Minas Constantinides

Complications of static facial suspensions with Expanded polytetrafluoroethylene (ePTFE)

Background Expanded polytetrafluoroethylene (ePTFE) is a synthetic porous material that has been used for static suspension in facial paralysis. It is manufactured in thin (1‐mm or 2‐mm) sheets that can be cut into strips and implanted through keyhole facial incisions. Regional deformities are addressed by multiple suspensions that provide cosmetic and functional therapy. The use of ePTFE eliminates donor site morbidity associated with the traditional harvest of fascia from either the temporal area or fascia lata. However, properties unique to this alloplast contribute to the complications that have occurred after its use in facial reanimation.

Curative radiotherapy for anterior commissure laryngeal carcinoma.

There is continuing controversy surrounding the most effective treatment of glottic carcinoma involving the anterior commissure (AC). Surgery has been the preferred method of treatment, since studies previously indicated early tumor invasion of the thyroid cartilage at the AC, thereby assuming less curability by radiotherapy (RT). Subsequent laryngeal anatomic studies and refinement of RT techniques have brought into question the ineffectiveness of curative irradiation. A retrospective review of 174 patients with early-stage glottic carcinoma treated with standard fractionation curative RT revealed 34 patients with T1 and T2 lesions involving the AC. Allowing for a follow-up of at least 3 years, we observed only a 12% (4 of 34 patients) local recurrence rate after RT alone, with excellent voice quality and no major complications related to the irradiation. The 4 local recurrences were controlled by total laryngectomy, although 2 patients developed distant metastatic disease. Radiotherapy represents an effective method of treating T1 squamous cell carcinoma of the glottis with AC involvement. The small number of T2 glottic carcinomas in this study prevents a meaningful conclusion concerning treatment of these lesions.

Surgical and Nonsurgical Treatments of the Nasal Valves

Nasal obstruction is known to be associated with a major decrease in disease-specific quality of life, and nasal valve dysfunction can play a considerable role in nasal airflow obstruction. Diagnosis and treatment of nasal valve dysfunction requires a thorough understanding of normal anatomy and function as well as pathophysiology of common abnormalities to properly treat the exact source of dysfunction. As the pathophysiology of the nasal valves has become better understood, surgery designed to treat its dysfunction has evolved. Here, we explore the progress we have made in treating the nasal valves, and the deficiencies we still face.

Squamous cell carcinoma in older patients without risk factors.

Ten patients over sixty years of age with no history of tobacco or alcohol use were treated for squamous cell carcinoma of the upper aerodigestive tract between 1979 and 1991. Nine of these ten patients were women with lesions confined to the oral cavity and oropharynx. Modes of treatment included surgery, radiation, or a combination of surgery and radiation. Followup from 1 to 10 years revealed two deaths from local and distant spread, and eight patients with no evidence of disease. Recurrences after treatment were aggressive and occurred within the same region as the primary lesion. Although most patients with upper aerodigestive squamous cell carcinoma are men with alcohol and/or tobacco exposure, this study demonstrates findings consistent with field cancerization in a group of older women with no risk factors.

Cartilage Grafting in Nasal Reconstruction

Nasal reconstruction after resection for cutaneous malignancies poses a unique challenge to facial plastic surgeons. The nose, a unique 3-D structure, not only must remain functional but also be aesthetically pleasing to patients. A complete understanding of all the layers of the nose and knowledge of available cartilage grafting material is necessary. Autogenous material, namely septal, auricular, and costal cartilage, is the most favored material in a free cartilage graft or a composite cartilage graft. All types of material have advantages and disadvantages that should guide the most appropriate selection to maximize the functional and cosmetic outcomes for patients.

Subjective and Objective Improvement in Breathing After Rhinoplasty

OBJECTIVE To determine whether rhinoplasty improves subjective and objective nasal patency. DESIGN Retrospective study including subjective breathing scores and acoustic rhinometry before and 6 to 9 months after septorhinoplasty among a cohort of 31 patients. We used a paired t test to analyze the difference between preoperative and postoperative values. SETTING Academic medical center. PATIENTS Patients undergoing septorhinoplasty with potassium titanyl phosphate laser turbinate reduction at a single institution. RESULTS The mean subjective breathing scores improved significantly, with an overall improvement of 38%. The overall mean volume increased and the overall resistance decreased, but the changes were significant only on the right side. The minimal cross-sectional area (MCA) did not change, but the distance of the MCA of the nasal cavity moved anteriorly by 0.23 cm on the left side. The patients were stratified into subsets based on other procedures undergone, including spreader grafts and alar batten grafts, and on the absence of osteotomies. These groups had similar results. In patients with severe obstruction, all measured values improved more than any other subgroup, including the MCA, which improved significantly by an average of 55%. Patients with normal preoperative MCA values did not experience any significant changes except for an anterior shift in MCA. CONCLUSIONS Septorhinoplasty increases nasal volume, decreases nasal resistance, and advances the MCA anteriorly. These changes coexist with subjective improvements in nasal patency, which suggests that this new anatomic configuration creates a positive outcome on nasal airflow. Spreader grafts do not increase the MCA significantly. Patients with preoperative severe obstruction have the best overall improvement, whether measured subjectively or objectively.

Quantitative Comparison Between Microperforating Osteotomies and Continuous Lateral Osteotomies in Rhinoplasty

OBJECTIVE To determine the difference in nasal bone narrowing between 2 techniques: the low lateral intranasal perforating osteotomy technique and the low lateral continuous osteotomy technique. METHODS A retrospective analysis of preoperative and postoperative photographs to determine the changes of the dorsal width of the nose (width of plateau of the nose, or dorsal nasal highlight) and the ventral width (junction of the flattened surface of the maxilla and the ascending nasal process of the maxilla). RESULTS Twenty patients underwent continuous osteotomies, and 40 underwent intranasal perforating osteotomies. The continuous osteotomy technique had a preoperative to postoperative decrease in the ventral width of 7.0% (P < .01). The perforating osteotomy technique had a decrease in the ventral width of 3.6% (P < .001). Neither technique resulted in a statistically significant change in dorsal width (P < .25). There was no significant difference in ventral and dorsal narrowing when comparing continuous osteotomies to perforating. CONCLUSIONS Both the continuous and perforating osteotomy technique resulted in a decrease in the ventral nasal bone width. No statistical difference was found between continuous and perforating osteotomy techniques in the amount of nasal bone narrowing (P < .25).

Alar Retraction Etiology, Treatment, and Prevention

IMPORTANCE The effect of different rhinoplasty maneuvers on alar retraction remains to be elucidated. OBJECTIVE To determine the etiology and treatment of alar retraction based on a series of specific rhinoplasty maneuvers. DESIGN Retrospective review of a single surgeons rhinoplasty digital photo database, examining preoperative alar retraction from January 1, 2002, to December 31, 2005, in 520 patients. Patients with more than 1 mm of alar retraction on preoperative photographs were identified. Postoperative photographs were examined to determine the effect of specific rhinoplasty maneuvers on the position of the alar margin; these maneuvers included cephalic trim, cephalic positioning of the lower lateral cartilage, composite grafts, alar rim grafts, alar batten grafts, and overlay of the lower lateral cartilage. SETTING Tertiary care academic health center. PARTICIPANTS Forty-five patients with alar retraction met inclusion criteria, resulting in 63 nasal halves with alar retraction. MAIN OUTCOMES AND MEASURES Intraoperative findings, postoperative results. RESULTS Forty-seven percent of the patients (n = 21) had prior surgery; 47% also had cephalically positioned lower lateral cartilages. Among patients with less than 4 mm of cartilage width at the outset, 46% of those who received supportive grafts achieved target correction vs only 7% for patients who did not undergo supportive cartilage grafting. In patients who underwent more than 4 mm of cephalic trim, those who received supportive grafts achieved 46% of target correction vs 11% among those who did not. Ninety-five percent of composite grafts, 69% of alar strut grafts, 47% of alar rim grafts, 43% of vertical lobule division, and 12% of alar batten grafts achieved their target correction values. CONCLUSIONS AND RELEVANCE Alar retraction is a highly complex problem. It can be seen de novo and is associated with cephalically positioned lower lateral cartilages. Structurally supportive grafting-including composite grafts, alar strut grafts, alar rim grafts, vertical lobule division, and alar batten grafts-can improve alar retraction. LEVEL OF EVIDENCE 4.

Trends in functional rhinoplasty 2008

Purpose of reviewThis article reviews the recent literature on functional rhinoplasty for the most important contributions in the field. Recent findingsSurgical techniques for improving the internal nasal valve include upper lateral cartilage fold-in flap, splay graft, alar batten graft, Z-plasty, and the alloplastic Monarch implant. The Nasal Obstruction Septoplasty Effectiveness (NOSE) score and the Rhinoplasty Outcomes Evaluation score have been applied to objectify outcomes in functional rhinoplasty. Functional endoscopic sinus surgery (FESS) and rhinoplasty continue to be safely used in the same surgical sitting. SummaryThe last few years have seen improved perspective on what surgery can do, substantiating the inherent difficulties of establishing reproducible outcomes in form and function of the nose.

Reformatted Computed Tomography to Assess the Internal Nasal Valve and Association With Physical Examination

OBJECTIVES To assess the cross-sectional area and angle of the internal nasal valve more accurately by reformatting computed tomography (CT) scans of the nasal airway according to a more appropriate orientation than scans traditionally sectioned in the coronal plane and then to compare the results with clinical data on the nasal valve obtained from physical examination. METHODS We performed a retrospective review of the medical records of 24 rhinoplasty patients treated at a private practice facial plastic surgery office affiliated with a tertiary care university hospital. The patients had fine-cut (0.75-mm section) CT scans ordered for nasal airway obstruction or nasal valve compromise at the same institution. These patients were evaluated from January 1, 2000, through December 31, 2010. The previously acquired CT scans were reformatted to obtain sections through the internal nasal valve at a more appropriate orientation. The internal nasal valve cross-sectional area and valve angle were measured through a standardized section (1 cut immediately anterior to the head of the inferior turbinate) from the reformatted scans. The cross-sectional area was also measured through the same point on the traditionally oriented CT scan, and the values were compared. The results from each patients scan were compared with data from the patients medical record and analyzed against the patients preoperative modified Cottle examination findings. RESULTS The CT scans oriented in the reformatted plane through the internal nasal valve provided a narrower valve angle than the traditionally oriented CT scans and more closely approximated the hypothesized true value of the internal nasal valve of 10° to 15° (P < .001). In a comparison of the same-side internal nasal valve angle and cross-sectional nasal valve area between the 2 different CT scan orientations, a statistically significant difference in the internal nasal valve angles between the 2 scan orientations was discovered, but this finding did not reach significance when distinguishing the nasal valve cross-sectional area. Finally, no correlation was found with regard to the preoperative modified Cottle maneuver scores for the internal nasal valve angle and cross-sectional valve area values in either scan orientation. CONCLUSIONS Precise preoperative evaluation of the internal nasal valve is critical to the workup for reconstruction or repair of problems that involve this area. Although tools such as acoustic rhinometry exist to evaluate the cross-sectional area of the nasal valve, many rhinoplasty surgeons do not have access to this expensive equipment. A CT scan with reformatting in the proper plane of the internal nasal valve can provide the surgeon with improved anatomical information to assess that region. With this in mind, however, the surgeon should always perform a thorough preoperative physical examination and treat the patient and his or her symptoms, not the imaging studies, when considering a candidate for a surgical intervention.