Howard Krein

Assessment of Microvascular Anastomosis Training in Otolaryngology Residencies: Survey of United States Program Directors

16 (62%) of the labs were sponsored by otolaryngology departments with 6 (23%) supported by general surgery and the remainder from other sources. Albeit somewhat smaller than human vessels (0.5-1.0 mm vs. 1.95-2.95mm average inner diameters), rat femoral vessels are most commonly employed in training techniques. Thus, while providing the optimum tactile replication, rat vessels prove to be a formidable and challenging training model.

Parotid gland trauma.

Parotid trauma can lead to both short and long-term complications such as bleeding, infection, facial nerve injury, sialocele, and salivary fistula, resulting in pain and disfigurement. Facial injuries inferior to a line extended from the tragus to the upper lip should raise concern for parotid injury. These injuries can be stratified into three regions as they relate to the masseter muscle. Injuries posing the greatest risk of damage to Stensens duct include those anterior to the posterior border of the masseter and necessitate exploration. When the duct is disrupted, emphasis should be placed on primary repair or re-creation of the papilla; however, proximal ductal lacerations can be treated by ligation of the proximal segment. Isolated parenchymal injury can be treated with more conservative means. Sialocele and salivary fistula can frequently be managed nonoperatively with antibiotics, pressure dressings, and serial aspiration. Anticholinergic medications and the injection of botulinum toxin represent additional measures before resorting to surgical therapies such as tympanic neurectomy or parotidectomy.

Management of Auricular Hematoma and the Cauliflower Ear

Acute auricular hematoma is common after blunt trauma to the side of the head. A network of vessels provides a rich blood supply to the ear, and the ear cartilage receives its nutrients from the overlying perichondrium. Prompt management of hematoma includes drainage and prevention of reaccumulation. If left untreated, an auricular hematoma can result in complications such as perichondritis, infection, and necrosis. Cauliflower ear may result from long-standing loss of blood supply to the ear cartilage and formation of neocartilage from disrupted perichondrium. Management of cauliflower ear involves excision of deformed cartilage and reshaping of the auricle.

Subcutaneous vs Intramuscular Botulinum Toxin Split-Face Randomized Study

IMPORTANCE Much has been published regarding rejuvenation of the upper face with botulinum toxin A injection; however, the optimal target tissue layer has not been specifically examined. OBJECTIVE To seek a difference between subcutaneous (SC) and intramuscular (IM) administration. DESIGN, SETTING, AND PARTICIPANTS Prospective, randomized study at a tertiary care university facial plastic surgery practice. Nineteen patients who underwent botulinum toxin A treatment to the forehead were randomized so that each patient received IM injection on one side of the face and SC injection on the contralateral side. INTERVENTION Patients were assessed on the basis of eyebrow elevation before treatment, and at 2 weeks, 2 months, and 4 months following injection. Patients also completed a subjective questionnaire examining discomfort during injection, bruising, and tenderness, as well as their perception of their appearance after treatment. MAIN OUTCOME AND MEASURE Eyebrow height measurements between SC and IM techniques. RESULTS There was no difference in eyebrow height measurements between SC and IM techniques (0.00 [95% CI, -0.02 to 0.02]). Patients did report greater discomfort when receiving IM injections compared with SC injections (-0.76 [95% CI, -1.53 to 0.0005]). Patient satisfaction scores did not demonstrate a statistically significant difference between IM and SC techniques when measured on the first and second posttreatment visits; however, there was a trend toward significance on the final follow-up visit. CONCLUSIONS AND RELEVANCE Subcutaneous injection of botulinum toxin A is equally effective in achieving paralysis of the underlying frontalis muscle as IM botulinum toxin A administration. In addition, the SC route may result in less pain to patients receiving botulinum toxin A injection for rejuvenation of the upper face.

Nerve monitoring and stimulation during endoscopic neck surgery in the pig.

Objectives: To determine the feasibility of recurrent laryngeal nerve monitoring and stimulation during endoscopic neck surgery in an animal model.

Assessment of microvascular anastomosis training in otolaryngology residencies: Survey of United States program directors

OBJECTIVE To assess current microvascular training strategies in otolaryngology residency programs. STUDY DESIGN Cross-sectional study. SETTING U.S. otolaryngology residency programs. SUBJECTS AND METHODS A total of 104 U.S. otolaryngology program directors received surveys inquiring about program size, the presence of fellowship training in microvascular surgery, the number of microvascular cases per month, the use of microvascular animal laboratory, and whether residents, fellows, or co-attendings assist in the anastomoses. RESULTS A 51 percent response rate was achieved, and of the 54 programs that responded, 78 percent reported no microvascular fellowship positions in plastics or head and neck reconstruction. A total of 52 percent reported performing three or fewer microvascular surgeries per month. Of the programs that did not have a microvascular fellow, only five (12%) performed eight or more surgeries per month. A total of 65 percent of the programs reported that residents assist during the anastomosis at least 75 percent of the time. Of the programs where residents assist 75 percent or more of the time, 70 percent have a formal training in microvascular technique ranging from demonstrating laboratory competencies to multiday courses. A total of 48 percent of the responding programs report having an animal laboratory for microvascular surgery. All animal laboratories used the rat as the model. CONCLUSION Many programs find value in providing residents with microvascular training, both in the operating room and in the laboratory. Only a small minority of programs without fellowship positions responded that they perform microvascular surgery on a regular basis (4 or more surgeries per month).

Use of the Anterolateral Thigh in Cranio-Orbitofacial Reconstruction

Objective. To detail the clinical outcomes of a series of patients having undergone free flap reconstruction of the orbit and periorbita and highlight the anterolateral thigh (ALT) as a workhorse for addressing defects in this region. Methods. A review of 47 patients who underwent free flap reconstruction for orbital or periorbital defects between September 2006 and May 2011 was performed. Data reviewed included demographics, defect characteristics, free flap used, additional reconstructive techniques employed, length of stay, complications, and follow-up. The ALT subset of the case series was the focus of the data reviewed for this paper. Selected cases were described to highlight some of the advantages of employing the ALT for cranio-orbitofacial reconstruction. Results. 51 free flaps in 47 patients were reviewed. 38 cases required orbital exenteration. The ALT was used in 33 patients. Complications included 1 hematoma, 2 wound infections, 3 CSF leaks, and 3 flap failures. Conclusions. Free tissue transfer allows for the safe and effective reconstruction of complex defects of the orbit and periorbital structures. Reconstructive choice is dependent upon the extent of soft tissue loss, midfacial bone loss, and skullbase involvement. The ALT provides a versatile option to reconstruct the many cranio-orbitofacial defects encountered.

Morbidity and Survival in Elderly Patients Undergoing Free Flap Reconstruction: A Retrospective Cohort Study

Objective To review a single institution’s outcomes of free flap reconstruction of the head and neck in patients aged ≥80 years as compared with those <80 years. Study Design Retrospective cohort study. Setting Tertiary academic hospital. Subjects and Methods Patients aged ≥ 80 years who underwent free flap reconstruction of the head and neck between 2007 and 2013 were identified and matched by type of reconstruction with a cohort of younger patients. Outcome measures included flap success, length of stay, discharge disposition, complications, and 2-year mortality. Associations between complications and comorbidities were also evaluated. Results Sixty-six patients aged ≥80 years were identified, and a paired sample <80 years old was selected. There were 3 flap failures per group and 1 perioperative mortality in the elderly group. There was no significant difference in length of stay or major complications between groups. Significantly more elderly patients were discharged to a nursing facility. There was no significant difference in mortality rates at 2 years postoperatively. No associations were seen between level of comorbidity and complications among the elderly group. Conclusion Free flap reconstruction of the head and neck remains a viable option in patients of advanced age. Similar outcomes in terms of flap success, complications, and length of hospitalization can be achieved as compared with younger patients undergoing similar reconstructions. The role of comorbid disease as a predictor of complications remains unclear. There is no significant difference in 2-year mortality for elderly free flap patients versus younger controls.

Microvascular Free Flap Reconstruction of Orbitocraniofacial Defects

ABSTRACT Purpose: To examine the etiology, surgical extent and techniques, complications, and outcomes of microvascular free flaps (MFF) in the reconstruction of orbitocraniofacial defects. Design: A retrospective, institutional review board approved study was performed of all patients undergoing MFF to repair orbitocraniofacial defects over 51 months. Participants: Fifty-eight patients undergoing MFF to repair orbitocraniofacial defects were included. Material and Methods: Variables analyzed included demographics, etiology, resection area(s), donor site, flap size, duration of surgery, complications, length of hospital stay, flap survival, and mortality. Results: Fifty-eight patients underwent 61 MFFs from June 2007 to September 2011. The majority of patients were white (79.3%) and male (72.4%). The mean age was 64.1 years. The most common etiology was intraorbital and skull base extension of cutaneous squamous cell carcinoma (29.3%) followed by sinonasal squamous cell carcinoma (13.8%). Dura and/or brain were exposed in 44.8% of cases. MFFs were harvested from the anteriolateral thigh in 71.4% of cases with a 180.9 cm2 mean flap area. The mean length of hospital stay was 15.3 days and mean length of surgical time was 11 h and 17 min. Conclusions: Complex orbitocraniofacial defects require a multi-disciplinary team skilled in surgical extirpation and advanced reconstructive techniques. MFF should be considered in the management of large defects, especially when there is dura or brain exposure. Intensive postoperative monitoring is indicated for both systemic and flap-related complications. MMFs provide excellent coverage of large areas of exposed critical skull base structures, including dura and brain, and may allow for earlier adjuvant treatment.

Management of acute soft tissue injury to the auricle.

The external ear is commonly involved in facial trauma. Injuries to the ear can range from simple lacerations to complete avulsions. We review the normal auricular anatomy and vascular supply, as well as the initial management of any auricular injury. Furthermore, we review the literature on soft tissue injuries of the ear and present a simple algorithm for classifying injuries. The classification is based on whether or not cartilage is involved. Injuries to the lobule do not involve cartilage and thus are more easily repaired by simple closure or Z-plasty. Injuries involving cartilage are further classified into partial or complete avulsions. A complete avulsion is then categorized by having a wide or narrow pedicle. There is no standardized, definitive management for the various types of auricular trauma, and this schema may assist in deciding which of the various reconstructive options is most appropriate for a particular case.