Taha Z. Shipchandler

Saddle Nose Deformity Reconstruction With a Split Calvarial Bone L-Shaped Strut

OBJECTIVE To describe a technique for creation of a split calvarial bone L-shaped strut that provides dorsal support while increasing tip projection in patients with substantial septal saddle nose deformities from various underlying inflammatory conditions and surgical resection. METHODS Case series and review of the literature. RESULTS Fifteen patients underwent nasal reconstruction at our institution using the split calvarial bone L-shaped strut technique with postoperative follow-up to 36 months (range, 9-36 months). The causes of septal perforation leading to saddle nose deformity included cocaine use, infection, sarcoidosis, malignant lesion, iatrogenic causes, and Wegener granulomatosis. All cases resulted in an augmented, straightened nasal dorsum and increased tip projection. Results were maintained throughout follow-up with no evidence of graft infection, resorption, or migration. CONCLUSIONS The split calvarial bone L-shaped strut provides dual benefits of dorsal support and increased tip projection. Numerous techniques have been discussed for dorsal augmentation with varied success; however, the long-term maintenance of this graft in patients with severely compromised vascularity owing to underlying inflammatory conditions such as Wegener granulomatosis highlights its presumed advantages. The procedure can be performed using the external rhinoplasty approach, obviating the need for radix incisions for plating or intranasal mucosal incisions. These advantages make the L-shaped strut technique excellent for nasal reconstruction in patients with substantial septal saddle nose deformities regardless of cause and duration of defect.

Split hypoglossal-facial nerve neurorrhaphy for treatment of the paralyzed face.

BACKGROUND Several methods of neural rehabilitation for facial paralysis using 12-7 transfers have been described. The purpose of this study is to report on a series for dynamic reinnervation of the paralyzed face by using a split 12-7 nerve transposition. The goals of this procedure are to minimize tongue morbidity and to provide good facial reinnervation. METHODS Prospective case series. Melolabial crease discursion, overall facial movement, and degree of tongue atrophy and mobility were recorded. RESULTS Thirteen patients underwent facial reanimation using a split hypoglossal-facial nerve transfer with postoperative follow-up to 58 months (range, 6-58 months). All patients achieved excellent rest symmetry and facial tone. Of 13 patients, 10 had measurable coordinated movement and discursion of their melolabial crease. Of 13 patients, 12 had mild to moderate ipsilateral tongue atrophy. The mean time to onset of visible reinnervation was 3 months. CONCLUSION Split hypoglossal-facial nerve transposition provides good rehabilitation of facial nerve paralysis with reduced lingual morbidity. Long-term rest symmetry and potential learned movement can be achieved. This technique may provide a favorable alternative to the traditional method of complete hypoglossal sacrifice or jump grafting.

Use of fracture size and soft tissue herniation on computed tomography to predict diplopia in isolated orbital floor fractures

PURPOSE To determine the role of fracture size and soft tissue herniation as measured by computed tomography in predicting the development of persistent diplopia in patients with isolated orbital floor fractures. METHODS A retrospective chart review identified patients presenting between March 2009 and 2012 with isolated orbital floor fractures. Computed tomographic scans were assessed for transverse fracture size and absence or presence of soft tissue herniation and rectus involvement. Presence of diplopia at 6-10 days, decision for surgical repair, and presence of diplopia were recorded. RESULTS Fifty-six patients fulfilled inclusion criteria. Eighteen of 56 patients (32%) had preoperative diplopia. In Type A fractures, 0/9 (0%) small, 1/8 (12.5%) medium, and 2/14 (14%) large fractures had diplopia. For Type B fractures, 3/4 (75%) small, 9/13 (69%) medium, and 4/8 (50%) large fractures had diplopia. Type B fractures were significantly more likely to cause diplopia than Type A fractures in the small (p = 0.003) and medium (p = 0.007) size groups but not in the large groups (p = 0.07). CONCLUSION Transverse fracture size and presence of soft tissue herniation on CT imaging can predict development of persistent diplopia in isolated orbital floor fractures. Small and medium sized fractures with soft tissue herniation are more likely to cause diplopia than large sized fractures. We recommend early repair or closer observation of small and medium sized orbital floor fractures with soft tissue herniation due to the high risk of diplopia.

Three-Dimensional Printing and Its Applications in Otorhinolaryngology–Head and Neck Surgery

Objective Three-dimensional (3D)-printing technology is being employed in a variety of medical and surgical specialties to improve patient care and advance resident physician training. As the costs of implementing 3D printing have declined, the use of this technology has expanded, especially within surgical specialties. This article explores the types of 3D printing available, highlights the benefits and drawbacks of each methodology, provides examples of how 3D printing has been applied within the field of otolaryngology–head and neck surgery, discusses future innovations, and explores the financial impact of these advances. Data Sources Articles were identified from PubMed and Ovid MEDLINE. Review Methods PubMed and Ovid Medline were queried for English articles published between 2011 and 2016, including a few articles prior to this time as relevant examples. Search terms included 3-dimensional printing, 3D printing, otolaryngology, additive manufacturing, craniofacial, reconstruction, temporal bone, airway, sinus, cost, and anatomic models. Conclusions Three-dimensional printing has been used in recent years in otolaryngology for preoperative planning, education, prostheses, grafting, and reconstruction. Emerging technologies include the printing of tissue scaffolds for the auricle and nose, more realistic training models, and personalized implantable medical devices. Implications for Practice After the up-front costs of 3D printing are accounted for, its utilization in surgical models, patient-specific implants, and custom instruments can reduce operating room time and thus decrease costs. Educational and training models provide an opportunity to better visualize anomalies, practice surgical technique, predict problems that might arise, and improve quality by reducing mistakes.

Free Anterolateral Thigh Fascia Lata Flap for Complex Nasal Lining Defects

OBJECTIVE To introduce a novel technique for the reconstruction of complex nasal lining defects using the free vascularized anterolateral thigh fascia lata flap. METHODS Free anterolateral thigh fascia lata flaps were used to replace nasal lining in 5 patients with total or subtotal rhinectomy defects. We performed a retrospective medical record review. RESULTS No flap failure or lining loss was observed, and harvest site morbidity was negligible. Patients achieved satisfactory nasal form and patent nasal airways without a need for repeated revisions. In 2 patients, the anterolateral thigh flap was used simultaneously to restore the midface contour or to repair anterior skull base defects. CONCLUSIONS In this case series, we demonstrate the novel use of vascularized fascia lata to provide viable nasal lining in total and subtotal nasal defect reconstruction. Potential advantages offered by this technique compared with more established methods include (1) single-stage replacement of nasal lining, structure, and skin coverage; (2) fewer additional stages of reconstruction to achieve functional and aesthetic results; (3) thin lining to allow for optimal airway contour; (4) less harvest site morbidity; and (5) development of composite soft tissue, cutaneous, and/or muscle flaps to repair adjacent defects.

The Effects of Alar Batten Grafts on Nasal Airway Obstruction and Nasal Steroid Use in Patients With Nasal Valve Collapse and Nasal Allergic Symptoms: A Prospective Study

IMPORTANCE Clinical management of nasal airway obstruction (NAO) in patients with and without nasal allergic symptoms and nasal valve collapse (NVC). OBJECTIVE To examine the impact that autologous alar batten grafts have on patients with NAO owing to NVC and their affect on nasal steroid use and allergic symptoms. DESIGN A prospective study. SETTING Indiana University Medical Center, Indianapolis. PARTICIPANTS Patients with NAO due to NVC with or without symptoms of nasal allergic symptoms. INTERVENTIONS All of the patients had placement of autologous batten grafts during the study period. STUDY SELECTION Prospective study of patients with dynamic NVC undergoing alar batten graft treatment. DATA EXTRACTION Nasal Obstruction Symptom Evaluation survey preoperatively and postoperatively, prospective outpatient questionnaire to determine use of nasal steroids and presence of nasal allergic symptoms preoperatively and postoperatively. RESULTS A total of 126 patients underwent surgical intervention for the treatment of NAO due to NVC. All of these patients were using nasal steroid sprays, and 78 patients (62%) also reported nasal allergic symptoms at their initial presentation. At 6-month and 1-year postoperative evaluations, 118 (94%) and 122 (97%), respectively, reported significant improvement of their NAO, regardless if they had presented with or without allergic nasal symptoms. Sixty-two of the 78 patients (79%) who initially presented with NAO owing to NVC and nasal allergic symptoms preoperatively reported significant improvement in their NAO and nasal allergic symptoms postoperatively. Eight of 126 (6%) restarted their use of nasal steroids postoperatively. All 8 of these patients reported nasal allergic symptoms preoperatively. No patients in the nonallergic group continued the use of nasal steroids postoperatively. There was no increase in nasal steroid use at the 12-month follow-up visit. CONCLUSIONS AND RELEVANCE Nasal airway obstruction due to NVC in patients can be surgically treated with autologous alar batten grafts. In addition, the use of alar batten grafts may improve NAO in patients with nasal allergic symptoms and reduces their use of nasal steroids. These results support the idea of potential surgical repair of the nasal valve to treat patients with NAO due to nasal allergic symptoms and NVC. LEVEL OF EVIDENCE 4.

The Crooked Nose

Straightening a crooked nose is a challenge. Several techniques exist ranging from simple to technically complex. It is important to approach the nose systematically and to remember that perfection may be impossible to achieve. If straightening is not attainable, softening grafts or onlay grafts should be used to camouflage subtle irregularities.

Single-Stage Repair of Paralytic Ectropion Using a Novel Modification of the Tarsoconjunctival Flap

Patients with facial paralysis present with a constellation of ocular manifestations. Ectropion resulting from downward displacement of the lower eyelid appears after loss of orbicularis tone and function.1 In addition, upper eyelid retraction, resulting in lagophthalmos and a decrease in tear production and/or proper tear distribution and channeling,may result in dry eyes and epiphora. Tear flow is impairedbecause of a dysfunctional orbicularis oculimuscle and a decrease in transportation of tears.2 Thegoalsof surgery forparalytic lowereyelidectropionand lagophthalmos are to preserve visual acuity, improve corneal exposure, reduce ocular complaints, and restore facial symmetry. Initial management would include the application of an ocular lubricant, use of a moisture chamber, or possibly temporary tarsorrhaphy.Whenparalysis is expected to persist, a more permanent procedure is needed. The use of a laterally based tarsoconjunctival flap combinedwith a standard lower eyelid ectropion repair allows for correction of the constellations of symptoms observed in patients with paralytic ectropion in a single-stage surgical procedure. The technique can be viewed in the Video.

Endoscopic forehead lift in patients with male pattern baldness

PURPOSE The presence of male pattern baldness poses a significant challenge when attempting to optimize treatment of the upper third of the face. The purpose of this study is to demonstrate and discuss results of the endoscopic forehead lift in patients with male pattern baldness. MATERIALS AND METHODS This was a retrospective case series done in an academic medical center. Eleven patients with male pattern baldness (Norwood class IV-VII) underwent endoscopic forehead lift for forehead creases and brow ptosis. RESULTS All patients achieved smoothing of the forehead and elevation of the brow with no scalp anesthesia at 1 month postoperatively. All patients were pleased with the healing of their incisions in midline, paramedian, and temporal regions. Alloplastic fixation devices used were visible postoperatively in 2 patients initially. CONCLUSIONS The endoscopic forehead lift is a suitable approach for treating the upper third of the face in the presence of male pattern baldness. The use of alloplastic fixation devices may be used in this patient population, but other fixation methods should be considered.

Midcervical scar satisfaction in thyroidectomy patients

Assess long‐term patient satisfaction with conventional thyroidectomy scars and the impact of thyroidectomy scars on patient quality of life.