Jennifer C. Kim

PREVENTION OF WOUND COMPLICATIONS FOLLOWING SALVAGE LARYNGECTOMY USING FREE VASCULARIZED TISSUE

Total laryngectomy following radiation therapy or concurrent chemoradiation therapy is associated with unacceptably high complication rates because of wound healing difficulties. With an ever increasing reliance on organ preservation protocols as primary treatment for advanced laryngeal cancer, the surgeon must develop techniques to minimize postoperative complications in salvage laryngectomy surgery. We have developed an approach using free tissue transfer in an effort to improve tissue vascularity, reinforce the pharyngeal suture line, and minimize complications in this difficult patient population. The purpose of this study was to outline our technique and determine the effectiveness of this new approach.

The versatility of the temporoparietal fascia flap in head and neck reconstruction

OBJECTIVES The temporoparietal fascia flap (TPFF) is a versatile tool in head and neck reconstruction. This article aims to describe the spectrum of TPFF applications through a series of case studies and related review of the literature. METHODS Medical records were reviewed to identify cases that represent major TPFF application categories. A literature review was performed to support the presentation and discussion of each case category. RESULTS Seven cases were identified each representing a distinct application category. These included auricular reconstruction, hair-bearing tissue transfer, facial soft tissue augmentation, cutaneous and mucosal oncologic defect repair, reconstruction after salvage laryngectomy, skull base reconstruction, and orbital reconstruction. CONCLUSION The TPFF is a uniquely versatile tool in head and neck reconstructive surgery. Outstanding in its pliable, ultra-thin yet hardy and highly vascular form, the temporoparietal fascia flap is a workhorse for the creative head and neck reconstructive surgeon.

Potential of an Electric Prosthesis for Dynamic Facial Reanimation

Chronic facial paralysis is a devastating condition with severe functional and emotional consequences. The current surgical armamentarium permits the predictable reestablishment of a protective blink as well as good resting symmetry. Yet the ultimate goal of symmetric, spontaneous emotional expression remains elusive despite significant progress in the areas of peripheral nerve grafting and free tissue transfer. This commentary explores the possibility of an implantable electrical prosthesis for facial reanimation. It reviews animal studies supporting this concept as well as recent human data suggesting that such an implant could rescue denervated facial musculature, thus overcoming a major hurdle for existing reanimation techniques.

Outcomes Following Temporalis Tendon Transfer in Irradiated Patients

OBJECTIVE To compare objective outcomes and complications following temporalis tendon transfer in patients with and without a history of radiation to the parotid bed. METHODS Retrospective medical chart review comparing dynamic movement of the oral commissure and resting symmetry achieved in 7 irradiated patients (group R) and 7 nonirradiated patients (group N) after temporalis tendon transfer for unilateral facial paralysis. RESULTS There were no significant differences between the 2 groups of patients in terms of age, additional facial reanimative procedures, baseline lip position, or follow-up time. Postoperatively, good resting symmetry was achieved in both groups. The mean commissure excursion was significantly inferior in the irradiated group of patients (-1.5 mm in group R vs 2.1 mm in group N; P < .05). Two patients in the irradiated group experienced surgical site infections requiring hospital admission and eventual debridement of their tendon transfers. CONCLUSIONS Temporalis tendon transfer seems to produce less dynamic movement in patients who have received radiation to the parotid bed, and these patients may also be at higher risk of postoperative infection. Temporalis tendon transfer can achieve good resting symmetry in both irradiated and nonirradiated patients.

Facial Nerve Reconstruction With Concurrent Masseteric Nerve Transfer and Cable Grafting.

IMPORTANCE Reconstruction of the facial nerve after radical parotidectomy is commonly performed with cable grafting, which is associated with slow recovery of nerve function and synkinesis. OBJECTIVE To describe facial nerve reconstruction after radical parotidectomy using concurrent masseteric nerve transfer and cable grafting. DESIGN, SETTING, AND PARTICIPANTS This retrospective medical record review at a tertiary referral hospital included 9 patients who underwent concurrent masseteric nerve transfer and cable grafting for facial nerve reconstruction performed by a single surgeon from January 1, 2014, to October 31, 2015. Final follow-up was completed on March 14, 2016. MAIN OUTCOMES AND MEASURES Improvement in resting facial symmetry and oral commissure excursion and synkinesis. RESULTS Nine patients (6 women; mean age, 62.6 years; age range, 51-73 years) underwent immediate facial nerve reconstruction after radical parotidectomy using concurrent cable grafting and masseteric nerve transposition. All patients had return of oral commissure motion within 2 to 7 months after surgery with good excursion and minimal synkinesis. CONCLUSIONS AND RELEVANCE Masseteric nerve transposition can be combined with cable grafting to improve outcomes in facial rehabilitation after radical parotidectomy. LEVEL OF EVIDENCE 4.

Ideal Female Brow Aesthetics

The concept of the ideal female eyebrow has changed over time. Modern studies examining youthful brow aesthetics are reviewed. An analysis of ideal female brow characteristics as depicted in the Western print media between 1945 and 2011 was performed. This analysis provided objective evidence that the ideal youthful brow peak has migrated laterally over time to lie at the lateral canthus. There has been a nonstatistically significant trend toward lower and flatter brows. These findings are discussed in relation to current concepts of female brow aging, with repercussions regarding endoscopic brow lift and aesthetic forehead surgery.

Age-Related Histologic Changes in Human Nasal Cartilage

IMPORTANCE Understanding age-related changes is important when considering cartilage-based implants or grafts during rhinoplasty and nasal reconstructive surgery. OBJECTIVE To characterize the cellular and architectural changes in human nasal cartilage with aging. DESIGN Laboratory study. PARTICIPANTS Nasal septal cartilage was harvested from 50 consecutive patients undergoing septoplasty, rhinoplasty, or septorhinoplasty. INTERVENTION Cartilage specimens were stained with hematoxylin-eosin (H&E) and safranin O for cartilage. MAIN OUTCOME MEASURES A modified Mankin histologic grading scale was used to analyze each cartilage sample for H&E findings and safranin O staining. Higher H&E scores indicated more degenerative changes, while higher safranin O scores indicated reductions in proteoglycan content within the cartilage matrix, representing decreased active chondrocyte activity. Correlation between H&E and safranin O scores and patient age was determined. RESULTS There was positive correlation between safranin O staining scores and age, with higher scores seen with advancing age (P = .01). A linear regression best-fit equation was determined to calculate a potential safranin O staining score for a given age. CONCLUSIONS AND RELEVANCE We have quantitatively determined that advancing age is positively correlated with reductions in cartilage proteoglycan content and active cartilage growth. This finding not only enhances our current understanding of the natural changes that occur in cartilage with aging but may also affect surgical decision making when cartilage grafting is considered during functional, reconstructive, and aesthetic rhinoplasty. LEVEL OF EVIDENCE NR.

Patient assessment of psychosocial dysfunction following nasal reconstruction.

Background: Postoperative psychosocial distress is a critical aspect of surgery, particularly in aesthetically sensitive areas. In this study, the authors assess the level of psychosocial distress associated with nasal reconstruction. The authors also compare postoperative distress levels associated with different reconstructive techniques throughout the healing process. Methods: The authors conducted a prospective study of patients undergoing nasal reconstruction following excision of cutaneous malignancy. The main outcome measure was the Derriford Appearance Scale 24, a measure of psychosocial distress. The Derriford Appearance Scale was administered at preoperative assessment, 1 < x < 4 weeks, 4 ⩽ x < 12 weeks, and x ≥ 12 weeks. The entire cohort was analyzed with respect to distress levels before and after surgery. Reconstructions were categorized as interpolated, local tissue, or full-thickness skin graft. Analyses were performed for reconstruction type, patient, and defect data. Results: Fifty-nine patients were enrolled. Reconstructions included 14 interpolated flaps, 17 local tissue flaps, and 28 full-thickness skin grafts. For the entire cohort, distress levels were significantly higher at the first postoperative visit (p < 0.05), with normalization at subsequent follow-up evaluations. At the first assessment, the interpolated flap group had significantly higher levels of distress in comparison with the full-thickness skin graft group (p < 0.05). At late follow-up, levels of distress were equivalent. Conclusions: Nasal reconstruction is associated with short-term increases in psychosocial distress that corrects by approximately 12 weeks after surgery. Interpolated flaps cause significantly higher distress at early assessment. Distress levels at late follow-up appear to be equivalent to those following a full-thickness skin graft despite larger and deeper initial defects. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, II.

Neural Reanimation Advances and New Technologies

Facial paralysis can have a profound effect on the patient from both an aesthetic and functional point of view. Just as there are numerous etiologies of facial paresis, there are as many therapeutic options and variations of these options. The purpose of this article was to review the most current surgical options for neural reanimation of a damaged facial nerve, including recent advances in nerve repair, conduit technology, and nerve transfers, as well as emerging technology in translational research with biomedical engineering and tissue engineering.

A Facial Plastic and Reconstructive Surgery Training Module Using Surgical Simulation for Capacity Building

OBJECTIVE To introduce 3 novel intensive facial plastic and reconstructive surgery teaching modules for surgical capacity building using simulation in a low-middle income country. DESIGN Prospective cohort study. SETTING University-based medical center in Quito, Ecuador. PARTICIPANTS First- and second-year otolaryngology residents in Quito, Ecuador. RESULTS Residents participated in an intensive 3-day teaching program focused on microtia, nasoseptal abnormalities, and facial paralysis that included didactic lectures, simulation workshops, and live surgery. Residents underwent rigorous pre- and postmodule testing including written, oral, and practical examinations in each subject area. All participants completed anonymous feedback surveys with ratings on a Likert scale from 0 (very poor) to 10 (excellent). Nineteen residents completed both pre- and postmodule testing. The training module was successfully implemented and testing performance across all 3 subject areas significantly improved. Resident feedback was exceedingly positive, with average scores for each component ranging from 8.9 to 9.8, with highest scores given to the simulation workshops. The postmodule survey indicated that all residents found the course helpful and they desired additional courses covering more subject areas. CONCLUSIONS Implementation of an intensive surgical training module combining didactics, surgical simulation, and live surgery resulted in the successful transfer of both skills and knowledge. While the long-term benefit of this program is yet to be determined, this model of training may prove to be a useful tool to help address surgical capacity building in the developing world.