Joseph L. Leach

Comparison of two methods of tonsillectomy

No consensus exists regarding the best method of tonsillectomy. This report concerns two popular methods: 1. electrocautery excision and 2. dissection/snare followed by point coagulation of bleeding sites. To compare these methods, a prospective, randomized, single-blinded study was conducted in which 28 patients had one tonsil removed by dissection/snare and selective cautery of bleeders and the other removed by the electrocautery. Operative time and blood loss were compared. Patients rated the severity of their pain and blood loss postoperatively. Intraoperative bleeding was significantly less on the side of cautery excision, although the operative time was longer. At follow-up, pain was rated worse on the side of cautery excision.

Endoscopic resection of the intranasal frontal sinus floor

The current accepted treatment for chronic frontal sinus disease unresponsive to medical management and endoscopic surgery is an external approach to either obliterate the sinus or restore communication to the nasal cavity. Here reported is an endoscopic approach for resection of the intranasal frontal sinus floor, a modification of a procedure first described by Lothrop in 1899. Eleven patients underwent this operation from April 1993 to December 1993. One complication, a cerebrospinal fluid leak treated successfully endoscopically, has occurred. Of the 7 patients followed up 3 months or longer after surgery, only 1 has developed symptoms of recurrent frontal sinusitis. On the basis of this limited preliminary experience, the endoscopic Lothrop procedure shows promise as an effective operation designed to establish a physiologic communication between the frontal sinus and the nasal cavity in selected patients who would otherwise be candidates for an external approach.

Comparison of microtia reconstruction outcomes using rib cartilage vs porous polyethylene implant.

IMPORTANCE Auricular reconstruction is a unique blend of cosmesis and functionality. The choice of the optimal framework material to use is an important decision for the patient with microtia. OBJECTIVE To evaluate and compare the outcomes of reconstruction of microtia using porous polyethylene implants and rib cartilage grafts. DESIGN, SETTING, AND PARTICIPANTS Retrospective medical record review from January 1, 2001, through December 31, 2012, at a tertiary academic institution. Thirty-five patients (36 ears) undergoing microtia repair were divided into groups using high-density porous polyethylene (17 ears), rib cartilage (17 ears), and both materials (2 ears). Only patients with completed repair were included in the analysis. EXPOSURES Reconstructive surgery for microtia. MAIN OUTCOME AND MEASURES We compared groups in terms of mean number of operations, age at treatment initiation, and complications (infection, extrusion, cartilage exposure, and pneumothorax). Photographs were graded by blinded observers to give each patient a score on protrusion, definition, shape, size, location, and color match. RESULTS The cartilage group was older than the polyethylene group (mean age, 8.0 vs 6.9 years; P = .23). The mean number of operations was 4.88 for the cartilage group vs 3.35 for the polyethylene group (P = .004). Two patients in the polyethylene group had postoperative infections and implant extrusion and underwent subsequent reconstruction with cartilage grafts. Patients in the cartilage group had no infection or extrusion; 1 had a minor cartilage exposure. No patient had pneumothorax. Patients in the polyethylene group had significantly better grades for ear definition and size match, whereas those in the cartilage group had a significantly better color match. Patients in the cartilage group had better protrusion and location outcomes, although the difference was not significant. CONCLUSIONS AND RELEVANCE Comparison of reconstruction with porous polyethylene implants and rib cartilage grafts showed neither material to be clearly superior. Polyethylene implants may achieve a better cosmetic outcome in the categories of ear definition, shape, and size with a higher risk for infection and extrusion. Patients in the cartilage group were older and underwent significantly more surgical procedures, which should factor into the decision on which technique to choose. LEVEL OF EVIDENCE 3.

Aesthetics and the Hispanic Rhinoplasty

Objectives/Hypothesis Current aesthetic standards for rhinoplasty have been formulated for an Anglo‐American population. Nevertheless, these standards vary, and it is doubtful that these norms are universally applicable to Anglo populations, much less Hispanic ones.

Correlation Between Intraoperative Hypothermia and Perioperative Morbidity in Patients With Head and Neck Cancer

OBJECTIVE To determine if intraoperative hypothermia correlates with perioperative complications in patients undergoing head and neck surgery with regional or free flap reconstructions. DESIGN Retrospective medical chart review. SETTING Academic tertiary care hospital. PATIENTS A sample of 136 patients who underwent ablative surgery for head and neck cancer and subsequently required reconstruction with free tissue or a regional flap in the last 10 years. MAIN OUTCOME MEASURES Rate of early (within 3 weeks of surgery) perioperative complications and its correlation with patient hypothermia (core body temperature, <35 degrees C). RESULTS There were 43 patients with complications. Two patients died. Complications included 10 partial or total flap losses, 9 hematomas, 8 episodes of pneumonia, 7 fistulas, 7 wound infections, 5 wound breakdowns, and 2 cerebrospinal fluid leaks. Factors that did not correlate with complications included having received prior chemotherapy (P = .84), having stage IV cancer (P = .16), sex (P = .43), tobacco use (P = .58), prior radiotherapy (P = .30), the presence of comorbidities (P = .43), age (P = .27), length of surgery (P = .63), and the use of blood products perioperatively (P = .73). Patients who were hypothermic had a significantly higher rate of complications that normothermic patients (P = .002). Stepwise logistic regression analysis identified intraoperative hypothermia as a significant independent predictor for the development of early perioperative complications (odds ratio, 5.122; 95% confidence interval, 1.317-19.917). CONCLUSIONS Intraoperative hypothermia in head and neck surgery is correlated with perioperative complications. Maintaining normothermia through aggressive warming may decrease the incidence of perioperative morbidity for these patients.

Four suture tip rhinoplasty: A powerful tool for controlling tip dynamics

Objective To evaluate the short-term effectiveness of using a 4-suture technique to control nasal tip dynamics. The 4 sutures include a medial crural suture, bilateral intradomal sutures, and an interdomal suture. Study Design and Setting Retrospective photograph analysis of preoperative and postoperative photographs of 77 patients with respect to 7 dynamic variables: supratip break, projection, rotation, tip shape, tip definition, tip symmetry, and the presence of a double columellar break. Results Seventy-four patients underwent primary rhinoplasty and had an overall average score of 5.2 on a −7 to +7 scale, with a mean follow-up period of 3.8 months. The 3 patients undergoing revision rhinoplasty had an overall average score of 5.0 and a mean follow-up of 8.7 months. Conclusion The 4-suture technique worked best with respect to projection and tip symmetry, although the technique proved to be an effective tool overall in controlling all 7 variables mentioned above. EBM rating: C-4

Prevention of Flash Fires during Facial Surgery Performed under Local Anesthesia

As more surgical procedures are being performed under local anesthesia and intravenous sedation, complications associated with these techniques are more likely to be experienced. We report a case of an intraoperative flash fire that occurred while supplemental oxygen was being used in this scenario. A literature review and suggestions for prevention of this complication are discussed.

Techniques for improving ear definition in microtia reconstruction

Surgeons involved in microtia repair recognize the difficulty in creating a natural appearing ear. One key to successful reconstruction is to provide sufficient relief between the helix, scaphoid fossa and antihelix to create the illusion of thin skin overlying thin cartilage. Problems such as thick skin, hair-bearing skin and poor-quality cartilage serve to frustrate the surgeons attempt to achieve the desired result. Surgical techniques to improve cartilaginous framework definition in microtia repair are discussed.

Lateral Thigh Flap Reconstruction in the Head and Neck

The lateral thigh free flap is a fasciocutaneous flap based on the cutaneous perforators of the deep femoral vessels. Although originally described in 1983, it has had very few reports in the literature. This article describes the flap and reports our findings and outcomes in nine cadavers (18 thighs) and 33 clinical cases. The position of the vascular pedicle may vary in each case but has always been found to be present. Successful transfer occurred in 30 of 33 cases. Flap loss was attributable to infection, fistula, and hematoma in three of four cases. The flap was especially useful in large defects, most commonly total and base-of-tongue defects. We have found this flap to be reliable and to result in minimal morbidity.

Chronic sinusitis as a manifestation of primary immunodeficiency in adults

Twenty-three adult patients evaluated at a university medical center for severe refractory sinusitis were found to have a primary immunodeficiency on the basis of total immunoglobulin, IgG subclass, and vaccine response determinations. The most common finding was IgG3 deficiency with antibody hyporesponsiveness to pneumococcal vaccine. Treatment options included prophylactic antibiotics and aggressive management of associated allergies with intravenous immunoglobulin reserved for severely affected patients who failed more conservative therapy.