Waleed H. Ezzat

The Use of Poly-l-Lactic Acid Filler in Facial Aesthetics

The use of poly-L-lactic acid in facial aesthetic surgery has been utilized for over a decade. More recently approved by the Food and Drug Administration as a stimulatory filler for the correction of shallow to deep facial lines, it is gaining popularity in the United States. The advantages of its use include its stimulatory action on collagen formation, the longevity of its effect, and the low side effect profile. Despite these advantages, meticulous preparation practices and injection techniques are paramount to achieving a satisfactory outcome. We review poly-L-lactic acid as a filler, along with its associated side effects, indications of use, and techniques of injection.

Impact of total radiotherapy dose on survival for head and neck Merkel cell carcinoma after resection

Head and neck Merkel cell carcinoma (MCC) is commonly treated with surgery and adjuvant radiotherapy (RT) for high‐risk features. The optimal radiation dose is unknown.

Extended use of perioperative antibiotics in head and neck microvascular reconstruction

PURPOSEnMany head and neck surgical procedures are considered clean-contaminated wounds and antibiotic prophylaxis is recommended. Despite prophylaxis, the incidence of surgical site infections remains significant - especially in the setting of free tissue transfer. The antibiotic course is often of a longer duration after free tissue transfer than the recommended 24hour post-operatively. Currently, there is no consensus on appropriate antibiotic regimen or duration at this time. This study investigates the outcomes of a 7-day perioperative antibiotic regimen after microvascular reconstruction of the head and neck at our institution.nnnMATERIALS AND METHODSnA retrospective review was performed of 72 patients undergoing microvascular free tissue at our institution between 09/2011 and 03/2014. The antibiotic regimen, post-operative surgical (including surgical site infections) and medical complications were noted. Our rates of complications and adverse events were compared to all surgical patients, as well as all inpatients hospital-wide with use of the University Health System Consortium database.nnnRESULTSnSeventy-two subjects met inclusion criteria for this study. The majority of subjects received cefazolin/metronidazole (69.4%). Subjects with beta-lactam allergy received clindamycin (12.5%). The remainder received an alternative regimen (18.1%). All received at least 7days of antibiotics. The rate of hospital acquired C. difficile diarrhea was 0.57% hospital-wide, 1.13% in Otolaryngology patients, and 1.4% in this study. There were no instances of a multi-drug resistant infection or any adverse reactions to the administration of antibiotics. When compared with other antibiotic regimens, clindamycin was associated with a significantly increased rate of either medical or surgical infections (OR 14.38, p=0.02) and longer hospital stay (average=18days, p<0.05).nnnCONCLUSIONnThe use of a 7-day prophylactic antibiotic regimen is not associated with an increased risk of antibiotic-associated infections, multi-drug resistant infections, or antibiotic-associated complications. The use of clindamycin is associated with increased risk of medical and surgical infections post-operatively and should be avoided in the prophylactic perioperative phase after free tissue transfer of the head and neck.

Assessment of Fibula Flap Skin Perfusion in Patients Undergoing Oromandibular Reconstruction: Comparison of Clinical Findings, Fluorescein, and Indocyanine Green Angiography

IMPORTANCEnComplications of partial flap necrosis contribute substantially to morbidity in patients who undergo head and neck reconstructive surgery.nnnOBJECTIVEnTo assess the usefulness of clinical findings, intraoperative fluorescein angiography, and intraoperative indocyanine green angiography (ICGA) for evaluation of flap skin paddle perfusion in patients undergoing oromandibular reconstruction who are at high risk of partial skin paddle necrosis.nnnDESIGN, SETTING, AND PARTICIPANTSnRetrospective medical record review from May 21, 1996, to May 27, 2015, at a tertiary care academic medical center. Participants were 73 patients who underwent reconstruction of through-and-through defects of the mucosa, mandible, and skin using fibula free flaps that contained large bilobed skin paddles.nnnMAIN OUTCOMES AND MEASURESnThe rates of partial skin paddle necrosis and revision reconstructive surgery.nnnRESULTSnThe rates of partial flap necrosis were 8% (nu2009=u20092) among 25 patients in whom the skin paddle was trimmed based on ICGA and 33% (nu2009=u200916) among 48 patients in whom the skin paddle was trimmed according to clinical findings (Pu2009=u2009.02). The rates of revision reconstructive surgery were 20% (5 of 25) when flap skin paddles were trimmed using ICGA and 42% (20 of 48) when trimmed per clinical findings (Pu2009=u2009.06).nnnCONCLUSIONS AND RELEVANCEnThe use of ICGA may reduce the risk of partial skin flap necrosis in free flaps used in patients undergoing head and neck reconstruction who are at high risk of developing flap necrosis. Indocyanine green angiography imaging should be considered in any flap in which skin paddle viability is uncertain based on clinical findings and in patients in whom the skin paddle extends beyond the primary and adjacent angiosomes.nnnLEVEL OF EVIDENCEn3.

Reconstructive Techniques for the Saddle Nose Deformity in Granulomatosis With Polyangiitis: A Systematic Review

Importance Repairing the saddle nose deformity in the setting of granulomatosis with polyangiitis disease is a rare but challenging situation for any surgeon. Given that the available data in the literature is based on case reports and small case series, there is little evidence available to help delineate which reconstructive techniques are optimal. Objective To examine which techniques were most successful in reconstructive rhinoplasty for a saddle nose deformity secondary to granulomatosis with polyangiitis. Evidence Review PubMed, MEDLINE, Cochrane Collaboration Databases, and Web of Science were searched using the terms Wegener’s granulomatosis or granulomatosis with polyangiitis cross-referenced with saddle nose deformity or acquired nasal deformity. These databases were supplemented with 2 cases from Boston Medical Center. Databases were queried from inception of article collection through December 14, 2015, to identify publications reporting the repair of a saddle nose deformity and granulomatosis with polyangiitis. Findings A total of 10 studies met inclusion criteria yielding a cohort of 44 patients. The overall success rate for rhinoplasty, both primary and secondary, was 84.1% (37 of 44 patients), with a complication rate of 20%. The use of a single L-shaped graft fared better than individually placed grafts. An increased risk of graft failure was noted as the number of overall grafts increased and if nonautologous tissue was used. Conclusions and Relevance Rhinoplasty for saddle nose deformity is a safe and effective procedure in the setting of granulomatosis with polyangiitis. In the face of this disease, reconstruction should focus on placing a robust, L-shaped strut graft with autologous tissue over individual grafts. Additionally, the use of split-calvarial bone appears to have a slightly lower complication rate over costal cartilage.

Role of adjuvant chemoradiotherapy in T4N0 stage IV head and neck cancer: A National Cancer Database analysis

The purpose of this study was to evaluate the role of postoperative adjuvant radiotherapy (surgeryu2009+u2009adjuvant RT) versus adjuvant chemoradiotherapy (surgeryu2009+u2009adjuvant CRT) in patients with T4N0M0, stage IV head and neck squamous cell carcinoma (HNSCC).

Comparative Study of Functional Nasal Reconstruction Using Structural Reinforcement

Importance Nasal reconstruction after Mohs surgery is a unique challenge in that it must satisfy both functional and aesthetic goals. Despite some advocacy in the literature for using structural reinforcement to achieve both functional and aesthetic outcomes in soft-tissue reconstruction, no study has validated this claim by comparing reconstruction with and without structural support. Objective To evaluate the effectiveness of and need for structural reinforcement when reconstructing the nasal alar and sidewall subunits. Design, Setting, and Participants This study was a retrospective review of the medical records of 190 patients 18 years or older who underwent nasal reconstruction after Mohs surgery in a tertiary care academic center between January 1, 2013, and August 31, 2015. Data on each patient included demographics, comorbidities, smoking status, details of the lesion, size of defect, subunits involved, and reconstructive technique. Patients were divided into 2 cohorts composed of those who had reconstruction with structural reinforcement (ie, cartilage grafting or suspension suture) and those with only soft-tissue reconstruction. Patients with nasal obstruction from the functional collapse of the reconstructed area and no history of nasal obstruction were included (nu2009=u200938). Patients who had a follow-up of less than 2 months, no alar or sidewall involvement, nasal obstruction secondary to turbinate hypertrophy, septal deflection or other nonstructural causes, and incomplete documentation for analysis were excluded (nu2009=u2009102). Main Outcomes and Measures Rates of postoperative nasal obstruction secondary to nasal sidewall collapse and need for revision surgery. Results Of the 38 patients who met the inclusion criteria, 22 were men and 16 were women with a mean (range) age of 64.5 (35-92) years. Twenty-three patients (61%) underwent reconstruction by a facial plastic surgeon and 15 (39%) by 2 dermatologic surgeons. Three (8%) underwent reconstruction without reinforcement and experienced postoperative nasal obstruction. The mean size of reconstructed defects that resulted in nasal valve collapse was 2.1 cm in diameter (range, 1.2-2.6 cm). Defect size was associated with incidence of postoperative nasal obstruction. For defects greater than 1.2 cm in diameter, patients reconstructed without reinforcement had a statistically significant increase of nasal obstruction secondary to functional nasal collapse compared with patients reconstructed with reinforcement (3 of 14 [21%] vs 0 of 17; 95% CI, 0.005-0.358; Pu2009=u2009.04). Conclusions and Relevance Nasal defects greater than 1.2 cm in diameter and involving the alar and sidewalls were associated with lower incidence of postoperative nasal obstruction when a structural reinforcement technique was used in reconstruction. The findings of this study support the structural reinforcement of the nasal functional subunits during Mohs reconstructive surgery to achieve optimal outcomes. Level of Evidence 3.

Costal Cartilage Grafting for Dorsal Augmentation

The aesthetic and functional implications of an appropriate dorsal contour are immense and contribute significantly to the overall rhinoplasty results. The authors discuss anatomy of the upper, middle, and lower thirds of the nose, goals for augmentation, materials used for dorsal augmentation, evaluation of the patient, harvesting the grafts, determining the needs of the dorsum with contour deformity, contour deformity with middle nasal vault collapse, contour deformities with significant loss of structural support, and defects encompassing the bony dorsum. Augmentation and reconstruction of the nasal dorsum is a challenging component of rhinoplasty. The role of the middle nasal vault in function and aesthetics is vital, and maintenance of the support mechanisms is paramount to the ideal dorsal profile. The interplay between the nasal pyramid, cartilaginous septum and upper lateral cartilages, and lower third of the nose must be taken into consideration during reconstruction.

The web lift and posterior pull for the aging face.

There are many factors that contribute to the aging neck. We have recently begun employing a percutaneous suture spanning the submentum combined with a posterior platysma pull. We present our initial results with this technique. In this retrospective study, subjects underwent the combined procedure with and without concomitant rhytidectomy. Cephalometric analysis was used to compare the preoperative cervicomental angle (CMA) and hyomental distance (HMD) with postoperative values at 4 weeks. Subjects also were queried on their postoperative satisfaction. Twenty-five subjects were included in this study. At 4 weeks postoperatively, we achieved significant reductions in the average CMA (134.8 versus 122.8, p = 0.002). The postoperative HMD significant increased an average of 1.9 cm (8.5 versus 10.4, p = 0.009). We achieved a 92.3% satisfaction score at 33 weeks (range = 25 to 44). The combination of a percutaneous suture across the submentum and a posterior platysma pull is a safe and effective method of addressing the many facets of the aging neck. Our initial results are easily reproducible and entail minimal morbidity to the patient.

Stage II Oral Tongue Cancer: Survival Impact of Adjuvant Radiation Based on Depth of Invasion:

Objective To determine if adjuvant radiation therapy for patients with pT2N0 oral cavity tongue cancer affects overall survival. Study Design Retrospective cohort study. Setting National Cancer Database. Subjects and Methods Cases diagnosed between 2004 and 2013 with pathologic stage pT2N0 oral cavity tongue cancer with negative surgical margins were extracted from the National Cancer Database. Data were stratified by treatment received, including surgery only and surgery + postoperative radiation therapy. Univariate analysis was performed with a 2-sample t test, chi-square test, or Fisher exact test and log-rank test, while multivariate analysis was performed with Cox regression models adjusted for individual variables as well as a propensity score. Results A total of 934 patients were included in the study, with 27.5% of patients receiving surgery with postoperative radiation therapy (n = 257). In univariate analysis, there was no significant difference in 3-year overall survival between the patient groups (P = .473). In multivariate analysis, there was no significant difference in survival between the treatment groups, with adjuvant radiation therapy having a hazard ratio of 0.93 (95% CI, 0.60-1.44; P = .748). Regarding tumors with a depth of invasion >5 mm, there was no survival benefit for the patients who received postoperative radiation therapy as compared with those who received surgery alone (hazard ratio = 0.93; 95% CI, 0.57-1.53; P = .769). Conclusion An overall survival benefit was not demonstrated for patients who received postoperative radiation therapy versus surgery alone for pT2N0 oral cavity tongue cancer, irrespective of depth of tumor invasion.