Gregory H. Branham

Scalp Reconstruction An Algorithmic Approach and Systematic Review

IMPORTANCE Reconstruction of the scalp after acquired defects remains a common challenge for the reconstructive surgeon, especially in a patient with a history of radiation to the area. OBJECTIVE To review the current literature and describe a novel algorithm to help guide the reconstructive surgeon in determining the optimal reconstruction from a cosmetic and functional standpoint. Pertinent surgical anatomy, considerations for patient and technique selection, reconstructive goals, as well as the reconstructive ladder, are also discussed. EVIDENCE REVIEW A PubMed and Medline search was performed of the entire English literature with respect to scalp reconstruction. Priority of review was given to those studies with higher-quality levels of evidence. FINDINGS Size, location, radiation history, and potential for hairline distortion are important factors in determining the ideal reconstruction. The tighter and looser areas of the scalp play a major role in the potential for primary or local flap closure. Patients with medium to large defects and a history of radiation will likely benefit from free tissue transfer. CONCLUSIONS AND RELEVANCE Ideal reconstruction of scalp defects relies on a comprehensive understanding of scalp anatomy, a full consideration of the armamentarium of surgical techniques, and a detailed appraisal of patient factors and expectations. The simplest reconstruction should be used whenever possible to provide the most functional and aesthetic scalp reconstruction, with the least amount of complexity. LEVEL OF EVIDENCE NA.

Brow/Upper Lid Anatomy, Aging and Aesthetic Analysis

The upper eyelid serves the important anatomic function of protecting the eye and rewetting the cornea to maintain vision. The complex dynamic action of the upper eyelid explains its relatively complex anatomy. The brow has an important supportive role. Studies have revealed facial characteristics perceived as youthful and aged, and the anatomic basis of these changes is defined at many levels. Characteristic aging changes in the upper eyelid and brow create an appearance of aging and opportunities for functional and aesthetic improvement.

Revision Rates and Risk Factors of 175 842 Patients Undergoing Septorhinoplasty

IMPORTANCE Estimates of the rate of revision septorhinoplasty and the risk factors associated with revision are unknown because the current published literature is limited to small, retrospective, single-surgeon studies with limited follow-up time. OBJECTIVES To determine the rate of revision for septorhinoplasty surgery and to determine the risk factors associated with revision. DESIGN, SETTING, AND PARTICIPANTS Retrospective cohort analysis of 175 842 patients undergoing septorhinoplasty between January 1, 2005, and December 31, 2009, from the Healthcare Cost and Utilization Projects State Inpatient Databases, State Ambulatory Surgery and Services Databases, and State Emergency Department Databases from California, Florida, and New York. Revisit information for these patients was then collected from the 3 databases between January 1, 2005, and December 31, 2012, with a minimal follow-up time of 3 years; and study analysis done January 1, 2005, to December 31, 2012. MAIN OUTCOMES AND MEASURES Revision surgery after an index septorhinoplasty was the main outcome measure, and the rate of revision was calculated within subgroups of patients based on different demographic and clinical characteristics. A multivariable model was then used to determine independent risk factors for the performance of revision surgery. RESULTS The study cohort comprised 175 842 participants who underwent septorhinoplasty procedures; mean (SD) age was 41.0 (15.3) years, and 57.0% were male. The overall revision rate for any septorhinoplasty procedure was 3.3% (5775 of 175 842) (99% CI, 3.2%-3.4%). After separating the patients into primary septorhinoplasty and secondary septorhinoplasty groups, the primary group had an overall revision rate of 3.1% (5389 of 172 324), while the secondary group had an overall revision rate of 11.0% (386 of 3518). Patient characteristics associated with an increased rate of revision include younger age (5.9% [633 of 10 727]), female sex (3.8% [2536 of 67 397]), a history of anxiety (3.9% [168 of 4350]) or autoimmune disease (4.4% [57 of 1286]), and surgery for cosmetic (7.9% [340 of 4289]) or congenital nasal deformities (8.9% [208 of 2334]). CONCLUSIONS AND RELEVANCE The study results, derived from a large cohort of patients with long follow-up time, suggest that the rate of revision septorhinoplasty is low, but certain patient characteristics are associated with higher revision rates. These data provide valuable preoperative counseling information for patients and physicians. This study also provides robust data for third-party payers or government agencies in an era in which physician performance metrics require valid risk adjustment before being used for reimbursement and quality initiatives. LEVEL OF EVIDENCE 3.

Thirty-Day Hospital Revisit Rates and Factors Associated With Revisits in Patients Undergoing Septorhinoplasty.

Importance Estimates of the 30-day hospital revisit rate following septorhinoplasty and the risk factors associated with revisits are unknown in the current literature. Surgical 30-day readmission rates are important to establish, as they are increasingly used as a quality care metric and can incur future financial penalties from third-party payers and government agencies. Objective To determine the rate of 30-day hospital revisits following septorhinoplasty and the risk factors associated with revisits. Design, Setting, and Participants A retrospective cohort analysis was conducted of 175 842 patients undergoing septorhinoplasty between January 1, 2005, and December 31, 2009, using data from the Healthcare Cost and Utilization Project state inpatient database, state ambulatory surgery database, and state emergency department database from California, Florida, and New York. Information on revisits for these patients was collected from the 3 databases between January 1, 2005, and December 31, 2012. Data analysis was conducted from September 1, 2014, to May 1, 2015. Main Outcomes and Measures Hospital revisits within 30 days after an index septorhinoplasty and the primary diagnosis at the time of the revisit were the main outcome measures. The revisit rate was calculated within subgroups of patients based on different demographic and clinical characteristics. A multivariable model was then used to determine independent risk factors for the occurrence of a hospital revisit within 30 days of the septorhinoplasty procedure. Results In total, 11 456 of 175 842 patients (6.5%) who underwent septorhinoplasty procedures revisited the hospital within 30 days of the procedure. Most of these revisits (6353 [55.5%]) were to the emergency department. The most common primary diagnosis was bleeding or epistaxis, occurring in 2150 patients (1.2%). Multivariable logistic regression showed that patients aged 41 to 65 years (adjusted odds ratio [aOR], 1.09; 99% CI, 1.02-1.16) or older than 65 years (aOR, 1.23; 99% CI, 1.06-1.43) had an increased revisit rate, as did black patients (aOR, 1.39; 99% CI, 1.16-1.66); those with Medicare (aOR, 1.55; 99% CI, 1.32-1.81) and Medicaid (aOR, 1.63; 99% CI, 1.33-2.01); those with diagnoses of autoimmune disorders or immunodeficiency (aOR, 2.69; 99% CI, 1.20-6.03), coagulopathy (aOR, 2.06; 99% CI, 1.33-3.20), anxiety (aOR, 1.79; 99% CI, 1.55-2.07), and alcohol use (aOR, 1.70; 99% CI, 1.35-2.14); and those who had a conchal cartilage graft (aOR, 2.01; 99% CI, 1.29-3.14). Conclusions and Relevance The study results suggest that patients with more medical comorbidities and lower socioeconomic status most commonly returned to the emergency department for surgical complications, such as bleeding or epistaxis, in the 30-day period after the procedure. These data provide valuable preoperative counseling information for patients and physicians. In addition, this study provides data to third-party payers or government agencies in which postprocedure readmissions in the 30-day period are used as a quality care metric affecting reimbursements and financial penalties. Level of Evidence 3.

Septal Perforation Repair Using Polydioxanone Plates: A 10-Year Comparative Study.

Summary: Medium to large septal perforations are a challenging problem to the rhinoplasty surgeon. In this study, records and outcomes are reviewed for 25 patients who underwent septal perforation repair over a 10-year period. All patients underwent an open septorhinoplasty approach with use of bilateral opposing mucoperichondrial flaps and a unique intervening graft that included acellular dermis, temporalis fascia alone, or a novel closure technique using temporalis fascia and a polydioxanone plate. The authors identify that for medium to large septal perforations, the use of the polydioxanone plate with temporalis fascia provided the highest rate of closure as a method of scaffolding a fascial graft, and also provided ease of placement between opposing mucoperichondrial flaps. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Anatomical evidence of microbial biofilms in an alloplastic nasal implant.

Recently, bacterial biofilms have been proposed as a potential cause of the extreme resistance to antibiotics and impaired host responses in potentially infected facial implants. As opposed to the bacteria in a free-floating or planktonic state, biofilms exist in a sessile form, adherent to a solid or liquid interface and become embedded in a complex matrix that is oftentimes impenetrable to modern day antibiotics. This can lead to chronic infection of implants which ultimately necessitates their removal in a majority of cases. In this novel case report, we show the histomorphological appearance of biofilm formation in a patient with an alloplastic nasal implant that was persistently infected and had to be removed.Level of Evidence IVThis 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.

Titanium Mesh Nasal Repair without Nasal Lining

Abstract The objective of this study was to describe outcomes for patients who underwent titanium mesh reconstruction of full‐thickness nasal defects without internal lining repair. This is a retrospective cohort study. Patients with through‐and‐through nasal defects were identified at a single academic institution between 2008 and 2016. Nasal reconstruction was performed with either titanium mesh and external skin reconstruction without repair of the intranasal lining or traditional three‐layer closure. Five patients underwent titanium mesh reconstruction and 11 underwent traditional three‐layer repair. Median follow‐up was 11 months (range, 2‐66 months). The only significant difference between groups was older age in patients undergoing titanium reconstruction (mean, 81 vs. 63 years; difference of 18; 95% confidence interval [CI], 4‐32 years). Defect extent including overall size and structures removed was similar between groups (p > 0.05). Paramedian forehead flap was the most common external reconstruction in both groups (100% for titanium mesh and 73% for three‐layer closure). Time under anesthesia was significantly shorter for titanium mesh reconstruction (median, 119 vs. 314 minutes; difference of 195; 95% CI, 45‐237). Estimated blood loss and length of hospital stay were similar between groups (p > 0.05). Complication rates were substantial although not significantly different, 40 and 36% in titanium and three‐layer reconstruction, respectively (p > 0.05). All patients with complications after titanium reconstruction had prior or postoperative radiotherapy. Titanium mesh reconstruction of through‐and‐through nasal defects can successfully be performed without reconstruction of the intranasal lining, significantly decreasing operative times. This reconstructive technique may not be suitable for patients who undergo radiotherapy.

Lower Eyelid Blepharoplasty

The goal of lower eyelid blepharoplasty is to rejuvenate the lower lid while maintaining a natural, unoperated appearance. Successful lower eyelid blepharoplasty depends on knowledge of the anatomy and surgical techniques, accurate preoperative analysis, and attention to detail. Common issues of the lower eyelid such as malar descent, tear trough deformity, pseudoherniated fat, lid laxity, and skin texture changes as well as dermatochalasis and festoons must be recognized. Specific techniques to address these include transcutaneous and transconjunctival approaches, fat excision, fat transposition, orbicularis suspension, lateral canthal tightening, malar suspension, and skin excision/resurfacing.

Complications and Reoperations in Mandibular Angle Fractures

Importance Mandible angle fractures can be repaired in a variety of ways, with no consensus on the outcomes of complications and reoperation rates. Objectives To analyze patient, injury, and surgical factors, including approach to the angle and plating technique, associated with postoperative complications, as well as the rate of reoperation with regard to mandible angle fractures. Design, Setting, and Participants Retrospective cohort study analyzing the surgical outcomes of patients with mandible angle fractures between January 1, 2000, and December 31, 2015, who underwent open reduction and internal fixation. Patients were eligible if they were aged 18 years or older, had 3 or less mandible fractures with 1 involving the mandibular angle, and had adequate follow-up data. Patients with comminuted angle fractures, bilateral angle fractures, and multiple surgical approaches were excluded. A total of 135 patients were included in the study. All procedures were conducted at a single, large academic hospital located in an urban setting. Main Outcomes and Measures Major complications and reoperation rates. Major complications included in this study were nonunion, malunion, severe malocclusion, severe infection, and exposed hardware. Results Of 135 patients 113 (83.7%) were men; median age was 29 years (range, 18-82 years). Eighty-seven patients (64.4%) underwent the transcervical approach and 48 patients (35.6%) received the transoral approach. Fifteen (17.2%) patients in the transcervical group and 9 (18.8%) patients in the transoral group experienced major complications (difference, 1%; 95% CI, −8% to 10%). Thirteen (14.9%) patients in the transcervical group and 8 (16.7%) patients in the transoral group underwent reoperations (difference, 2%; 95% CI, −13% to 17%). Active smoking had a significant effect on the rate of major complications (odds ratio, 4.04; 95% CI, 1.07 to 15.34; P = .04). Conclusions and Relevance During repair of noncomminuted mandibular angle fractures, both of the commonly used approaches—transcervical and transoral—can be used during treatment with equal rates of complication and risk of reoperation. For a patient undergoing surgery for mandibular angle fracture, smoking status is more likely to predict surgical outcomes rather than how the surgeon chooses to approach and fixate the fracture. Level of Evidence 3.

A 3-Dimensional–Printed Short-Segment Template Prototype for Mandibular Fracture Repair

Importance After reduction of complex mandibular fractures, contouring of the fracture plates to fixate the reduced mandibular segments can be time-consuming. Objective To explore the potential application of a 3-dimensional (3-D)-printed short-segment mandibular template in the management of complex mandibular fractures. Design, Setting, and Participants A feasibility study was performed at a tertiary academic center using maxillofacial computed tomography data of 3 patients with comminuted mandibular fractures who required preoperative planning with a perfected complete mandible model. Interventions Thresholding, segmentation, and realignment of the fractured mandible were performed based on computed tomography data. Each reduced mandible design was divided to create 3-D templates for 6 fracture sites: right and left angle, body, and symphyseal/parasymphyseal. Sessions were conducted with junior otolaryngology and plastic surgery residents, during which mandibular fracture plates were contoured in a “preoperative” setting against the 3-D–printed short-segment templates, and an “intraoperative” setting against the previously manufactured, complete mandible model. The previously manufactured, complete model served as a surrogate for the intraoperative mandible with the fracture site reduced. Main Outcomes and Measures The time for 3-D template printing, the “preoperative” (measure of the time consumed preoperatively), and “intraoperative” (measure of the time saved intraoperatively) times were recorded. Comparisons were made for cost estimates between a complete model and the 3-D–printed short-segment template. The operating room charge equivalent of the intraoperative time was also calculated. Results Of the 3 patients whose data were used, 1 was a teenager and 2 were young adults. The total time for 3-D modeling and printing per short-segment template was less than 3 hours. The median (range) intraoperative time saved by precontouring the fracture plates was 7 (1-14), 5 (1-30), and 7 (2-15) minutes, and the operating room charge equivalents were