Abstract
Academic Development in LMICs: Sustainable Teaching and Database Development
Natalie S. Justicz (Presenter); Dina Busaba; Shaina Lamour; Myriam Leandre; Patrick Marc Jean-Gilles, MD; Mack Cheney, MD; Theresa A. Hadlock, MD
Objectives: Surgical capacity building has become a high global priority. Quantitative data establishing efficacy and long-term effectiveness of skills transfer for in-country surgeons is lacking. We conducted a focused educational module and simultaneously launched an electronic data repository (EDR) for cataloguing and documenting surgical results in Haiti.
Methods: Haitian otolaryngology trainees participated in an educational module involving surgical rehabilitation for facial palsy. Pretesting was administered and lectures, practical teaching, and interventions for patients with facial palsy were carried out. A router, computer, and camera were provided to house an encrypted EDR (EnlightenMD, MEEI). Individual tutorials regarding EDR use were provided. Postmodule testing was conducted. Assessment of early adoption of the EDR was determined using survey administration. We followed the number of EDR entries vs those written in the surgical logs.
Results: Eight 30-minute lectures were delivered, 2 practical facial nerve–grading workshops were undertaken, and 9 facial reanimation operations were performed. Posttest scores were significantly improved; initial scores on the written, oral, and practical tests averaged 35.7%. Postmodule scores averaged 73.5% (P < .001). Participants described EnlightenMD as highly likely to permit academic study of case series that they could not otherwise properly catalog.
Conclusions: Our results further support that the combination of didactics, practical teaching, and interventions results in successful transfer both of skills and knowledge. Furthermore, our preliminary observations highlight the potential role of EDR implementation in increasing academic output in resource-constrained environments.
The Application of Open-Source Three-Dimensional Planning Software in Virtual Reconstruction
Dann Joel Chavez Caro (Presenter); Ferdinand G. Pamintuan, MD
Objectives: To present our in-house 3-dimensional (3D) planning protocol using open-source computer-aided design (CAD) software and discuss its specific applications in reconstruction of craniomaxillofacial defects. Specifically, our aim is to demonstrate its possible benefits in achieving aesthetic and functional outcomes.
Methods: Case series setting: tertiary private hospital. This study focused on 10 patients who underwent CAD-assisted reconstructive surgeries from February 2017 to May 2018.
Results: A total of 10 patients were included. Seven mandibular reconstructions were surgically reconstructed using our own 3D planning protocol and achieved symmetric mandibular contour, with good functional occlusion after surgery. One cranioplasty and 1 orbital trauma case also achieved good symmetry and adequate correction of enophthalmos, respectively. However, inadequate soft-tissue correction was seen in 1 case of maxillary reconstruction despite achieving symmetric bony contour.
Conclusions: Our 3D planning protocol using open-source CAD applications is a good alternative to its professional and expensive counterparts. Additional prospective studies should be conducted to better demonstrate its benefits in terms of accuracy and decreasing intraoperative time in craniomaxillofacial and head and neck reconstruction.
Armed versus Unarmed Assaults: Differences in Need for Operative Intervention?
William C. Harris, MD (Presenter); Ryan Winters, MD
Objectives: Assault is one of the leading causes of facial fractures and because of the sparsity of current literature, further exploration was performed as to whether armed vs unarmed assault cases involving facial trauma demonstrate differences in need for operative intervention. The primary objective is to offer facial trauma surgeons a more complete picture as to how management may differ in these 2 groups. In addition, this study analyzed several secondary endpoints, which help further define the epidemiology of facial fractures.
Methods: A 5-year retrospective chart review was performed to compare the need for operative intervention in unarmed vs armed facial trauma cases. Adult patients (>age 18 years) seen by the otolaryngology department at a large urban tertiary medical center for assault with associated facial fracture were included initially. These cases were further narrowed to 311 patients based on exclusion criteria. A 2-sample t-test was used to analyze these 2 groups. In addition, differences in sex, fracture patterns, demographics, comorbidities, and drug or alcohol use during time of assault were evaluated similarly.
Results: Armed facial assault cases as a whole had a 32% higher rate of operative intervention required when compared with unarmed facial assault cases (P < .05). Men between age 18 and 30 years were found to make up 78% of facial assault cases presenting within this particular institution.
Conclusions: Armed facial assault cases sustained more significant injuries as well as more complex fractures, which required a significantly higher rate of operative intervention. Young men were found to be significantly more likely to be involved in assault cases as well as armed assault cases specifically.
Barriers to Seeking Consultation for Rhinoplasty
Jenny X. Chen (Presenter); David A. Shaye, MD; Jessica Occhiogrosso; Linda N. Lee, MD
Objectives: A substantial number of patients delay the treatment of functional and cosmetic nasal pathologies for many years. In this study, we studied patient fears and concerns that contribute to delayed consultation for rhinoplasty.
Methods: Consecutive patients seen by 2 facial plastic surgeons for rhinoplasty consultation at a large academic medical center were prospectively surveyed from July 2018 to January 2019.
Results: A total of 129 patients participated in this study. The median age was 30 to 39 years. Sixty-four patients were female (50%), whereas 65 patients were male (50%). Half of all patients (47%) had waited more than 3 years prior to seeking consultation for rhinoplasty. Twenty-one percent of patients delayed consultation by more than 10 years. Interest in cosmetic changes is associated with an increased time to consultation (multivariable regression, P = .016), whereas sex, age, and interest in functional changes were not associated (P > .05). The most common patient fears were cost, undesired cosmetic outcome, and pain. Patients were less concerned about nasal packing, narcotic use, and anesthesia risks. Prior to consultation, patients felt they were “somewhat knowledgeable” about rhinoplasty. Notably, 44% of patients cited the internet as a source of information, whereas 50% cited their primary care provider.
Conclusions: This is the first study to prospectively identify patient fears and barriers to rhinoplasty consultation, which should be addressed through targeted educational efforts at the first visit. As the internet is a highly cited source, the dissemination of accurate web-based education materials may be useful to decrease the time to consultation.
Can Complexity of Septoplasty Be Explained by What Surgeons Do While Operating?
S. Swaroop Vedula, PhD, MBBS (Presenter); Lisa E. Ishii, MD, MHS; Anand O. Malpani; Sonya Malekzadeh, MD; Hadley VanRenterghem; Masaru Ishii, MD, PhD
Objectives: Explain the relation between what surgeons do while operating and perceived technical complexity of septoplasty procedures.
Methods: We analyzed data from 142 septoplasty procedures performed between July 2016 and October 2018 at 2 tertiary care hospitals. We used manual annotations of tasks in the procedure that faculty and trainee surgeons performed and the instruments they used, and the faculty reported technical complexity of procedure on a scale of 1 (below average) to 10 (very high). We computed 16 variables, namely, overall case duration, occurrence and duration of suction use, opening septum, raising septal flaps, removing cartilage, reconstruction, closing incision, and other steps, and a binary flag indicating trainee participation. We computed the Pearson’s correlation coefficient between each variable and technical complexity. We used linear regression to estimate root mean squared error (RMSE) in predicting technical complexity with 10-fold cross-validation.
Results: Correlation for all 19 variables was below 0.40. The RMSE in predicted values was 1.67 (compared with a standard deviation of 1.69 in ground truth).
Conclusions: Tasks surgeons perform and instruments they use are informative about technical complexity in septoplasty. Other variables such as patient anatomy and surgical skill may further explain technical complexity of the procedure.
Closed Spreader Grafts: A Cadaveric Study
Celeste C. Gary, MD (Presenter); Laura E. Hetzler, MD; Jason D. Pou, MD; Christopher M. Tran, MD
Objectives: Describe the surgical technique of closed spreader grafts. Become comfortable with the placement of closed spreader grafts as an adjunct to septoplasty for treatment of nasal obstruction. Analyze the anatomic location of spreader grafts placed with a closed technique.
Methods: A cadaveric study was performed by the authors in April 2017. Incompetent internal nasal valve treatment with spreader grafts placed with a closed technique without visualization of the dorsal septum was investigated using fresh cadaver heads. Spreader grafts were placed with a closed technique, and the skin of the nose was then removed to investigate the anatomic location of the graft. The location was compared with where a spreader graft would be placed with an open technique. The anatomic locations were compatible for both techniques.
Results: Cadaver noses were opened after placement of spreader grafts with a closed technique and showed the grafts in the same anatomic location as those placed with an open technique.
Conclusions: Spreader grafts placed with a limited closed technique are anatomically located in the same location as those placed with an open technique.
Diabetes Mellitus in Head and Neck Free Flap Reconstruction: Systematic Review
Sepehr Shabani, MD (Presenter); Mathew Caputo; Matthew J. Mifsud, MD
Objectives: The effect of diabetes mellitus in head and neck free-flap reconstruction outcome continues to be controversial as there are multiple papers showing either increased rates of free-flap complications or no effect at all. The primary aim of this study is to perform a systematic literature review of the effect of diabetes on free-flap outcome in head and neck reconstructions. We specifically look at the following correlations: preoperative hemoglobin A1C vs free-flap complications and postoperative blood glucose vs free-flap complications.
Methods: PubMed, EMBASE, and Clinicaltrials.gov were searched using a premade search term to capture studies including diabetes mellitus and free flap in head and neck. These articles will be reviewed independently by the 2 authors and applicable studies will be selected.
Results: The search has concluded in 272, 560, and 2 articles in PubMed, EMBASE, and Clinicaltrials.gov, respectively. Currently, the articles are being reviewed.
Conclusions: Diabetes mellitus could be an independent factor in head and neck free-flap outcomes, and strict preoperative and postoperative glycemic control can have a large impact on outcomes.
External and Internal Sidewall Dimensions in the Adult Thai Nose
Vissuta Uppapant (Presenter); Sarinya Urathamakul, MD; Dhave Setabutr, MD
Objectives: Nasal bone length remains a commonly referenced attribute when referring to the aesthetic nose. Short nasal bone length is suggested to predispose to a greater risk of middle vault collapse after rhinoplasty. We report on normative measurements of nasal bones and associated structures in Thai subjects.
Methods: Using 12 adult cadavers, common external nasal landmarks were identified and measured to approximate the dimensions of the nasal bones and upper lateral cartilages. These clinically relevant surface landmarks were correlated to direct measurements of dissected nasal bones and the upper lateral cartilage in these same cadavers. In addition, external landmarks of 10 volunteers were examined.
Results: The average measured length of a nasal bone was 1.9 cm; the average measured length of the upper lateral cartilage was 1.36 cm. Measurements obtained via external landmarks were 1.76 and 1.30 cm, respectively. The relationship of the nasal bone internal length to the external measurement (A) was a ratio of 1.10:1, whereas the internal length of the upper lateral cartilage to the corresponding external measurement (B) was 1.04:1. On average, the nasal bones contributed to 58% of the middle vault nasal sidewall.
Conclusions: The average length of the Thai adult nasal bone is 1.9 cm, whereas that of the upper lateral cartilage is 1.36 cm. The relationships of the accepted external landmarks to the underlying anatomic structures were established using a t-test. This normative data will generate useful parameters when evaluating the Thai rhinoplasty patient.
Extracorporeal Septoplasty for Rhinoplasty in Asians
Hahn Jin Jung, MD (Presenter); Min Hyuck Kang
Objectives: Extracorporeal septoplasty (ECS) is a surgical technique for correcting a severely deviated septum. In ECS, the whole septum is removed and neo-L strut is built extracorporeally; this can achieve septum correction and tip projection at the same time. This study aims to describe the functional and aesthetic results of the ECS technique in rhinoplasty for Asian patients.
Methods: We retrospectively reviewed the medical records of 64 patients who underwent rhinoplasty with the ECS technique between January 2016 and March 2018. Patient satisfaction was evaluated, and the surgical outcomes were evaluated objectively using the objective rhinoplasty outcome score (OROS). Nasal obstruction improvement was assessed on a visual analog scale (VAS). Anthropometric changes were assessed and compared using the preoperative and postoperative facial photographs. Complications and revision after surgery were also reviewed.
Results: The study group comprised 48 male and 16 female patients and had a mean age of 29.0 years. The mean operation time was 89.3 minutes. Sixty-one patients (95.3%) were satisfied with the cosmetic outcome, and the overall result was 3.4 in OROS. Preoperative nasal obstruction symptoms (mean VAS, 7.9 ± 1.2) were improved postoperatively (mean VAS, 3.1 ± 1.3; P < .0001). The nasofrontal angle (26.6-31.2, P < .001), nasolabial angle (88.8-91.5, P = .162), and nasal tip projection (0.60-0.65, P = .021) values were improved in anthropometric measurement. Redeviation of nasal septum, external nose redeviation, and tip deprojection were not observed during the mean follow-up duration of 13.3 months. There was no revision case because of lack of satisfaction.
Conclusions: The ECS technique was effective, safe, and satisfactory in rhinoplasty for Asian patients.
Football-Related Injuries to the Head and Neck: A Major Headache
Brandon Cowan (Presenter); Houmehr Hojjat; Michael A. Carron, MD
Objectives: To analyze the incidence, demographics, and injury patterns of patients presenting to emergency departments (EDs) nationwide for head and neck injury from playing football.
Methods: The National Electronic Injury Surveillance System (NEISS), a nationwide database, was surveyed for head and neck injuries for football from 2013 to 2017. Relevant entries were examined for incidence, location of injury, type of injury, and disposition. Entry narratives were also analyzed for correlation between helmet use and the nature of the injury.
Results: There were 14,447 NEISS entries, extrapolating to an estimated 441,006 ED visits for football over the selected 5 years. Patients had a median age of 13 years, and 95% were male. Head injuries were the most common complaint at 69%, with greater than 90% reported concussions or closed head injuries. Injuries to the face, ear, and mouth made up 19% of visits, with a 52% rate of laceration. Fractures and nerve injuries accounted for only 2.7% and 0.1% of football injuries, respectively, yet up to 30% of these injuries required hospitalization. Finally, 16% of entries specified helmet use and helmet-to-helmet contact was described in 12% of visits.
Conclusions: A high index of suspicion is reasonable to assess for lacerations, fractures, and nerve injuries, as they can have serious functional and cosmetic sequela. There is also a high rate of helmet-to-helmet contact leading to injuries. With the median age at 13 years, adoption of policies to reduce head contact in college and amateur leagues would be prudent to reduce further head and neck injuries from football.
Frontal Bone Osteomas: Case Report and Literature Review
Dhruv Sharma, MD (Presenter); Alexander Hayden; Abideen Yekinni, MD
Objectives: Describe the surgical techniques that have been used to excise frontal bone osteomas by reviewing the literature. Present the endoscopic approach used to resect multiple frontal bone osteomas in this case.
Methods: Case report and comprehensive literature review.
Results: Osteomas are benign osseous lesions characterized by proliferation of mature compact or cancellous bone. These bony tumors mainly affect the craniomaxillofacial skeleton, most commonly originating in the paranasal sinuses and mandible. Isolated frontal bone osteomas have been rarely documented. Several surgical techniques have been reported in the literature for managing these frontal bone lesions, including direct, bicoronal, anterior hairline, and more recently the endoscopic approach. We present a case of a 61-year-old African American woman who presented with 2 distinctly separate frontal bone osteomas that were resected entirely endoscopically with excellent cosmetic result. To date, more than 6 months after complete excision, she is without recurrence or complications.
Conclusions: Multiple osteomas of the craniofacial region should raise concern for Gardner’s syndrome. In this report, a comprehensive review of frontal bone osteomas in the English literature is presented. The endoscopic approach is often sufficient to visualize and excise most frontal bone osteomas in an aesthetically appropriate fashion.
Gliding into the Emergency Department: Scooter Injuries to the Head and Neck
Houmehr Hojjat (Presenter); Brandon Cowan; Jordyn Lucas; Michael A. Carron, MD
Objectives: To estimate the incidence of head and neck injuries and patient demographics who present to emergency departments (EDs) for head and neck injuries from riding scooters.
Methods: The National Electronic Injury Surveillance System (NEISS) was surveyed for head and neck injuries from scooter accidents from 2013 to 2017. Unpowered scooters were compared with powered scooters, including hoverboards. Relevant entries were examined for incidence, locations of injury, and type of injury. Google Trends was evaluated for popularity of search topics “scooter” and “hoverboard.”
Results: There were 3458 NEISS entries, extrapolating to a total 107,879 estimated ED visits attributable to scooters from 2013 to 2017. Overall, 82% of these were attributed to unpowered scooters. However, injury from powered scooters increased 310% from 2013 to 2017, whereas the incidence of injury from all scooters remained constant. In addition, powered scooters resulted in a significantly higher proportion of head injuries (P < .01). Online searches for “hoverboards” also increased 350% in this period.
Conclusions: Injury from powered scooters has increased over the past 5 years in conjunction with the trending topic of hoverboards. More recently, increasingly popular rental companies are providing powered scooters to users across the United States with limited regulatory oversight. The significantly greater risk of head injuries among powered scooters in our study is concerning and warrants further discussion on stricter regulation mandating protective gear. In addition, physicians should be aware of injury patterns and frequencies resulting from these new transportation devices.
Labia Myocutaneous Free Flap: Angiography Study of the Internal Pudendal Artery
Mingyang L. Gray, MD (Presenter); Joshua D. Rosenberg, MD; Brittany Barber, MD; Brett A. Miles, MD, DDS
Objectives: The purpose of this study is to use 3-dimensional (3D) reconstruction of pelvic angiography to map the perforators of the internal pudendal artery and establish the extent of tissue perfusion to inform the design of the labia myocutaneous free flap (LMFF).
Methods: The LMFF is a new design for a free-tissue transfer consisting of a portion of the labia minora, labia majora, and a portion of the bulbospongiosus muscle with the internal pudendal artery as the main feeding vessel. The internal pudendal artery can be identified on angiography and embolized when necessary. Twenty female computed tomography (CT) pelvic angiography scans were deidentified and reconstructed in 3D for analysis.
Results: A previous cadaveric study demonstrated a mean pedicle length of 3.78 cm from the pudendal canal to the first identifiable perforator. Pedicle length, number of perforators, and extent of perfusion can be traced and measured on CT pelvic angiography.
Conclusions: The internal pudendal artery and its perforators are visible on pelvic angiography, which further supports the design of the LMFF.
The Measurement of Blow-out Fractures Cannot Be Made with Geometric Estimations
Karl Johan Fredrik Borstedt, MD (Presenter); Babak Alinasab, MD
Objectives: Measuring areas and volumes correctly in blow-out fractures (BOF) is crucial in the decision to operate or not. Comparing areas and volumes measured with precise and/or proven methods to calculations with geometric formulas will demonstrate the need for consensus in how to take these measurements.
Methods: This was a retrospective review of BOF in patients admitted to the Department of ENT and Head & Neck Surgery at Karolinska University Hospital in Stockholm, Sweden, from 2011 to 2015. In the computed tomographic images, the fractured area was measured with a proven method and the volume with a meticulous new method. The sizes of the same shapes were estimated using geometric formulas in which the area was assumed to resemble an ellipse and the volume a hemi-ellipsoid. The results were visualized with Bland-Altman plots, and accuracy, sensitivity, and specificity were analyzed. Comparison was also made with sizes initially measured by radiologists.
Results: A total of 82 patients were included from 2 ongoing studies (43% women, 57% men; mean age 49.7 years [5-90 years]). Sensitivity was 0.9 to 0.95, and specificity was 0.5 to 0.87. The accuracy rate was 0.73 to 0.9. The radiologists had an accuracy of 0.84, a sensitivity of 0.86, and a specificity of 0.85.
Conclusions: Geometric approximations have high sensitivity and low specificity, which can lead to overestimation of the size of the injury. Thus, patients may be exposed to the risk of an operative repair unnecessarily. For this reason, simplifications cannot be made from a clinical perspective. Radiologists are better at measuring area but inferior at volumes compared to surgeons with geometric calculations. The author’s opinion is that measurements should be taken with accurate methods and not with geometric calculations to avoid misdiagnosis.
Osteoblastoma of the Frontal Sinus: A Case Report
David Michael Adkins (Presenter); Christopher A. Roberts, MD; Mark A. Armeni, MD
Objectives: To describe the surgical management of osteoblastoma involving the anterior table of the frontal sinus, with attention to a unique method of reconstruction using split calvarial bone grafting.
Method: Case report.
Results: We reviewed the management of a 15-year-old boy who presented at our institution with a 6-month history of a firm, tender right forehead swelling that developed after an episode of acute sinusitis treated with oral antibiotics. A computed tomography scan showed a heterogeneous radiolucent lesion of the frontal sinus with central density. Fine-needle aspiration was performed that suggested a bony neoplasm. The lesion was excised en bloc using a bicoronal approach/osteoplastic flap. The remaining anterior frontal sinus defect was repaired using split calvarial bone grafting, secured with absorbable sutures (rather than rigid plates). Extended clinical follow-up examinations and 11-year postoperative radiography show that the patient has remained free of disease, with excellent integrity of the frontal sinus reconstruction.
Conclusions: Osteoblastoma is a rare benign tumor of bone that typically arises in the spinal column and long bones of male patients in the second decade of life; only 10% to 15% of these occur in the craniofacial skeleton. This case illustrates the successful resection of an osteoblastoma from the anterior plate of the frontal sinus with a unique method of reconstruction that has remained intact, without complications at long-term follow-up. Furthermore, this suture technique represents a viable option for craniofacial reconstruction that avoids long-term sequelae associated with implanted hardware.
Outcomes of Dog Bite Avulsion Injury Reconstruction with Urinary Bladder Matrix
Adrian A. Ong, MD (Presenter); Ryan Nagy; Michelle Fincham, MD; Mark L. Nagy, MD
Objectives: To review our experience using porcine urinary bladder extracellular matrix (UBM) for the management of dog bite avulsion injuries in the pediatric population.
Methods: This is a single-institution case series with chart review of pediatric patients who underwent reconstruction of dog bite avulsion injuries using UBM. Demographic data, location and size of avulsion injury, wound dehiscence, graft failure, infection rate, and need for additional procedures were reviewed.
Results: Four patients were identified; all patients were male. The average age at surgery was 7.0 ± 0.9 years. Two (50%) patients underwent reconstruction of the nose; the other 2 patients underwent reconstruction of the forehead/glabella and auricle. The average size of the avulsion defect was 6.6 ± 2.5 cm2. No patient developed wound dehiscence, graft loss, or wound infection. All patients achieved satisfactory wound closure. Three (75%) patients received pulsed dye laser treatment to improve wound cosmesis.
Conclusions: Use of UBM is a safe and effective reconstructive option after dog bite avulsion injuries of the head and neck. Given the advantage of convenient availability and avoidance of donor site morbidity, UBM can be considered for reconstruction of other traumatic avulsion injuries or Mohs micrographic defects as an alternative to local flap reconstruction.
A Population-Based Analysis of Combat Sport-Related Maxillofacial Injuries
Scott J. Schwartz (Presenter); Jordan L. Wallin, MD
Objectives: The popularity of combat sports (defined to include boxing, wrestling, and martial arts) has seen a meteoric rise in over the past 10 to 15 years, coinciding with the growth of the Ultimate Fighting Championship and megastars in boxing such as Floyd Mayweather. Most of these disciplines are practiced without any protective headgear at the amateur and professional levels. Our objective was to characterize national trends among patients presenting to emergency departments (EDs) for facial injuries sustained while practicing a combat sport.
Methods: The National Electronic Injury Surveillance System was searched for combat-sport related facial injuries, with analysis for incidence, specific injury diagnosis, sex, age, and facial locations
Results: From 2013 to 2017, there were an estimated 25,997 ED visits for combat sport–related facial injuries. Lacerations were the most common form of injury across all visits (42.2%) and also across each individual practice (boxing, wrestling, and martial arts). Fractures and contusions/abrasions were the next 2 most common forms of injuries. The vast majority (93.8%) of the total patient population were male. The number of yearly ED visits decreased over the 5-year span, with a 17.3% decline in visits from 2013 to 2017. The average age of injury was 20.4 years, but more than 51% of patients were younger than age 18 years.
Conclusions: Although the overall incidence of ED visits for facial trauma from combat sports has consistently decreased over the past 5 years, the large proportion of minors participating in combat sports and ultimately sustaining injuries raises concern. Given this, encouragement of proper protective equipment should be stressed to all participants in combat sports.
Reconstruction of Complex Oromandibular Defects: The Chimeric Subscapular Flap
Luca Gazzini, MD (Presenter); Luca Lanaro; Andrea For; Daniele Marchioni, MD; Pier Francesco Nocini; Gabriele Molteni, MD
Objectives: The excision of head and neck advanced cancers may cause hesitation in large composite defects of different soft tissues and bone. This topic is particularly challenging in salvage surgery after radiation therapy. Reconstructive techniques in these cases are very complex and traditionally require the use of multiple microvascular flaps. The chimeric free flaps based on the subscapular system allow complex reconstructions, providing soft tissue as well as bone on a single vascular peduncle. The purpose of this study is to present this reconstructive choice and to show the personal experience of the authors.
Methods: The regional anatomy of the subscapular system and the possible chimeric flaps that can be harvested, the reconstructive surgical technique, and the positioning of the patient will be explained. Two clinical cases of complex head and neck reconstructions after radiotherapy will be presented. Data about preoperative condition, intraoperative pictures, and radiologic and clinical documentation will be collected.
Results: Plenty of chimeric flaps can be harvested from the subscapular system. These flaps can include different tissues (skin, bone, muscle) on a single vascular peduncle. This characteristic is particularly useful in complex defects following large en bloc excision of advanced head and neck tumors. In this case, the gold standard traditionally has been the reconstruction with a double free microvascular flap. Another advantage of this flap is that it is possible to use a 2-team approach: the demolitive and the reconstructive surgeon can work concurrently, placing the patient in a 30° semidecubitus position.
Conclusions: Free flaps based on the subscapular system can be an excellent reconstructive choice in complex head and neck defects.
Returning Quality of Life with Personalized Facial Prosthesis
Omar Alberto Gutierrez, MD (Presenter)
Objectives: Rehabilitation with facial prosthesis allows clinicians to improve the quality of life of patients who do not have the possibility of favorable reconstructive reconstruction with traditional surgical methods and their corresponding social integration. This study aimed to evaluate the perception of the change in the quality of life in patients who have adapted facial prostheses during 20 months in Bogotá, DC, Colombia, and the social and family impact of this treatment.
Methods: We contacted a total of 48 patients (adults and children)—through telephone, e-mail, and/or personal contact—who were beneficiaries of facial reconstruction with auricular, nasal, and periorbital prostheses performed by the same anaplastologist. The World Health Organization Quality of Life-BREF instrument was adapted for use in this study, to measure the changes in the quality of life of these patients in pre- and postprosthetic adaptation states.
Results: There was an observed improvement in physical appearance of greater than 95%, improvement in self-esteem of more than 90%, satisfaction in the development of daily activities of more than 90%, perception of social acceptance at 85%, perception of decreased physical pain in high percentage, and decreased of feelings of frustration of lower than 12% with the use of the prosthesis.
Conclusions: Facial reconstruction with a custom prosthesis improves the patients’ self-esteem, restores their confidence, and facilitates their family, school, work, and social reintegration in their community (children and adults), allowing them to enjoy better lives.
Submental Island Flaps versus Free Tissue Transfer: A Systematic Review
Shirley Hu, MD (Presenter); Caleb Fan, MD; Joshua D. Rosenberg, MD
Objectives: To compare the surgical outcomes of the submental artery island flap (SMIF) and microvascular free-tissue transfer (FTT) for the reconstruction of ablative defects of the oral cavity and lateral temporal bone.
Methods: Data sources included Ovid MEDLINE, EMBASE, Cochrane Library, and Google Scholar databases. Article screening and data extraction were performed by 2 authors. Studies directly comparing SMIF and FTT for oral cavity or temporal bone defects were included, and only outcomes described by 5 or more studies were assessed in the meta-analysis. Data were pooled with random-effects meta-analysis to calculate standardized mean differences (SMDs), risk differences (RDs), and 95% confidence intervals (CIs). Heterogeneity was evaluated with the I2 statistic. The Methodological Index for Non-Randomized Studies tool was used to assess bias.
Results: The initial search yielded 353 studies, of which 7 remained for final analysis. Pooled sample sizes for the SMIF and FTT groups were 145 and 166, respectively. SMIF was correlated with a reduction both in operative time and the duration of hospitalization by a large effect size (SMD, −1.27; 95% CI, −1.53 to −1.02; SMD, −3.06; 95% CI, −3.45 to −2.67). Larger flap areas were harvested with FTT (SMD, 1.13; 95% CI, 0.87-1.39). Rates of total flap loss and partial flap necrosis were similar between the 2 procedures. SMIF was associated with lower donor site morbidity (9.4% RD, number needed to treat [NNT] 11) and fewer recipient site complications including the need for debulking/revision (7.9% RD, NNT 13).
Conclusions: SMIF requires less operative time and shorter hospital stays and may have fewer perioperative complications compared with FTT in the reconstruction of oral cavity and temporal bone defects.
Surgical Treatment of a Giant Rhinophyma: Case Report
Catarina Tinoco (Presenter); Diogo Oliveira E Carmo, MD; Ana Helena Campos; Pedro Henriques, MD; João Paço
Background: Rhinophyma is a disease characterized by progressive hypertrophy of the epidermal and dermal elements of the nose, which causes an enlargement of the nose and results both in functional and cosmetic impairment. It is considered the most severe stage of rosacea; however, the etiology of rhinophyma is unknown. In rare cases, these lesions can reach a giant size and be a challenge.
Methods: We present a case of a 55-year-old man with a giant rhinophyma with a slowly progressive development of approximately 10 years. In the past few months, he noticed a progressive nasal obstruction.
Case report: Clinical examination revealed a giant, multilobulated, uniformly firm, and erythematous nasal mass protruding from the nasal tip, dorsum, and alae causing nasal functional impairment. The huge mass was removed under general anesthesia by decortication with an electrosurgical knife preserving all the nasal structure. We also used radiofrequency for tissue volume reduction. The wounds healed by secondary intention, with an immediate and late cosmetic and functional result very satisfactory.
Conclusions: In advanced forms of rhinophyma, the main method of treatment is surgery, which can sometimes be challenging. In our opinion, in giant rhinophyma, conservative electrosurgical excision complemented by radiofrequency followed by secondary intention healing is simple, safe, and pain free and provides a pleasant aesthetic result and functional improvement.
Unilateral Nasal Physical Examination Findings Are Predictive of an Elevated Nasal Obstruction Symptom Evaluation Score
Allen L. Feng (Presenter); Natalie S. Justicz; Shekhar K. Gadkaree; Robin W. Lindsay, MD
Objectives: The Nasal Obstruction Symptom Evaluation (NOSE) survey is a validated quality-of-life instrument for patients with nasal obstruction. We sought to investigate the relationship between NOSE scores and unilateral and bilateral nasal obstruction.
Methods: A retrospective chart review of patients with recorded NOSE scores prior to any surgical intervention was performed. Basic patient demographics including age and sex were recorded along with nasal physical examination findings. These included total internal valve narrowing (IVN), external valve narrowing (EVN), internal valve collapse (IVC), external valve collapse (EVC), and septal deviations (inferior and superior). Findings were reported for the left, right, and both sides. Nasal valve and septal findings were recorded on 3- and 4-point Likert scales, respectively, for each side of the nose.
Results: A total of 1646 patients were included in the study. On univariate analysis, a significant correlation was seen between NOSE scores and all individual examination findings (P < .001). On multiple linear regression, the septal deviation (P < .001) and IVN (P < .01) were predictive of an increased NOSE score when considering either unilateral or bilateral scores. Age, sex, total EVN, total IVC, and total EVC were not predictive of an increased NOSE score. These physical examination scores were not found to be collinear, with an average variance inflation factor of 2.18 (range, 1.68-3.42).
Conclusions: Physical examination findings, including septal deviation and IVN, are predictive of an increased NOSE score, regardless of laterality.
The Use of Multiple Techniques for Grade 1 Microtia Repair
Michael J. Bauschard, MD (Presenter); Rajanya S. Petersson, MD
Objectives: Microtia reconstruction varies depending on the grade of microtia and patients’ desired goals. Current methods for grade 1 microtia repair often use otoplasty techniques and sometimes require harvested cartilage for reconstruction. We present a case of grade 1 microtia repair performed in 2 stages, several years apart, as the patient’s goals evolved.
Methods: An 11-year-old boy with grade 1 microtia underwent previous surgery using otoplasty techniques with V-Y advancement of the helical crus. He was satisfied with this for several years but started having trouble wearing glasses and sought out further treatment. He was noted to have a lack of support superiorly in the area of the helical crus because of the lack of cartilaginous support. As he had skin laxity in the area, a rib cartilage graft was tunneled into the area without extensive dissection of skin overlying the native cartilage. This technique is described in detail.
Results: Excellent cosmesis was achieved with the reconstructed helical height matching the opposing ear, allowing for more comfortable wearing of glasses. There was still some height discrepancy at the lobule, but this caused no functional problems. The patient recovered well with low morbidity.
Conclusions: The techniques used here allowed for improved appearance, with low morbidity and increased function. Discussing what is achievable and managing expectations is important in microtia repair. Using a stepwise approach in grade 1 microtia repair may be of benefit to achieve definable goals without risking an undesired aesthetic outcome.