Paul S. Nassif

Hearing preservation following surgical removal of meningiomas affecting the temporal bone

It is a common clinical impression that preservation of hearing is more often achieved when removing a meningioma than a similarly sized acoustic tumor. However, relatively few reports have focused on postoperative hearing results after meningioma removal, and detailed audiometric data are not commonly provided, particularly in the neurosurgical literature.

Selection of surgical approaches for meningiomas affecting the temporal bone.

The varied locations of meningiomas within the temporal bone require a wide array of neurotologic approaches to accomplish complete resection with minimal morbidity. We reviewed 56 consecutive patients with temporal bone meningiomas. The six surgical approaches are described with regard to site of lesion, morbidity of procedure, and long-term patient outcome. Recommendations are made for selection of surgical approach. Hearing preservation was attempted in 25%. Middle fossa tumor removal was performed in nine patients (16%), retrosigmoid (suboccipital) in five patients (9%), translabyrinthine In 24 patients (43%), transcochlear in 15 patients (27%), infratemporal fossa In two patients (4%), and retrolabyrinthine In one patient (2%). Overall, meningioma surgery has higher morbidity, poorer facial nerve outcome, and higher recurrence rates than acoustic neuroma surgery. Thirteen percent of patients were unable to resume full preoperative activities after their surgery. Facial nerve transection occurred In 9% of the cases, and 83% of cases with more than 1 year followup had satisfactory or Intermediate facial function (grades I to IV). Meningiomas of the temporal bone are insidious and aggressive lesions. Particular care is required to select the surgical approach appropriate for location, level of hearing, and the anatomic structures Involved. Patients must be realistically counseled about the surgical morbidity and long-term outcome associated with each approach.

Adjunctive applications for botulinum toxin in facial aesthetic surgery

Botulinum toxin (Botox) has firmly established itself as one of the premier nonsurgical therapies. Recently, Botox is also being used as an adjuvant to many aesthetic procedures, both surgical and nonsurgical. This combined therapeutic use for Botox may not only create an added benefit toward facial rejuvenation but may create a synergistic one as well. This article examines such uses for Botox and reviews the current medical literature.

Epidermal growth factor and transforming growth factor-α in middle ear effusion

Epidermal growth factor (EGF) and transforming growth factor-α (TGF-α) promote the differentiation and proliferation of epithelia as well as the proliferation and chemotaxis of fibroblasts. Additionally, EGF promotes wound healing in tissues composed largely of epithelial cells and fibroblasts. We hypothesized that EGF and TGF-α regulate the differentiation and proliferation of the epithelial lining and the migration and proliferation of fibroblasts in the subepithelial space of the middle ear mucosa in children with otitis media. As an initial test of this hypothesis, EGF and TGF-α concentrations were measured in 82 middle ear effusions of children undergoing tympanostomy tube placement. EGF was present in 45% of these effusions, and TGF-α was present in 6%. The mean concentration ± SEM values for EGF and TGF-α were 19 ± 7.6 and 3.7 ± 7.9 pg/mL, respectively. In addition, neutrophils, macrophages, and lymphocytes in middle ear effusions stained for EGF by immunocytochemistry. We conclude that growth factors are frequently present in middle ear effusions of children with otitis media

Microbiology and Antibiotic Prophylaxis in Rhinoplasty: A Review of 363 Consecutive Cases

IMPORTANCE A practical technique for reducing infectious complications from rhinoplasty would represent an important surgical advance. OBJECTIVES To describe the microbial flora of patients undergoing septorhinoplasty and to evaluate the role of preoperative and postoperative antibiotic prophylaxis. DESIGN, SETTING, AND PARTICIPANTS We performed a retrospective medical record review of 363 consecutive adult patients who underwent preoperative nasal swab testing and rhinoplasty or septorhinoplasty in a single private practice: 279 women (76.9%) and 84 men (23.1%). The average patient age was 35.9 years (age range, 17-70 years). MAIN OUTCOMES AND MEASURES Identification of endogenous nasal flora and pathogenic bacteria treated with culture-directed antibiotics; evaluation of comorbidities, perioperative infections, and antibiotic treatments. RESULTS A total of 174 patients (47.9%) underwent primary rhinoplasty, and 189 (52%) underwent revision rhinoplasty. On preoperative nasal culture, 78.2% of patients had normal flora; 10.7% had Staphylococcus aureus; and 0.28% had methicillin-resistant S aureus (MRSA). In 7.4% of patients, fecal coliforms including Escherichia coli, Enterobacter species, and Citrobacter species were found. Age, sex, smoking, the use of oral contraceptives, or the presence of seasonal allergies did not significantly change the nasal flora or the postoperative infection rate. Patients with adult acne were found to have an increased incidence of colonization with fecal coliforms (43.8%; P < .001). Patients with diabetes were found to have an increased incidence of colonization with S aureus (66.7%; P = .002). The overall infection rate was 3.0% (11 of 363 patients), with 4.0% (7 of 174 patients) seen in primary septorhinoplasties and 2.1% (4 of 189 patients) seen in revision cases. Coliforms accounted for 5 cases (45.5%) of postoperative infections, while S aureus was responsible for 4 cases (36.4%), including 1 case of MRSA. CONCLUSIONS AND RELEVANCE The results of this study suggest that risk factors alone may not reliably predict the subset of patients in whom antibiotic prophylaxis is indicated. Knowledge of the endogenous nasal flora and the microbiology of common pathogens in patients undergoing septorhinoplasty will help to further reduce the incidence of infectious complications. LEVEL OF EVIDENCE 3.

Transconjunctival Lower Blepharoplasty: Fat Excision or Repositioning

In lower blepharoplasty, the eyelid fat pads can be accessed externally through the skin (transcutaneously), or internally through the conjunctiva (transconjunctivally). Transconjunctival surgery leaves key anatomic structures (orbicularis muscle/orbital septum) undisturbed, which reduces the incidence of postoperative lower lid malposition. For this reason, the transconjunctival approach to surgery has gained wide acceptance over the last 20 years. Transconjunctival surgery does not directly address excess lower lid skin or eyelid laxity. When these deficits are present, a skin pinch and canthal suspension can be added. Transconjunctival surgery is a more complex procedure than the traditional transcutaneous approach. However, when the technique is mastered, results are enhanced and patient satisfaction is high.

Avoiding and Managing Complications in the Periorbital Area and Midface

The eyes play a central role in the perception of facial beauty. The goal of periorbital rejuvenation surgery is to restore youthful proportions and focus attention on the eyes. Blepharoplasty is the third most common cosmetic procedure performed today. Because of the attention placed on the periorbital region, preventing and managing complications is important. Obtaining a thorough preoperative history and physical examination can significantly reduce the incidence of many of the complications. This article focuses on the preoperative evaluation as it relates to preventable complications, followed by common intraoperative and postoperative complications and their management.

Rhinoplasty and bony vault complications.

Complications of bony nasal vault surgery can be avoided with a thorough preoperative assessment of the nasal anatomy and meticulous surgical technique. When complications arise, it is imperative to identify the irregularity and undertake the corrective measures. This article highlights possible complications of bony nasal vault surgery and their etiologies, appearances, and management.

Use of 5-Fluorouracil for Management of the Thick-Skinned Nose

Abstract Patients with a thick nasal skin and soft tissue envelope can have unpredictable results and irregular scarring after rhinoplasty surgery. These patients typically have sebaceous tissue over the nasal tip and are particularly susceptible to soft tissue polly beak formation and excess scar tissue in the radix, tip, and septum. Targeted injections of 5‐fluorouracil alone or mixed with low concentrations of steroid can be useful to prevent and treat excess postoperative scar tissue deposition. Ideally, four to six injections are performed every 1 to 4 weeks beginning 1 week postoperatively. The injections are most beneficial when performed within the first 3 months after surgery. Even a single injection may improve outcomes with minimal side effects.

Correction of the Lower Face and Neck

&NA; Rejuvenation of the lower face and neck strives to reverse signs of aging while optimizing the patients natural anatomy. Common features of an aesthetically pleasing lower face include a well‐defined and appropriately balanced mandible and an acute cervicomental angle. Correction of the aging lower face and neck is accomplished through multiple surgical interventions, performed either alone or in combination. Determination of appropriate procedures is based on individual anatomic pathology. Intimate knowledge of facial anatomy and the complexity of the aging process is paramount to achieve a natural and aesthetic result. Thorough patient evaluation and counseling should precede any intervention. Specifically, the surgeon should be cognizant of the patients skeletal structure, soft tissue distribution, muscular anatomy, and skin quality. Appropriate postoperative care and management of complications are vital to success.