Eric W. Cerrati

The Natural History of Soft Tissue Hypertrophy, Bony Hypertrophy, and Nodule Formation in Patients With Untreated Head and Neck Capillary Malformations.

BACKGROUND A percentage of patients with capillary malformation (CM) develop soft tissue hypertrophy, bony hypertrophy, and/or nodule formation. OBJECTIVE To determine the incidence, age of onset, anatomic distribution of soft tissue/bony hypertrophy, and nodule formation in patients with untreated CM. METHODS A retrospective medical records review of head and neck CM patients presenting to a tertiary referral center over a 7-year period (2004–2011) was performed. RESULTS Of the 160 patients with CM, 96 demonstrated progression of disease to include either soft tissue/bony hypertrophy or nodule formation. Of these, 87 patients had not received previous treatment and met the inclusion criteria for analysis. On average, soft tissue hypertrophy began at 9 years of age. The V2/maxillary segment was most commonly involved with upper lip hypertrophy being the most prominent. Fourteen percent of the patients also presented with bony hypertrophy, which began at an average age of 15 years. Nodules were present in 38/87 (44%) of patients with an average age of onset of 22 years. CONCLUSION This study demonstrates the nature progression of CM and quantifies the clinical characteristics of hypertrophy and nodule formation with untreated head and neck CM. Early and continuous treatment is recommended in hopes of preventing CM progression.

The Efficacy of Oral Celecoxib for Acute Postoperative Pain in Face-lift Surgery

IMPORTANCE Exploring methods of potentially improving patient comfort and pain control in cosmetic facial surgery. OBJECTIVE To examine the effects of celecoxib in reducing pain and possible opioid consumption following face-lift surgery. DESIGN, SETTING, AND PARTICIPANTS We reviewed the medical records of 100 patients: 50 consecutive patients who underwent a face-lift without receiving perioperative celecoxib and 50 patients who underwent face-lift and received immediate preoperative and standing postoperative celecoxib. MAIN OUTCOMES AND MEASURES In addition to demographic information, the following outcome measures were recorded for each group: visual analog scale patient-reported pain, acetaminophen and/or opioid consumption rates, and related analgesic adverse effects. RESULTS The participants in the noncelecoxib vs celecoxib groups had similar demographic characteristics: mean age, 59.6 vs 57.9 years; mean BMI, 23.3 vs 22.3; history of chronic pain or opioid use, 7 (14%) vs 6 (12%); and 94% of both groups were women. Postoperative pain scores were higher in the noncelecoxib vs celecoxib groups; mean (SD) overall pain score was 3.88 (2.20) vs 2.31 (2.36) (P < .001). The noncelecoxib group had a higher number of postoperative opioid doses than did the celecoxib group: 9.40 (4.30) vs 5.18 (4.58) (P < .05). The noncelecoxib group had a higher incidence of postoperative nausea and vomiting: 12 (24%) vs 0 in the celecoxib group. CONCLUSIONS AND RELEVANCE Preemptive treatment with oral celecoxib appears to be effective in decreasing acute postoperative pain and opioid consumption in patients undergoing face-lift. Given the well-documented adverse effects of opioids, celecoxib is a desirable alternative. LEVEL OF EVIDENCE 3.

The Safety of Antithrombotic Therapy During In-office Laryngeal Procedures—A Preliminary Study

INTRODUCTION In-office laryngeal procedures present an alternative to the risks and costs associated with general anesthesia. However, the inherent control afforded by the operative theater is decreased potentially increasing the risk of complications. Many patients undergoing these procedures have traditional surgical risk factors, such as antithrombotic (AT) medical therapy. We sought to quantify complication rates for in-office procedures as a function of AT therapy. METHODS A retrospective review of 127 diverse, in-office laryngeal procedures was performed and patients were then stratified based on AT medication status and type of procedure. The primary dependent variables were intraoperative and postoperative complications. Additionally, in those patients undergoing procedures with the goal of voice improvement, Voice Handicap Index (VHI)-10 scores were used to quantify the success of the procedure as a function of AT therapy. RESULTS Of the 127 procedures, 27 procedures (21.2%) involved patients on some form of AT agent that was not ceased for the procedure. Across all patients, no intraoperative complications were encountered, irrespective of therapeutic status. Three postoperative complications were noted; all in patients not on AT therapy. A statistically significant improvement in VHI-10 scores was noted across all patients, irrespective of AT status. CONCLUSIONS AT medications do not appear to increase the risk of complications associated with in-office laryngeal procedures. Furthermore, AT therapy seemed to have no negative impact on the voice outcomes of patients undergoing procedures for voice improvement.

Magnetic Resonance Imaging of the Effortful Swallow

Objective: The effortful swallow was designed to improve posterior mobility of the tongue base and increase intraoral pressures. We characterized the effects of this maneuver via dynamic magnetic resonance imaging (dMRI) in healthy patients. Methods: A 3-T scanner was used to obtain dMRI images of patients swallowing pudding using normal as well as effortful swallows. Ninety sequential images were acquired at the level of the oropharynx in the axial plane for each swallow; 3 series were obtained for each swallow type for each patient. Images were acquired every 113 ms during swallowing. The images were analyzed with respect to oropharyngeal closure duration, anteroposterior and transverse distance between the oropharyngeal walls, and oropharyngeal area before and after closure. Results: Preswallow reduced pharyngeal area was observed (P = .02; mean = 212.61 mm2 for effortful, mean = 261.92 mm2 for normal) as well as prolonged pharyngeal closure during the swallow (P < .0001; mean = 742.18 ms for effortful, mean = 437.31 ms for normal). No other differences were noted between swallow types. Interrater and intrarater reliability of all measurements was excellent. Conclusion: This preliminary investigation is the first to evaluate the effects of effortful swallows via dMRI. In our cohort, consistent physiologic changes were elicited, consistent with clinical dogma regarding this maneuver.

Surgical treatment of head and neck port-wine stains by means of a staged zonal approach.

Background: The majority of patients with capillary malformations (port-wine stains) develop soft-tissue and bony hypertrophy leading to gross facial asymmetry and functional deficits in vision, breathing, speech, and feeding. The authors describe and illustrate a surgical approach for the treatment of these malformations with restoration of facial symmetry and contour based on facial subunits. Methods: The authors conducted a retrospective case series of patients from 2004 to 2011 presenting for primary evaluation and treatment to a tertiary referral center specializing in vascular anomalies. The medical records and photographs of patients with facial capillary malformations and soft-tissue hypertrophy were reviewed. Results: Of the 160 patients who presented with the diagnosis of facial capillary malformation/port-wine stain, 96 (60 percent) had soft-tissue hypertrophy in one or more dermatomes resulting in facial asymmetry. Only 4.4 percent of patients had solely V1 involvement, 38.8 percent had V2 involvement, and 15.6 percent had V3 involvement. The technique and incisions used for each facial zone are described in detail. In all cases, incisions were placed along existing boundaries of facial subunits. Serial pulsed-dye laser treatments were also performed. Conclusions: Sixty percent of patients with facial capillary malformation experience soft-tissue hypertrophy with or without bony remodeling, and surgical correction is required. The authors describe a staged surgical treatment for these patients based on a subunit and zonal approach to the face. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Isolated congenital maxillomandibular synechiae

INTRODUCTION Congenital maxillomandibular syngnathia, or fusion of the jaws, is a rare condition that has a broad spectrum of presentations. The restricted mouth opening can lead to issues with feeding, swallowing, and respiration resulting in failure to thrive and temporomandibular joint ankylosis. Early recognition and treatment is necessary for proper growth and development. CASE REPORT We report a 1-day-old male with isolated bilateral soft tissue alveolar fibrous bands. He presented with difficulty feeding secondary to trismus. No bony or muscular involvement in the synechiae was noted and the remainder of the physical exam was unremarkable. The bilateral alveolar synechiae were divided under local anesthesia using surgical scissors. The patient immediately showed improvement in mouth opening and had resolution of his feeding problems. He is now gaining weight and developing appropriately. DISCUSSION The accompanying review of the literature demonstrates only 11 cases worldwide of isolated maxillomandibular fusion. Depending upon the composition of the synechiae, simple surgical division under local anesthesia can be curative.

Diode Laser for the Treatment of Telangiectasias following Hemangioma Involution

Objective Infantile hemangiomas are well known for their rapid growth during the first 6 to 9 months of life, followed by a spontaneous but slow involution. The standard of care is to treat these lesions at an early age with propranolol to expedite the involution process; however, surgery still remains an active component in the management. Medical treatment with propranolol or natural involution will often result in residual telangiectasias. We evaluated the efficacy of using a diode laser as a treatment for telangiectasias following cervicofacial infantile hemangioma involution. Study Design Case series with chart review. Setting Tertiary care hospital and practice specializing in the care of vascular anomalies. Subjects and Methods Twenty patients, aged 4 months to 11 years (average 2.69 years), underwent treatment with a 532-nm diode laser to treat the residual telangiectasias following hemangioma involution. All procedures were performed in the operating room. To assess the efficacy, we independently evaluated pre- and posttreatment digital photographs and ranked them on a 0- to 4-point scale (0 = no change and 4 = complete response). Adverse reactions were also recorded. Results The telangiectasias showed considerable improvement following treatment. In more than half of the patients treated, the affected area demonstrated a complete response. No adverse reactions were noted. Conclusion A 532-nm diode laser effectively treats the remaining telangiectasias following hemangioma involution. Whether used independently or in conjunction with other treatment modalities, the diode laser should be part of the surgical armamentarium when treating infantile hemangiomas.

Facial Plastic Surgery in the Geriatric Population

Greater life expectancy with advancements in technology and medicine has led to an increasing interest in facial rejuvenation. Facial aging is an inevitable process that largely results from soft tissue descent and volumetric deflation. However, a comprehensive knowledge of the aging process and precise assessment of the exact pathologies yielding the patients senescent appearance is essential to produce the best cosmetic outcome. The surgeon must evaluate each region independently and the aging face as a whole to ensure a pleasing, natural appearance.

The multicultural evolution of beauty in facial surgery

The concept of facial beauty has been defined in a variety of ways dating back to ancient times, and while the definition continues to develop, it has become clear that beauty crosses ethnic boundaries and has a significant cultural and economic impact. Subconsciously, beauty is perceived by humans as a sign of favorable genes and increased fertility, both of which play a role in mate selection. As a result, perceived attractive features that are subconsciously selected evolve much more quickly than other naturally selected characteristics. Additionally, the beautiful are more likely to get better grades in school, to be hired for a job, to receive higher salaries, and to be viewed as nicer, smarter and healthier.1 While beauty was once stated to be ‘‘in the eye of the beholder’’, more recent studies have suggested that beauty is an objective, quantifiable quality. The ancient Greeks began the quest for a universal standard of beauty and believed it was represented by the ‘‘golden ratio’’ also known as ‘‘phi,’’ which was thought to represent perfect harmony.1--3 In nature, the ratio appears in the spiral of seashells, in the growth rate of the human mandible, and in the DNA antihelix. Examples of its application include Egyptian art and architecture, the Fibonacci sequence, and geometric shapes such as the pentagon and decagon. Many still believe that phi corresponds to facial beauty as well.3 However, others have found it to be inexact. For example, Marquardt created an ‘‘ideal’’ facial standard based off of phi, and not only did it apply poorly to people of non-European/Caucasian descent but it also masculinized Caucasian women.4 The concept of beauty as a formula continued to evolve with the artists of the Renaissance period. Through Da Vinci and his contemporaries, the neoclassical ideals were largely based on phi. The art anatomists of the 17th and 19th

Association of Increasing Nasal Tip Projection With Lip Position in Primary Rhinoplasty

Importance The effects of rhinoplasty maneuvers on adjacent facial features are an important component in preoperative planning and patient counseling. Tip projection modifications are commonly performed in both cosmetic and reconstructive rhinoplasty. Objective To evaluate the subsequent change in lip projection that results from increasing nasal tip projection. Design, Setting, and Participants In this case series, 20 patients underwent primary rhinoplasty with the objective of increasing tip projection during the period from October 1, 2014, to September 25, 2015. Preoperative and postoperative photographs were evaluated. Main Outcomes and Measures The increased tip projection was verified using the Goode ratio. Upper lip projection was calculated by the Z angle, which is based on the intersection between the Frankfort horizontal plane and the profile line. Vermilion height was also assessed. Results Of the 20 patients in the study (19 females and 1 male; mean [SD] age, 26.8 [10.2] years; range, 16-52 years) 18 (90%) demonstrated an increase in upper lip projection when the tip projection was increased by either a columellar strut or tongue-in-groove maneuver. The Z angle demonstrated a statistically significant decrease of 2.7° (95% CI, 1.5°-3.9°; P < .001). Although the vermilion height did not change a significant amount, there was a trend toward an increase in mean height of 0.051 (95% CI, –0.00515 to –0.10685; P = .09). Conclusions and Relevance Increasing nasal tip projection causes a measurable increase in upper lip projection. This new causal association has been applied to our filler injection armamentarium as an alternative way to achieve the desired result of a more youthful upper lip. Level of Evidence 4.