Grant S. Hamilton

Three-Dimensional Surface Imaging and the Continuous Evolution of Preoperative and Postoperative Assessment in Rhinoplasty

During the preoperative assessment in rhinoplasty, the surgeon takes a thorough history, performs a complete examination by assessing functional and aesthetic aspects of the nose, obtains a clear understanding of the patients wishes, conducts facial analysis based on standardized photography, and communicates to the patient the goals and pitfalls of surgery. Computer imaging or morphing of the preoperative pictures of the nose has drawn a lot of interest in the last decade, and it is a sign of evolution of the preoperative consultation. Technological advances, also in the context of rhinoplasty, have led to the development of three-dimensional (3D) imaging techniques, and have completely revolutionized the way that surgeons manage their patients preoperatively and evaluate postoperative results today. The accurate 3D surface imaging aids the surgeon to communicate with the patient adequately before surgery, to set an appropriate surgical plan, and to measure the shape and volume changes of the patients nose that result from the intervention. The present review provides an analysis on the current knowledge of 3D surface imaging in rhinoplasty derived from the literature, and highlights future directions of preoperative and postoperative assessment in the field.

Form and Function of the Nasal Tip: Reorienting and Reshaping the Lateral Crus

Dysfunction of the external nasal valve affects both the form and function of the nose. Successful treatment of these problems is dependent on proper analysis and diagnosis of the aberrant anatomy. Cephalic malpositioning of the lateral crura has been described for nearly 30 years. Repositioning of the lateral crura in a more caudal orientation with lateral crural strut grafts will correct aesthetic abnormalities and reinforce the external nasal valve. Sagittal malpositioning has been more recently described and also has deleterious effects on both the shape of the nasal tip and breathing. Reorienting the short axis of the lateral crus is another powerful tool for the rhinoplasty surgeon to correct the weak and narrow external nasal valve.

Digital imaging analysis to assess scar phenotype

In order to understand the link between the genetic background of patients and wound clinical outcomes, it is critical to have a reliable method to assess the phenotypic characteristics of healed wounds. In this study, we present a novel imaging method that provides reproducible, sensitive, and unbiased assessments of postsurgical scarring. We used this approach to investigate the possibility that genetic variants in orofacial clefting genes are associated with suboptimal healing. Red‐green‐blue digital images of postsurgical scars of 68 patients, following unilateral cleft lip repair, were captured using the 3dMD imaging system. Morphometric and colorimetric data of repaired regions of the philtrum and upper lip were acquired using ImageJ software, and the unaffected contralateral regions were used as patient‐specific controls. Repeatability of the method was high with intraclass correlation coefficient score > 0.8. This method detected a very significant difference in all three colors, and for all patients, between the scarred and the contralateral unaffected philtrum (p ranging from 1.20−05 to 1.95−14). Physicians’ clinical outcome ratings from the same images showed high interobserver variability (overall Pearson coefficient = 0.49) as well as low correlation with digital image analysis results. Finally, we identified genetic variants in TGFB3 and ARHGAP29 associated with suboptimal healing outcome.

Endoscopic Forehead Approach for Minimally Invasive Benign Tumor Excisions

IMPORTANCE Direct transcutaneous resection has been a widely accepted standard for the removal of benign forehead lesions. In recent years, the endoscopic approach has become more prevalent because of its noninvasiveness. To date, only a few studies with limited case numbers have reported on this technique. We report our findings from one of the largest cohorts of patients undergoing tumor resection of the forehead via the endoscopic approach. OBJECTIVES To evaluate results of the endoscopic forehead approach for benign tumor excisions, to give a more nuanced insight into this procedure, and to discuss technical pearls and potential pitfalls from our experience. DESIGN, SETTING, AND PARTICIPANTS Multicenter, retrospective case study at 2 university centers and 1 private practice among 36 patients aged 18 to 72 years (mean age, 44 years) who underwent the endoscopic forehead approach for benign tumor resections. MAIN OUTCOMES AND MEASURES Symptoms at presentation, surgical procedure and duration, type of lesions, intraoperative and postoperative complications, recurrences, and patient satisfaction. RESULTS In total, 34 patients had an asymptomatic forehead mass, while 2 patients reported discomfort and headache. Among all patients, complete tumor excision was achieved endoscopically. The mean operative time was 36 minutes. Histopathological examination revealed 18 lipomas, 13 osteomas, 2 dermoid cysts, and 1 bone fragment after previous rhinoplasty. In 2 patients, no specimen was submitted. No hematomas, infections, scalp numbness, contour irregularities, temporal branch paralysis, or tumor recurrences occurred. One patient had a prolonged area of alopecia, which resolved on its own. All patients attested to a high satisfaction rate. CONCLUSIONS AND RELEVANCE The endoscopic approach offers excellent aesthetic results and allows for safe tumor removal. It has proven to be an effective and minimally invasive alternative to the conventional open approach. LEVEL OF EVIDENCE 4.

Evaluation of the Patient with Nasal Obstruction.

Nasal obstruction is often multifactorial and knowledge of the contributing factors is critical to appropriate evaluation, diagnosis, and execution of a treatment plan. Recognizing and appropriately managing all components of nasal obstruction will increase the likelihood of symptomatic improvement and patient satisfaction.

Regenerative Medicine and Nasal Surgery

Nasal surgery is a constellation of operations that are intended to restore form and function to the nose. The amount of augmentation required for a given case is a delicate interplay between patient aesthetic desires and corrective measures taken for optimal nasal airflow. Traditional surgical techniques make use of autologous donor tissue or implanted alloplastic materials to restore nasal deficits. Limited availability of donor tissue and associated harvest site morbidity have pushed surgeons and researchers to investigate methods to bioengineer nasal tissues. For this article, we conducted a review of the literature on regenerative medicine as it pertains to nasal surgery. PubMed was searched for articles dating from January 1, 1994, through August 1, 2014. Journal articles with a focus on regenerative medicine and nasal tissue engineering are included in this review. Our search found that the greatest advancements have been in the fields of mucosal and cartilage regeneration, with a growing body of literature to attest to its promise. With recent advances in bioscaffold fabrication, bioengineered cartilage quality, and mucosal regeneration, the transition from comparative animal models to more expansive human studies is imminent. Each of these advancements has exciting implications for treating patients with increased efficacy, safety, and satisfaction.

Healing Septal Perforations by Secondary Intention Using Acellular Dermis as a Bioscaffold

Objective: Several techniques are described in the literature for nasal septal perforation repair. Most of these involve interposition grafts in conjunction with local pedicled mucosal flaps. The following article describes our experience using acellular dermis as a bioscaffold to support the regrowth of nasal septal mucosa by secondary intention. Methods: Retrospective chart review of all patients who underwent repair of nasal septal perforations by the senior author using acellular dermis placed between the 2 sides of the perforation and covered with silastic splints to allow for mucosalization. Results: Thirteen patients underwent nasal septal perforation repair using this technique. All perforations repaired were under 2 cm in greatest dimension. Two-thirds of patients had complete closure of the perforation upon initial use of bioscaffolding technique. The remaining third achieved near-total closure with bioscaffolding technique and were able to be completely closed with a single additional procedure. Conclusions: Acellular dermis offers an alternative to most currently described complex flaps. The method can be used in patients with defects less than 2 cm, but initial data suggest caution when using in those with wound healing impediments. This technique is also an excellent choice for patients with multiple small septal perforations.

The Use of Open-Cell Foam and Elastic Foam Tape as an Affordable Skin Simulator for Teaching Suture Technique

The techniques of suturing and local tissue transfer are skills that areacquiredthroughmultipleyearsofsurgicalexperienceandcountless hours in the operating room. Each skill is challenging to acquire and implementbuteventuallyworks itsway into theprocedural repertoire of physicians in fields ranging fromfamilymedicine to plastic surgery.Equally challenging is the task of teachingmedical students and surgical residents these skillswithout compromisingpatient safetyor satisfaction.Dutyhour restrictionsandchanges in billing requirements pose new challenges for the medical student and junior resident seeking experience in the operating room. Thismakes the preparedness of student surgeons prior to their appearance in theoperativeenvironmentparamount. Simulatorsprovide early, safe experience for the beginning surgeon. Traditionally, suturingskills areacquiredbypracticingonananatomic substitute (eg, the pig’s foot), a skin simulator (eg, commercially available synthetic triple-layered material), or an object that has no anatomic semblance at all (eg, tying board). The pig’s foot, whichhasbeenused for decades as the “first ever suture recipient” by generations ofmedical students, has its share of problems from aneducational andpractical standpoint. Pigs’ feet canbemessyand relativelyexpensive (approximately

Novel technique for peritonsillar abscess drainage.

1.50perpound), and theymay not accurately resemble the true trilayered nature of skin owing to atrophy. Storage and disposal requires refrigeration and sanitary transport. The inability to save used specimens in a safe, nonodiferousmanner isanothercompellingargumentagainst theiruse.Likewise, synthetic skin, which is specifically engineered for the purposeofpracticingsuture technique, canbecumbersometoget from manufacturer to medical student. These single-use kits generally come with surgical instruments, which most training facilities alreadyhave, andarealmostprohibitively expensive,with costs ranging from

Saddle nose deformity and septal perforation in granulomatosis with polyangiitis

30toseveralhundreddollarsperkit. Sutureboards, sometimes consisting of only a “hook-in-cup” and/or 2 opposing latex Video at jamafacialplasticsurgery.com