Ira D. Papel

Transsphenoidal approach to the sella: The johns hopkins experience

The transsphenoidal hypophysectomy has become a relatively frequent procedure in recent years, with the otolaryngologist playing a major role in its renewed popularity. This paper reviews the evoluation of pituitary surgery, duscusses the surgical technique currently used, and reviews the results and complications of 114 cases over a 13‐year period.

Drosophila alcohol dehydrogenase activity in vitro and in vivo: Effects of acetone feeding

When adult Drosophila are placed on medium containing 0.5% acetone, their level of alcohol dehydrogenase activity drops rapidly. At the same time, the proportion of activity in the various electrophoretic forms of the enzyme shifts; most of the activity becomes localized in what is ordinarily a minor form of the enzyme. Moreover, the loss of enzyme activity occurs in vivo as well, as shown by sensitivity to ethanol poisoning, insensitivity to pentenol treatment, and inability to utilize ethanol as an energy source. These observations are discussed in light of a model advanced for the origin of the multiple forms of alcohol dehydrogenase in Drosophila.

Caudal Septal Deviation

The nasal septum is a structure poorly understood and appreciated by the lay public and the nonotolaryngologist--head and neck surgeon alike. Deviation of the caudal portion of the nasal septum may result in nasal obstruction, a crooked nose, and columellar irregularities. The correction of a severely deviated caudal septum is one of the most difficult challenges of the otolaryngologist and facial plastic surgeon. A variety of options are available for correction of mild, to the most severe, deflections. This condition, as with all challenges in medicine, should not be a one size fits all or one surgery fits all situation. The skilled surgeon should understand the multiple options available for surgical correction and tailor fit the procedure to the deformity.

Compression plates in the treatment of advanced anterior floor of mouth carcinoma

Advanced anterior floor of mouth squamous cell carcinoma has been traditionally treated with wide excision in conjunction with mandibulectomy and radical neck dissection. This has resulted in significant mandibulofacial defects with functional and cosmetic significance. Efforts at primary reconstruction in the past using bone grafts, osteomyocutaneous flaps, and other methods have yielded unsatisfactory results. A history of prior irradiation has made this problem even more refractory.

Impact of crooked nose rhinoplasty on observer perceptions of attractiveness

To evaluate the impact of a crooked nose on observer perceptions of facial asymmetry and attractiveness and the ability of rhinoplasty to minimize it. We hypothesized that the presence of a crooked nose would penalize symmetry and attractiveness ratings as compared to normal faces. We further hypothesized that straightening rhinoplasty would restore symmetry and improve attractiveness.

DEPROJECTING THE NASAL PROFILE

The nose is the most prominent aesthetic feature of the facial profile. Nasal length, tip rotation, and tip projection are integral aspects in analysis of the nasal profile. In most rhinoplasties the surgeon has the difficult task of increasing or maintaining tip projection of an underprojected or normally projected nasal tip. Less commonly, the rhinoplastic surgeon is presented with an overprojected nasal tip, and efforts are focused on deprojecting the nasal profile. In this article, the authors present a discussion of the overprojected tip, elucidating strategies of analysis, etiologies, and management of the nasal profile and give clinical examples.

Prevalence of Body Dysmorphic Disorder and Surgeon Diagnostic Accuracy in Facial Plastic and Oculoplastic Surgery Clinics

Importance Body dysmorphic disorder (BDD) is a relative contraindication for facial plastic surgery, but formal screening is not common in practice. The prevalence of BDD in patients seeking facial plastic surgery is not well documented. Objective To establish the prevalence of BDD across facial plastic and oculoplastic surgery practice settings, and estimate the ability of surgeons to screen for BDD. Design, Setting, and Participants This multicenter prospective study recruited a cohort of 597 patients who presented to academic and private facial plastic and oculoplastic surgery practices from March 2015 to February 2016. Methods All patients were screened for BDD using the Body Dysmorphic Disorder Questionnaire (BDDQ). After each clinical encounter, surgeons independently evaluated the likelihood that a participating patient had BDD. Validated instruments were used to assess satisfaction with facial appearance including the FACE-Q, Blepharoplasty Outcomes Evaluation (BOE), Facelift Outcomes Evaluation (FOE), Rhinoplasty Outcomes Evaluation (ROE), and Skin Rejuvenation Outcomes Evaluation (SROE). Results Across participating practices (9 surgeons, 3 sites), a total of 597 patients were screened for BDD: 342 patients from site 1 (mean [SD] age, 44.2 [16.5] years); 158 patients, site 2 (mean [SD] age, 46.0 [16.2] years), site 3, 97 patients (mean [SD] age, 56.3 [15.5] years). Overall, 58 patients [9.7%] screened positive for BDD by the BDDQ instrument, while only 16 of 402 patients [4.0%] were clinically suspected of BDD by surgeons. A higher percentage of patients presenting for cosmetic surgery (37 of 283 patients [13.1%]) compared with those presenting for reconstructive surgery (21 of 314 patients [6.7%]) screened positive on the BDDQ (odds ratio, 2.10; 95% CI, 1.20-3.68; Pu2009=u2009.01). Surgeons were only able to correctly identify 2 of 43 patients (4.7%) who screened positive for BDD on the BDDQ, and the positive likelihood ratio was only 1.19 (95% CI, 0.28-5.07). Patients screening positive for BDD by the BDDQ had lower satisfaction with their appearance as measured by the FACE-Q, ROE, BOE, SROE, and FOE. Conclusions and Relevance Body dysmorphic disorder is a relatively common condition across facial plastic and oculoplastic surgery practice settings. Patients who screen positive on the BDDQ have lower satisfaction with their facial appearance at baseline. Surgeons have a poor ability to screen for patients with BDD when compared with validated screening instruments such as the BDDQ. Routine implementation of validated BDD screening instruments may improve patient care. Level of Evidence NA.

Association of Face-lift Surgery With Social Perception, Age, Attractiveness, Health, and Success

Importance Evidence quantifying the influence of face-lift surgery on societal perceptions is lacking. Objective To measure the association of face-lift surgery with observer-graded perceived age, attractiveness, success, and overall health. Design, Setting, and Participants In a web-based survey, 526 casual observers naive to the purpose of the study viewed independent images of 13 unique female patient faces before or after face-lift surgery from January 1, 2016, through June 30, 2016. The Delphi method was used to select standardized patient images confirming appropriate patient candidacy and overall surgical effect. Observers estimated age and rated the attractiveness, perceived success, and perceived overall health for each patient image. Facial perception questions were answered on a visual analog scale from 0 to 100, with higher scores corresponding to more positive responses. To evaluate the accuracy of observer age estimation, the patients’ preoperative estimated mean age was compared with the patients’ actual mean age. A multivariate mixed-effects regression model was used to determine the effect of face-lift surgery. To further characterize the effect of face-lift surgery, estimated ordinal-rank change was calculated for each domain. Main Outcomes and Measures Blinded casual observer ratings of patients estimated age, attractiveness, perceived success, and perceived overall health. Results A total of 483 observers (mean [SD] age, 29 [8.6] years; 382 women [79.4%]) successfully completed the survey. Comparing patients’ preoperative estimated mean (SD) age (59.6 [9.0] years) and patients’ actual mean (SD) age (58.4 [6.9] years) revealed no significant difference (t2662u2009=u2009−0.47; 95% CI, −6.07 to 3.72; Pu2009=u2009.64). On multivariate regression, patients after face-lift surgery were rated as significantly younger (coefficient, −3.69; 95% CI −4.15 to −3.23; Pu2009<u2009.001), more attractive (coefficient, 8.21; 95% CI, 7.41-9.02; Pu2009<u2009.001), more successful (coefficient, 5.82; 95% CI, 5.05 to 6.59; Pu2009<u2009.001), and overall healthier (coefficient, 8.72; 95% CI, 7.88-9.56; Pu2009<u2009.001). The ordinal rank changes for an average individual were −21 for perceived age, 21 for attractiveness, 16 for success, and 21 for overall health. Conclusions and Relevance In this study, observer perceptions of face-lift surgery were associated with views that patients appeared younger, more attractive, healthier, and more successful. These findings highlight observer perceptions of face-lift surgery that could positively influence social interactions. Level of Evidence NA.

Spreader Grafts in Functional Rhinoplasty.

Management of the middle vault is paramount to achieving optimal aesthetic and functional outcomes in rhinoplasty. The ideal treatment for middle vault complications, such as internal nasal valve collapse, inverted-V deformity, and middle vault dorsal asymmetry, is prevention. Risk factors for middle vault problems in rhinoplasty that may be identified in preoperative consultation include short nasal bones, long and weak upper lateral cartilages, thin skin, previous trauma or surgery, preoperative positive Cottle maneuver, tension nose deformity, and anteriorly positioned inferior turbinates. When any of these risk factors are identified, preventive measures should be pursued. These include preservation of middle vault support structures, judicious resection in dorsal hump reduction, use of conservative osteotomies, and reconstruction of the cartilaginous middle vault with structural grafting. Spreader grafts have become the workhorse in middle vault reconstruction. They are invaluable in restoring nasal dorsal aesthetic lines, repairing or maintaining the internal nasal valve, and buttressing a corrected crooked nose. Functional and aesthetic problems related to the middle nasal vault are among the most common reasons for patients seeking revision rhinoplasty. Although complications in rhinoplasty are inevitable, underlying their etiology and instituting prophylactic treatment can significantly help reduce their occurrence.

Otolaryngology–Head and Neck Surgery at Johns Hopkins: The First 100 Years (1914–2014)

Early Days of Otolaryngology at Johns Hopkins As The Johns Hopkins Hospital opened in 1889 (Fig. 1), the Outpatient Department was organized under the direction of William S. Halsted. Nine divisions were initially formed: 1) the Department of General Medicine, directed by William Osler; 2) the Department of Diseases of Children, directed by William Osler and W.D. Booker; 3) the Department of Nervous Diseases, directed by William Osler and H.M. Thomas; 4) the Department of General Surgery, directed by William S. Halsted and John M.T. Finney; 5) the Department of Genitourinary Diseases, directed by William S. Halsted and James Brown; 6) the Department of Gynecology, directed by Howard A. Kelly and Hunter Robb; 7) the Department of Ophthalmology and Otology, directed by Samuel Theobald and Robert L. Randolph; 8) the Department of Laryngology, directed by John N. Mackenzie; and 9) the Department of Dermatology, directed by R.B. Morrison. From the beginning, there was controversy about how these departments were run. Most of the physicians were private practitioners and served without any compensation for their clinical or teaching efforts. The space provided to see patients was crowded, poorly equipped, and understaffed. William S. Halsted assigned no public beds to the clinical staff; therefore, many surgical procedures were done in the clinic exam rooms, with the patients discharged after ether anesthesia. All otolaryngology cases that required the main operating rooms were referred to the general surgery staff and operated on by John M.T. Finney, Joseph C. Bloodgood, or the resident surgeons. Thus, surgeons with little if any otolaryngology training performed the surgery, whereas staff members who were experienced in the field were excluded from the operating room. This system was kept in place until 1912. As was commonly the practice at that time, otology and laryngology were relegated to separate departments. It was not unusual for physicians of that time to specialize in diseases of the eyes, ears, nose, and throat. Such was the case with Samuel Theobald, an 1867 graduate of the University of Maryland School of Medicine, Baltimore, who studied in Vienna and London before practicing in Baltimore. He was appointed to the Johns Hopkins staff in 1896 and continued to head the ophthalmology section of surgery until his retirement in 1925. Later, he was a founder of the Baltimore Eye, Ear, and Throat Charity Hospital, one of the predecessors of Greater Baltimore Medical Center (GBMC). Robert L. Randolph was also a University of Maryland graduate, receiving his MD in 1884. He sought training in Vienna and was for a time the assistant to the chief of the Vienna Polyclinic Ophthalmology Department. After returning to Baltimore, Randolph was appointed to the Johns Hopkins staff in 1896 and served until his death in 1919, by which time he was an associate professor of clinical ophthalmology and otology. Randolph had a wide reputation for innovative lectures and clinical instruction. John N. Mackenzie was among several individuals in Baltimore who during the late 19th century became interested in laryngology. He graduated from the University of Virginia School of Medicine, Charlottesville, in 1876. After study at Metropolitan Throat Hospital and Dispensary of New York, he traveled abroad in 1879, studied in Vienna and Munich, and then served as chief of clinic in laryngology under Morrell Mackenzie (not related) at the Hospital for Diseases of the Throat and Chest in London. Morrell Mackenzie, perhaps the leading European laryngologist of his generation, managed the infamous affair of Kaiser Friedrich III’s laryngeal cancer in the 1880s. John N. Mackenzie was appointed to the Johns Hopkins staff in 1889. From the Department of Otolaryngology–Head and Neck Surgery, The Johns Hopkins University (H.W.F., I.P., I.L., W.K., D.T., P.F., S.L., B.M., S.B., J.C., A.L., P.B., D.W.E.), Baltimore, Maryland; the Department of Otolaryngology–Head and Neck Surgery, University of Pennsylvania (D.K.), Philadelphia, Pennsylvania; the Departments ofOtorhinolaryngology–Head and Neck Surgery and Pediatrics Albert Einstein College of Medicine Montefiore Medical Center (R.R.), New York, New York; the Department of Otolaryngology–Head and Neck Surgery, University of California at Los Angeles (F.L.), Los Angeles, California; and the Department of Otolaryngology–Head and Neck Surgery, Oregon Health Sciences University (P.F.), Portland, Oregon, U.S.A. Editor’s Note: This Manuscript was accepted for publication on June 15, 2015. The authors have no funding, financial relationships, or conflicts of interest to disclose. Send correspondence to David W. Eisele, MD, FACS, Department of Otolaryngology–Head and Neck Surgery, The Johns Hopkins University School of Medicine, 601 N. Caroline Street, Johns Hopkins Outpatient Center 6th Floor, Baltimore, MD 21287. E-mail: deisele1@jhmi.edu