characteristics with subdermal fat grafting of cutaneous scars. DESIGN Prospective cohort. METHODS Fourteen patients with various scar types were treated with subdermal fat grafting over 30 months. Dermal elasticity, vascularity, pigmentation, patient perception and satisfaction, and observer assessment of scar characteristics were evaluated preoperatively and 1 year after treatment with validated objective and subjective measures. RESULTS Significant improvements were observed in dermal elasticity, patient and observer perception of scar thickness, patient perception of stiffness, and observer perception of relief and pliability (P < 0.05). A trend toward significance was seen in observer assessment of height as evaluated by the Vancouver Scar Scale (P < 0.1). No significant differences were seen in quantitatively and qualitatively measured vascularity and pigmentation (P > 0.1). No significant difference in pain, pruritis, and irregularity were reported (P > 0.1). CONCLUSION Although fat grafting represents a subdermal process, it appears to improve certain quantitative and qualitative dermal characteristics. Fat grafting does not appear to affect skin color, vascularity, or patient symptoms.

Biomechanical properties of the facial retaining ligaments.

OBJECTIVE Osteocutaneous facial retaining ligaments play an important role in the aging face. We sought to better characterize the biophysical properties of these ligaments and, in doing so, provide an empirical basis for the natural descent seen in facial aging. METHODS Five fresh frozen cadaver heads yielding 10 hemifaces were dissected to expose the orbital, zygomatic, buccomaxillary, and mandibular osteocutaneous ligaments. Each ligament was assessed and subjected to biomechanical testing. The main outcome measures included ligament dimensions, stiffness, percentage of elongation, and force to initial and ultimate failure. RESULTS Initial and ultimate failure testing revealed the zygomatic ligament to be strongest, followed by the orbital, mandibular, and maxillary ligaments. The zygomatic ligament was also stiffest, followed by the orbital, maxillary, and mandibular ligaments. The percentage of elongation acted as a surrogate marker of elasticity, with the greatest elasticity maintained by the mandibular ligament, followed by the orbital, zygomatic, and buccomaxillary ligaments. Ligament dimensions and biophysical properties did not vary relative to cadaveric hemiface, age, or sex. CONCLUSIONS To our knowledge, this is the first investigation to quantify the biomechanical properties of the facial retaining ligaments. Inherent ligament properties seem to be related to the changes observed in facial aging, although further study is required.

Is three‐dimensional videography the cutting edge of surgical skill acquisition?

The process of learning new surgical technical skills is vital to the career of a surgeon. The acquisition of these new skills is influenced greatly by visual‐spatial ability (VSA) and may be difficult for some learners to rapidly assimilate. In many cases, the role of VSA on the acquisition of a novel technical skill has been explored; however, none have probed the impact of a three‐dimensional (3D) video learning module on the acquisition of new surgical skills. The first aim of this study is to capture spatially complex surgical translational flaps using 3D videography and incorporate the footage into a self‐contained e‐learning module designed in line with the principles of cognitive load theory. The second aim is to assess the efficacy of 3D video as a medium to support the acquisition of complex surgical skills in novice surgeons as evaluated using a global ratings scale. It is hypothesized that the addition of depth in 3D viewing will augment the learners innate visual spatial abilities, thereby enhancing skill acquisition compared to two‐dimensional viewing of the same procedure. Despite growing literature suggesting that 3D correlates directly to enhanced skill acquisition, this study did not differentiate significant results contributing to increased surgical performance. This topic will continue to be explored using more sensitive scales of measurement and more complex “open procedures” capitalizing on the importance of depth perception in surgical manipulation. Anat Sci Educ.

The Double Hatchet Flap A Workhorse in Head and Neck Local Flap Reconstruction

A double triangular flap, or hatchet flap, with a partial cutaneous pedicle, has great versatility for facial reconstruction, yet there has been little published discussion regarding the potential applications and/or modifications of the flap. A total of 483 cutaneous malignant neoplasms have been excised and repaired by the senior author (C.C.M.) using a modified bilateral hatchet flap; 366 of the neoplasms were located in the head and neck region. The flap has been used to reconstruct defects in the scalp, eyebrow, lower eyelid, nasal tip, cheek, chin, arms, and torso, with no cases of flap loss. The design of the flap and our modification will be discussed in detail, along with a description of 4 representative cases.

Carbon Dioxide Laser Treatment for Lentigo Maligna: A Retrospective Review Comparing 3 Different Treatment Modalities

OBJECTIVE To assess outcomes in managing primary lentigo maligna through surgical excision, radiation therapy, and carbon dioxide laser ablation. METHODS Retrospective case series review of all patients with primary lentigo maligna diagnosed and treated in London, Ontario, Canada, between July 2, 1991, and June 29, 2010. RESULTS Seventy-five patients aged 39 to 93 years (mean age, 64.8 years) were included in the study; 73 patients chose treatment. Twenty-seven patients were treated with surgical excision, 31 patients with radiation therapy, and 15 patients with carbon dioxide laser ablation. The median follow-up times were 16.6 months for surgical excision, 46.3 months for radiation therapy, and 77.8 months for carbon dioxide laser ablation (P < .001). Recurrence rates by treatment modality were 4.2% (1 of 27) for surgical excision, 29.0% (9 of 31) for radiation therapy, and 6.7% (1 of 15) for carbon dioxide laser ablation. CONCLUSIONS A trend toward lower recurrence rates with surgical excision and carbon dioxide laser ablation was identified, but the results were not statistically significant. Carbon dioxide laser ablation may have a role as an alternative treatment for lentigo maligna among patients in whom standard treatments, such as surgical excision and radiation therapy, are declined or carry significant morbidity.

Septopalatal Protraction for Correction of Nasal Septal Deformity in Cleft Palate Infants

OBJECTIVE: It is proposed to test the practicality of septopalatal protraction in the unilateral cleft palate infant for purposes of straightening the nasal septum and thus relieving nasal airflow obstruction and its detrimental sequelae. METHODS: Alternate infants affected with complete unilateral palatal clefts had septopalatal protraction for a period of 6 to 8 weeks (protraction group; n = 4). Septal deviation was measured by a standardized technique that used computed tomography scans. The remaining infants had no protraction and served as controls (nonprotraction group; n = 5). Septal deviation was measured in the nonprotraction group from palatoseptal dental molds. RESULTS: A total of 9 patients were studied. All patients in the nonprotraction group had worsening of nasal septal deviation over a period of 8 weeks compared with the protraction group, which had complete nasal septal straightening. Differences in septal angle deviation between the protraction group and nonprotraction group at the end of the study were statistically significant (P ≤ 0.01) as measured by the paired Student t test. CONCLUSIONS: Septopalatal protraction in the newborn appears to provide a means for correcting nasal septal deviation in complete unilateral cleft palate infants. Septopalatal protraction in the newborn is relatively easy and safe. EBM RATING: B-2

Development of a new visual analogue scale for the assessment of area scars.

OBJECTIVE Clinical scar assessment lacks standardized methodology and consensus on the most appropriate evaluation instrument. This study empirically evaluated whether area scars could be validly assessed by naive observers with the objective to develop and validate a novel multidimensional visual analogue scale (VAS) for the assessment of area scars. METHODS Standardized digital photographs of radial forearm free flap (RFFF) donor sites were obtained. Naive observers evaluated the images in three sequential psychophysical experiments, which led to the development of the new scar scale. These experiments involved initial evaluation of four dimensions (pigmentation, vascularity, observer comfort, acceptability) using a paired comparison (PC) paradigm and correlation with ratings of overall severity using a VAS, and initial VAS test phase followed by formal debriefing, and, subsequently, evaluation of a VAS for the four dimensions in addition to contour. Validation involved determination of intra- and interrater reliability and correlational analysis. RESULTS Across all three experiments, 56 observers evaluated 101 images, generating 12 720 observations for analysis. PC data demonstrated that observers could assess scars with high reliability and internal consistency for all dimensions (> 95%). Overall (VAS) severity correlated highly with all dimensions, including contour. The new VAS yielded high levels of correlation (r = .72-.98, p < .01). CONCLUSION Comprehensive VAS analysis demonstrates high reliability in mirroring PC results for multiple dimensions of area scars. These data support our novel multidimensional VAS method as a valid, reliable, simple, and time-efficient instrument for clinical and research use. We introduce the Western Scar Index as a new measurement tool with many potential applications.

Rounding of the inferior rectus muscle as an indication of orbital floor fracture with periorbital disruption

OBJECTIVE To determine if rounding of the inferior rectus muscle on coronal computed tomographic (CT) scans predicts disruption of the periorbita in orbital floor fractures and therefore predicts delayed enophthalmos. DESIGN Cadaveric study with CT scan analysis. SETTING Cadaveric laboratory and CT scanner at a tertiary care hospital in London, Ontario. METHODS Each orbit of each cadaveric head was randomly assigned to have either intact or disrupted periorbita. Progressively larger orbital floor fractures were made and CT scans were taken before fractures and after each fracture to assess the shape of the inferior rectus muscle. Measurements were made of the length of the long and short axis of the inferior rectus muscle using CT analysis software. The short to long axis ratio was then compared. MAIN OUTCOME MEASURES Change in the short to long axis ratio of the inferior rectus muscle and correlation of the ratio with intact and disrupted periorbita. RESULTS Orbital floor fractures measuring 1 x 1 cm show an increase in the short to long axis ratio (rounding) of the inferior rectus muscle only if the periorbita is disrupted. Orbital floor fractures measuring 2 x 2 cm show rounding of the inferior rectus muscle regardless of whether the periorbita is intact or disrupted; however, the degree of rounding is greater if the periorbita is disrupted. CONCLUSIONS For small orbital floor fractures, rounding of the inferior rectus muscle predicts periorbital disruption. This may therefore represent an indication for early surgical repair to prevent delayed enophthalmos.

Randomized control trial of fluorescence-guided surgical excision of nonmelanotic cutaneous malignancies

OBJECTIVE Protoporphyrin IX (PpIX) is an endogenous photosensitizer commonly used in photodynamic therapy. This study sought to assess if PpIX fluorescence can be applied clinically to improve the delineation and excision of nonmelanotic cutaneous malignancies. DESIGN Prospective, randomized control trial. SETTING A tertiary care skin cancer clinic. METHODS Fifty-one individuals with 65 cutaneous nonmelanotic cervicofacial malignancies were randomized into two groups. The control group was offered surgical excision with surgeon-delineated excision margins. The study group had their excision margins delineated while under fluorescence. MAIN OUTCOME MEASURES The delineated lesion borders, proposed excision margins, and projected lesion-free areas were compared among the two groups. Pathologic resection margins and completeness of excision were also assessed. RESULTS Excisions performed using fluorescence delineation were 20% narrower (p < .01) and 17% shorter (p < .04), with 35% less lesion-free skin excised (p < .005). All lesions excised using photodelineation had clear pathologic resection margins. A significant number of lesions excised via the traditional approach required reexcision owing to pathologically positive peripheral margins (p < .001). Follow-up at 2 years revealed no lesion recurrence among the study group and one recurrence within the control group. CONCLUSION AND SIGNIFICANCE The results demonstrate a reliable and novel application for photodynamic photodelination and support its application in the excision of nonmelanotic cutaneous malignancies.