James P. Newman

Surgical Morbidity of Neck Dissection after Chemoradiotherapy in Advanced Head and Neck Cancer

The use of chemotherapy and irradiation for organ preservation attempts to eliminate the need for extensive surgery in patients with advanced squamous cell carcinoma of the head and neck (SCCHN). We sought to characterize the morbidity of surgery in patients who needed surgery after treatment with induction chemotherapy followed by simultaneous chemotherapy and radiotherapy (chemoradiotherapy). The surgical morbidity within the first 30 postoperative days of 17 patients treated in an organ preservation approach between July 1991 and December 1994 was compared with a control group of patients undergoing similar surgical procedures during the same period. The organ preservation study patients underwent surgical procedures consisting of 18 neck dissections and 5 resections of the primary site. Six patients in the organ preservation study group experienced 8 surgical complications within the first 30 postoperative days, and most complications were minor. There was no significant difference in the duration of surgery or length of hospitalization between study patients and matched controls. Our surgical complication rate (35.3%) was higher but not statistically different from that of the control group, and compared favorably to reports of surgical morbidity (44% to 61%) in the literature on patients treated with chemoradiotherapy. The lower complication rate seen in this study may be a reflection of early surgical intervention as part of our organ preservation study scheme, the preponderance of neck dissections performed, and the limited number of pharyngeal procedures performed.

Review of closed dressings after laser resurfacing.

Background. Laser skin resurfacing has become an accepted technique for the treatment of facial rhytides and associated solar skin damage. Achieving a successful result is directly related to proper postoperative wound care during the reepithelialization process. There are open and closed approaches to the treatment of the post‐laser resurfacing patient with distinct advantages and disadvantages. Objective. To review the most commonly used closed dressings after facial laser skin resurfacing and compare their advantages and disadvantages. To compare clinical findings with a group of patients treated exclusively with an open technique. Methods. Review of composite foams, polymer film, polymer mesh, and hydrogel products and prospective observations of clinical outcomes of patients treated with each dressing category after facial laser skin resurfacing. We perform a retrospective chart review of a group of patients treated exclusively with an open technique comparing crust formation, comfort, and pruritus with the prospective group of patients treated with closed dressings. Results. The closed dressings available today each have unique structural configurations and adhesive properties intended to maintain an occlusive wound environment. Patient acceptance of these dressings was favorable, with improved comfort compared to the open dressing group. Complications of bacterial infections and contact dermatitis were not observed when closed dressings were used with a protocol for dressing changes performed at 48 hours. Rates of reepithelialization did not vary according to dressing category. Crust formation and postoperative pruritus occurred less frequently when closed occlusive dressings were worn by patients. Conclusions. When used properly, these dressings improve patient comfort, simplify their postoperative wound care, and do not increase the risk of infection or contact dermatitis. Overall satisfaction was highest with perforated mesh and polymer dressings for full‐face wounds.

Recognition and Surgical Management of the Upper Airway Resistance Syndrome

Patients with upper airway resistance syndrome (UARS) have clinical signs and symptoms of excessive daytime somnolence (EDS) in the absence of obstructive sleep apnea. These patients have increased upper airway resistance, reflected by an elevated intrathoracic pressure measurement, despite a normal respiratory disturbance index (RDI). Physical findings often include excessive palatal tissue and narrowing of the oropharynx and hypopharynx.

Management of the clinically positive neck in organ preservation for advanced head and neck cancer

BACKGROUND To investigate clinicopathologic predictive criteria for the optimal management of neck metastases in patients with advanced head and neck cancers treated with combined chemoradiotherapy. METHODS Prospective study, 48 patients. Mean length follow-up, 23 months. RESULTS Neck stage predicted neck response to chemoradiotherapy; N3 necks showed more partial responses (P = 0.04), and N1 necks showed more complete responses (P = 0.12). Primary tumor site strongly predicted the pathologic response found on neck dissection in patients with a clinical partial response (cPR) following chemoradiotherapy. There was no difference in survival between patients with a clinical complete response (cCR) after chemoradiotherapy, and patients with a pathologic complete response (pCR) after neck dissection (P = 0.20); however, when grouped together, these patients survived longer than did patients with a pPR at neck dissection (P = 0.06). CONCLUSIONS Clinical response to induction chemotherapy is a poor predictor of ultimate neck control. Induction chemotherapy followed by chemoradiotherapy, and planned neck dissection for patients with persistent cervical lymphadenopathy, provides good regional control.

Trends in the management of alcohol withdrawal syndrome

Alcohol use among head and neck cancer patients is common. Alcohol withdrawal (especially delirium tremens) poses significant potential morbidity to postsurgical patients. Treatment with newer benzodiazepines (BZDs) such as lorazepam and midazolam has become more widespread, and mortality rates from severe alcohol withdrawal have decreased in recent years.

Elastometry and Clinical Results After Bipolar Radiofrequency Treatment of Skin

BACKGROUND The healing process of a novel radiofrequency bipolar system was recently shown to produce a profound increase in collagen and elastin content. OBJECTIVE To determine the relationship between subjective clinical improvement scores and changes in objective measures of mechanical skin properties. METHODS AND MATERIALS Elastometry measurements were made at baseline and 3 months after treatment. All patients received a treatment zone on the lower face. Patient assessments of results and physician ratings of wrinkle and skin laxity were collected at baseline and 3 and 6 months after treatment. Elastometry and clinical results were then compared. RESULTS Three months after treatment, elastometry measurements showed statistically significant improvement (5–12% decrease in Youngs Modulus and 10–16% decrease in retraction time). The average improvement correlated to a 2.6‐year improvement in skin property. Physician scores at 3 months showed a statistically significant improvement of 1.42 grades on the Fitzpatrick scale for wrinkles and 0.66 grades on the Alexiades scale for skin laxity, increasing to 1.57 and 0.70 improvement, respectively, at 6 months. Eighty‐nine percent and 91% of patients were satisfied or very satisfied with the procedure at 3‐ and 6‐month follow‐up, respectively. CONCLUSION Elastometry data showed an average decrease in Youngs Modulus and retraction time, both of which suggest that radiofrequency bipolar treatment resulted in more youthful skin. Better mechanical characteristics were consistent with improvements in wrinkles, laxity, and skin quality and appearance. Funding provided by Primaeva Medical, Inc. Drs. Willey, Kilmer, Newman, and Hantash serve on the advisory board of Primeava Medical. Drs. Berube and Renton and Mr. Krishna and Mr. McGill are employees of Primaeva Medical.

Brow Elevation Ratio: A New Method of Brow Analysis

OBJECTIVE To introduce a novel quantitative method measuring preoperative and postoperative brow position and apply it to a cohort of patients undergoing endoscopic brow suspension. DESIGN Retrospective review of patients who underwent endoscopic brow- and forehead-lift using a consistent operative technique and method of fixation. Changes in brow position were measured using standardized digital photographs of patients taken before and after surgery. Brow elevation was determined using a novel measurement system based on the ratio of the vertical height of the brow to the distance between the lateral corneal limbus and the medial canthus. RESULTS Sixteen consecutive patients (32 eyebrows) underwent surgery between January 7, 2003, and January 15, 2006, without any major complications. With follow-up ranging from 6 to 31 months (mean follow-up, 18 months), a statistically significant elevation of brow position was found. Mean brow ratio measurements increased by 18.0% on the right side and 16.1% on the left side, for an overall mean increase in brow position of 17.1%. The brow elevation ratio remained increased by a mean of 16.8% for patients who were followed up for almost 2 years and beyond. CONCLUSIONS The brow elevation ratio can be applied to patients undergoing brow suspension procedures with standard office photography. The ratios provide the surgeon with a quantitative dimension for assessing outcomes of brow elevation and can be used in comparative analysis of each patients baseline brow position.

Prospective Multicenter Clinical Trial of a Minimally Invasive Temperature-Controlled Bipolar Fractional Radiofrequency System for Rhytid and Laxity Treatment

BACKGROUND A minimally invasive fractional bipolar radiofrequency (FRF) was developed. OBJECTIVE To evaluate safety and efficacy of FRF in reducing face and neck rhytides and laxity. MATERIALS AND METHODS This prospective, open‐label, multicenter clinical trial enrolled 100 subjects with mild to severe facial and neck rhytides and laxity at seven centers in a per‐protocol analysis. One single‐pass FRF treatment was administered through five 32 g‐needle electrode pairs at a preselected real‐time fixed temperature of 62 to 78°C, energy duration for 3 to 5 seconds, and impedance restrictions of 200 to 3,000 Ohms, ensuring intradermal delivery. Five blinded dermatologists and plastic surgeons graded randomized standardized baseline and follow‐up photographs of 53 and 42 subjects at 3‐ and 6‐month follow‐up intervals, respectively, using the Fitzpatrick wrinkle and Alexiades‐Armenakas laxity scales. Subject assessments and adverse events were recorded in 100 subjects. RESULTS Blinded evaluations revealed correct pre‐ and post‐treatment identification in 100% of scored cases, mean improvement of 25.6% on the Fitzpatrick Wrinkle Scale and 24.1% on the Alexiades‐Armenakas laxity scale at 6 months, and 100% response rate for rhytides and 95% for laxity. Subgroup analysis revealed maximal rhytid reduction in the mean target temperature of 66.7, energy duration of 4.2 seconds, and volume of denatured collagen of mm3 denatured collagen group. Adverse events included transient erythema, edema, and ecchymoses, resolving within 1 to 5 days, and two incidents of temporary pinpoint depressions. More than 90% of subjects were satisfied or very satisfied. CONCLUSION Real‐time temperature‐controlled FRF is a highly reproducible, safe, effective nonsurgical treatment of face and neck rhytides and laxity and provides important insights into neocollagenesis, neoelastogenesis, and clinical outcomes.

Advantages and disadvantages of computer imaging in cosmetic surgery.

background. Despite the growing popularity of computer imaging systems, it is not clear whether the medical and legal advantages of using such a system outweigh the disadvantages. objective. The purpose of this report is to evaluate these aspects, and provide some protective guidelines in the use of computer imaging in cosmetic surgery. methods. The positive and negative aspects of computer imaging from a medical and legal perspective are reviewed. Also, specific issues are examined by a legal panel. results. The greatest advantages are potential problem patient exclusion, and enhanced physician‐patient communication. Disadvantages include cost, user learning curve, and potential liability. conclusion. Careful use of computer imaging should actually reduce ones liability when all aspects are considered. Recommendations for such use and specific legal issues are discussed.

Lasers, Fillers, and Neurotoxins: Avoiding Complications in the Cosmetic Facial Practice

Lasers, injectable fillers, and neurotoxins are widely used in facial restoration and rejuvenation by a variety of practitioners. Although they are less invasive than traditional surgical modalities, they still carry risks for both transient as well as permanent complications. It is paramount for the practitioner to understand these complications, optimize their prevention, and initiate appropriate treatment when they are encountered. This article reviews early, often transient, complications as well as delayed, often prolonged or permanent, complications, with particular focus on prevention and management.