Prominauris is a common auricular deformity most often due to underdevelopment of the antihelical fold or overdevelopment of the conchal bowl. Significant psychosocial distress may result from prominent ears, leading to the development of a variety of surgical techniques over the years. A thorough understanding of the anatomy of both the normal and prominent ear is crucial for accurate analysis and surgical correction of the deformity. The procedure is well-tolerated and careful preoperative evaluation and adherence to meticulous cartilage-sparing techniques will lead to good results and low complication rates.

Background For patients with oral cavity squamous cell carcinoma (OCSCC) without evidence of nodal metastasis (cN0) on pre-operative evaluation, there are no clear guidelines who should undergo elective neck dissection (END) versus clinical surveillance. Objective To identify CT imaging characteristics of sub-centimeter lymph nodes that would help predict the likelihood of nodal metastases on pathology. Methods Retrospective review of cN0 OCSCC patients at a tertiary academic medical center was performed. Inclusion criteria included elective neck dissection, pre-operative CT imaging and presence of metastatic disease within lymph nodes. Control group consisted of patients without nodal metastases on pathology. CT features that were evaluated included asymmetric size, disrupted fatty hilum, asymmetric number, presence of cortical nodule, cortical nodule size, and round/oval shape. We evaluated the associations between CT LN features and the presence of metastases using multi-level mixed-effects logistic regression models. Model evaluation was performed using 5-fold cross-validation. The positive predictive value (PPV) and negative predictive value (NPV) were calculated. Results 26 patients in each study and control groups were included. Three-level mixed-effects logistic regression models indicated round/oval shape (OR = 1.39, p = .01), asymmetric number (OR = 7.20, p = .005), and disrupted fatty hilum (OR = 3.31, p = .04) to be independently predictive in a 3-variable model with sensitivity = 38.0%, specificity = 92.0%, and PPV = 93.8%. Conclusions In cN0 OCSCC patients undergoing END, round/oval shape, asymmetric number, and disrupted fatty hilum of lymph nodes on pre-operative CT imaging are novel and highly predictive of occult nodal disease.

Supplemental data not critical for the main conclusions of the work but important for critical review of the data.

OBJECTIVE:To identify patient factors in older patients associated with making posttreatment visits in the first year after major head and neck oncologic surgery.STUDY DESIGN:Retrospective cohort study.SETTING:Academic institution.METHODS:Patients aged ≥60 years who underwent a neck dissection with or without a free flap reconstruction were retrospectively analyzed. Data collected included patient demographics, comorbidities, social variables, perioperative course, and clinical visits.RESULTS:Within a 1-year postoperative period, the 181 patients in our cohort had a mean ± SD 6.37 ± 3.6 postoperative clinic visits; 70% attended at least 4 visits. Multivariable regression analysis showed a significant association with distance closer to the hospital (P = .013): for every 10-mile increase in distance, the number of visits decreased by 0.15 (SE = 0.06). Additionally, receiving adjuvant radiation therapy (P = .0096) demonstrated significant associations: when compared with no adjuvant therapy, radiation therapy had on average 1.5 (SE = 0.56) more visits, and chemoradiation had 0.04 (SE = 0.73) more visits.CONCLUSION:Older patients who undergo major head and neck oncology surgery are more likely to attend posttreatment visits in the 1 year following surgery if they are discharged home rather than to a skilled nursing facility, live closer to the hospital, and undergo adjuvant radiation therapy.

Background: Development of the craniofacial skeleton and different mechanisms of injury warrant different treatment paradigms for younger children versus those at skeletal maturity. Objective: To characterize the mechanism, fracture patterns, and management of mandible fractures across the pediatric age spectrum. Methods: A 10-year retrospective review of <18-year-old children with mandible fractures at a level 1 trauma center. Characteristics were compared by age subgroup analysis. Results: Of 220 patients meeting inclusion criteria, motor vehicle collision (n = 53, 40.8%), falls (n = 48, 36.9%), and assault (n = 19, 14.6%) were the most common mechanisms with more falls in younger children and more injury by assault in teenagers. Condylar fractures were most common in the 0- to <9-year-old children (n = 27, 38.4%); angle/ramus fractures (56, 62.6%) were most common in 15- to <18-year-old children (p < 0.001). Nonsurgical management was associated with younger age (p < 0.001). Fourteen of 125 patients (8.0%) undergoing surgical intervention experienced complications. Being uninsured was associated with shorter median (interquartile range) follow-up of 5.6 (1.4-10.7) weeks, compared with private [11.9 (4.3-49.0) weeks] and public insurance [11.7 (3.7-218.0) weeks] (p < 0.001). Conclusion: The mechanism, fracture sites, and treatment differed by age with the youngest frequently managed nonoperatively and teenagers treated with adult algorithms. Complications were rare overall within 6-12 weeks after injury, with or without surgical management.

BACKGROUND:Breast aesthetics impacts patients' quality of life after breast reconstruction, but patients and surgeons frequently disagree on the final aesthetic evaluation. The need for a comprehensive, validated tool to evaluate breast aesthetics independently from the patient motivated this study.METHODS:The 13-item Validated Breast Aesthetic Scale was developed after several internal meetings, and worded to be understood by a nonspecialist. Three items are common for both breasts, with the remaining being side-specific. To test the internal consistency of the scale subitems, postoperative photographs after different breast reconstruction techniques were graded by a six-member panel. To test interrater and intrarater correlation across time, four physicians evaluated the results of abdominally based breast reconstructions following nipple-sparing mastectomies.RESULTS:Graded aesthetic outcomes of 53 patients showed that the Cronbach alpha of the subitems of the scale was 0.926, with no single item that, if excluded, would increase it. Twenty-two patients underwent aesthetic outcomes grading at four different time points. The mean overall appearance was 3.71 ± 0.62. The mean grade for overall nipple appearance was 4.0 ± 0.57. The coefficient alpha of the panel overall aesthetic grade across different time points was 0.957; whereas intragrader reliability for graders 1 through 4 individually showed alpha coefficients of 0.894, 0.9, 0.898, and 0.688, respectively. Similar results were found for the other items of the scale.CONCLUSIONS:The proposed aesthetic scale evaluates different aspects of the breast reconstruction aesthetic result with excellent internal consistency among its subitems. Grading by a gender-balanced, diverse four-member panel using postoperative photographs showed higher reliability and reproducibility compared to single graders.

BACKGROUND:Patient-reported outcomes are the primary measurement of breast reconstruction success, but results may be affected by nontechnical factors such as socioemotional determinants. Third-party observers provide an independent assessment of aesthetic outcomes. Factors associated with disparity between patient and observer perceptions of outcomes are not well understood.METHODS:One hundred forty-seven patients underwent breast reconstruction at the authors' institution between 2009 and 2011, completed the BREAST-Q, and had photographs graded by a diverse panel using the Validated Breast Aesthetic Scale. Patient satisfaction with breasts scores that aligned with observer scores were categorized as group 2; patient satisfaction that exceeded observer scores were group 1; and those lower than observer scores were group 3. Statistical analysis was performed using SPSS, with values of p < 0.05 considered statistically significant.RESULTS:Twenty-eight patients (19 percent) were categorized as group 1, 93 (63 percent) in group 2, and 26 (18 percent) in group 3. Median overall appearance was highest in group 3 (median, 4.0; interquartile range, 4 to 4) and lowest in group 1 (median, 3.0; interquartile range, 2 to 3) ( p < 0.001). Psychosocial, sexual, and physical well-being were significantly associated with disparity (group 1 or 3 status) ( p < 0.01). Satisfaction with outcomes, nipples, abdomen, and breasts were significantly associated with disparity. Factors not significantly associated with disparity include age, body mass index, autologous or implant-based, adjuvant therapies, and timing of reconstruction.CONCLUSIONS:Incongruously high patient satisfaction with breast reconstruction aesthetics relative to third-party perception of aesthetic outcomes is associated with high quality-of-life scores. Incongruously low patient satisfaction with breast cosmesis compared with higher third-party perceptions was associated with low quality-of-life scores.CLINICAL QUESTION/LEVEL OF EVIDENCE:Risk, II.

Facial Plastic Surgery & Aesthetic MedicineVol. 24, No. 2 Invited CommentaryCommentary on “Augmented Skin Grafting: A New Rung in the Reconstructive Ladder” by Landeen et al: Less Invasive Options for Patients with Significant ComorbiditiesMegan V. Morisada and Travis T. TollefsonMegan V. MorisadaFacial Plastic and Reconstructive Surgery, Department of Otolaryngology—Head and Neck Surgery, University of California Davis Health, Sacramento, California, USA.Search for more papers by this author and Travis T. Tollefson*Address correspondence to: Travis T. Tollefson, MD, MPH, Facial Plastic and Reconstructive Surgery, Department of Otolaryngology—Head and Neck Surgery, University of California Davis Health, 2521 Stockton Boulevard, Suite 7200, Sacramento, CA 95817, USA, E-mail Address: [email protected]https://orcid.org/0000-0002-8658-8647Facial Plastic and Reconstructive Surgery, Department of Otolaryngology—Head and Neck Surgery, University of California Davis Health, Sacramento, California, USA.Search for more papers by this authorPublished Online:15 Mar 2022https://doi.org/10.1089/fpsam.2021.0382AboutSectionsView articleView Full TextPDF/EPUB Permissions & CitationsPermissionsDownload CitationsTrack CitationsAdd to favorites Back To Publication ShareShare onFacebookTwitterLinked InRedditEmail View article"Commentary on “Augmented Skin Grafting: A New Rung in the Reconstructive Ladder” by Landeen et al: Less Invasive Options for Patients with Significant Comorbidities." Facial Plastic Surgery & Aesthetic Medicine, 24(2), pp. 130–131FiguresReferencesRelatedDetails Volume 24Issue 2Apr 2022 InformationCopyright 2022, American Academy of Facial Plastic and Reconstructive Surgery, Inc.To cite this article:Megan V. Morisada and Travis T. Tollefson.Commentary on “Augmented Skin Grafting: A New Rung in the Reconstructive Ladder” by Landeen et al: Less Invasive Options for Patients with Significant Comorbidities.Facial Plastic Surgery & Aesthetic Medicine.Apr 2022.130-131.http://doi.org/10.1089/fpsam.2021.0382Published in Volume: 24 Issue 2: March 15, 2022Online Ahead of Print:January 21, 2022PDF download

The primary function of the eyelids is to maintain ocular health and protection. In facial paralysis, neurogenic dysfunction of the orbicularis oculi muscle complex leads to a spectrum of ocular and periocular issues including xerophthalmia, exposure keratopathy, and lower eyelid malposition contributing to epiphora and facial deformity. Conservative techniques can foster a safe environment for patients awaiting surgical intervention. Eyelid coupling using a combined lower eyelid tightening and modified tarsoconjunctival flap is our preferred technique for older patients with flaccid facial paralysis, usually performed with a platinum weight. Medial eyelid ectropion remains a difficult area for those with senile changes. For best lower eyelid outcomes, the midface must be lifted with reanimation, facial sling, or temporalis tendon transfer. Herein we describe several chosen techniques to improve patients’ ocular and cosmetic outcomes after facial paralysis. The primary function of the eyelids is to maintain ocular health and protection. In facial paralysis, neurogenic dysfunction of the orbicularis oculi muscle complex leads to a spectrum of ocular and periocular issues including xerophthalmia, exposure keratopathy, and lower eyelid malposition contributing to epiphora and facial deformity. Conservative techniques can foster a safe environment for patients awaiting surgical intervention. Eyelid coupling using a combined lower eyelid tightening and modified tarsoconjunctival flap is our preferred technique for older patients with flaccid facial paralysis, usually performed with a platinum weight. Medial eyelid ectropion remains a difficult area for those with senile changes. For best lower eyelid outcomes, the midface must be lifted with reanimation, facial sling, or temporalis tendon transfer. Herein we describe several chosen techniques to improve patients’ ocular and cosmetic outcomes after facial paralysis. Patients can present with facial paralysis from a variety of etiologies such as: acoustic neuroma, temporal bone trauma, idiopathic, iatrogenic, infectious, and autoimmune. Those with permanent, flaccid facial paralysis usually require surgical management to prevent functional and aesthetic periorbital impairment. Impaired orbicularis oculi function may lead to incomplete eye closure and reduced frequency and amplitude of blink, reducing tear film distribution and increasing risk for corneal desiccation.1.Bergeron CM Moe KS. The evaluation and treatment of lower eyelid paralysis.Facial Plast Surg. 2008; 24: 231-241Crossref PubMed Scopus (30) Google Scholar,2.Sibony PA Evinger C Manning KA. Eyelid movements in facial paralysis.Arch Ophthalmol. 1991; 109: 1555-1561Crossref PubMed Scopus (46) Google Scholar Increased exposure of the ocular surface can lead to progressive exposure keratopathy and eventual corneal epithelial defects, ulcerations, perforations, scarring, and rarely, endophthalmitis and loss of vision. At baseline, the function of the eyelid retractors allows for pronounced eyelid retraction and widening of the vertical palpebral fissure.3.Joseph SS Joseph AW Douglas RS et al.Periocular Reconstruction in Patients with Facial Paralysis.Otolaryngol Clin North Am. 2016; 49: 475-487Abstract Full Text Full Text PDF PubMed Scopus (11) Google Scholar Diminished periocular tone leads to decreased anti-gravitational pull of the lower lid and resultant paralytic ectropion.4.Bedran EG Pereira MV TF Bernardes Ectropion.Semin Ophthalmol. 2010; 25: 59-65Crossref PubMed Scopus (27) Google Scholar Punctal eversion away from the surface of the globe, in addition to abnormal active muscular pumping action and derangements in post-ganglionic parasympathetic activity leads to lacrimal dysfunction, tear laking, and epiphora (Figure 1).1.Bergeron CM Moe KS. The evaluation and treatment of lower eyelid paralysis.Facial Plast Surg. 2008; 24: 231-241Crossref PubMed Scopus (30) Google Scholar,5.Doane MG. Interactions of eyelids and tears in corneal wetting and the dynamics of the normal human eyeblink.Am J Ophthalmol. 1980; 89: 507-516Abstract Full Text PDF PubMed Scopus (303) Google Scholar Even patients who have facial nerve return of function may be plagued with facial synkinesis, which presents another set of eyelid dysfunctions. Treatment goals of the periocular complex in facial nerve paralysis include protection of the ocular surface, preservation of visual function, and restoration of facial symmetry. There are a variety of temporary and long-term treatment options for these patients, based on an anticipated recovery of facial nerve function (or lack thereof). Comprehensive examination should include determination of facial nerve function, ophthalmologic evaluation of corneal epithelium, scleral show, presence of Bell's phenomenon, MRD1 and 2 measurements, palpebral fissure width, levator function, lower lid laxity, ectropion/entropion, lagophthalmos, and brow ptosis. In the acute setting, aggressive lubrication, and humidification in the form of lubricating eye drops, ophthalmologic ointments, moisture chambers, taping, and even external eyelid weights serve to protect the corneal surface quickly and effectively from exposure. Adjunctive injectable techniques have been described including (1) chemodenervation of the levator palpebrae superioris with botulinum toxin to induce a protective ptosis6.Ellis MF Daniell M. An evaluation of the safety and efficacy of botulinum toxin type A (BOTOX) when used to produce a protective ptosis.Clin Exp Ophthalmol. 2001; 29: 394-399Crossref PubMed Scopus (62) Google Scholar and (2) hyaluronic acid injection augmentation of the upper lid for temporary loading with concurrent lower eyelid injection to induce expansion and reduce retraction.7.Mancini R Khadavi NM Goldberg RA. Nonsurgical management of upper eyelid margin asymmetry using hyaluronic acid gel filler.Ophthalmic Plast Reconstr Surg. 2011; 27: 1-3Crossref PubMed Scopus (43) Google Scholar Finally, suture tarsorrhaphy can be utilized to physically reduce the vertical palpebral fissure in the event that prior conservative measures fail to protect the corneal surface.8.Gossman MD Bowe BE Tanenbaum M. Reversible suture tarsorrhaphy for eyelid malposition and keratopathy.Ophthalmic Surg. 1991; 22: 237-239PubMed Google Scholar Long-term treatment options typically encompass surgical interventions – a selection of which is described below. Upper eyelid loading with surgically placed weights assists with closure of the upper lid by countering the upward pull of normal levator muscle retraction. The use of a platinum implant is advantageous in its smaller size (due to higher density compared to gold) and decreased capsular inflammation.10.Berghaus A Neumann K Schrom T. The platinum chain: a new upper-lid implant for facial palsy.Arch Facial Plast Surg. 2003; 5: 166-170Crossref PubMed Scopus (79) Google Scholar Proper selection of lid weight is based on the lightest weight that consistently provides complete eye closure with volitional blinking; this is tested using adhesive to apply different sized weights to the patient's upper lid. This procedure can be performed under local anesthesia and may be performed with other periocular reconstruction procedures. 1.Presurgical marking of the supraciliary crease (7-10 mm above the eyelashes) and midpupillary line are important for accurate implant placement. Approximately two-thirds to three-fourths of the weight length is planned to be medial to the midpupillary line – where function of the levator is maximal.2.Local anesthesia is induced with a subcutaneous injection of 1% lidocaine with 1:100,000 epinephrine on a 30-gauge needle to create hydro-dissection and hemostasis.3.An incision is made in the supraciliary crease through the orbicularis oculi muscle. Blunt elevation is performed to provide exposure to the tarsal plate perichondrium.4.Fine tipped scissor dissection creates a precise pocket to accommodate the size and shape of the platinum weight. Traditional placement is upon the tarsal plate perichondrium 2mm above the eyelid margin. However, placement of the implant more cephalically between the levator aponeurosis and the orbital septum can make the weight less visible but requires a heavier weight.5.The weight is then placed into the pocket and secured with 6-0 polyglactin suture through each hole (at least 2 sutures to avoid rotation of the weight; Figure 2A, B). The upper lid may be intermittently everted during dissection to avoid communication through conjunctiva. The muscle layer is then closed with interrupted 6-0 polyglactin suture and the skin is approximated with 6-0 fast absorbing gut or 6-0 polypropylene suture. A lateral tarsal strip canthoplasty is a traditional technique for shortening and tightening elongated lower eyelids.11.Anderson RL. The tarsal strip.Trans New Orleans Acad Ophthalmol. 1982; 30: 352-363PubMed Google Scholar 1.A canthotomy and inferior cantholysis is performed with a 15 blade, Wescott scissors, and/or monopolar cautery.2.After freeing the lower eyelid from ligamentous attachments at Whitnall's tubercle, the anterior lamellae (skin and orbicularis muscle) is excised from the tarsal strip.3.Full thickness excision of the lateral canthal tendon is performed based on the appropriate length needed to correct lower-eyelid laxity.4.The remnant tarsal strip conjunctival mucosa is denuded with a 15 blade.5.For suspension of the tarsal strip, a 5-0 polydioxanone suture is parachuted in horizontal mattress fashion from the lateral canthal tendon to the lateral orbital rim (posterior and superior to Whitnall's tubercle within the orbital vault). An alternative suture is a double armed 4-0 mersilene on S2 needle. This suture is tagged and later cinched down after completion of a lateral modified tarsoconjunctival flap (TCF), if planned concurrently (otherwise it is more difficult to place after inset of the TCF). If a TCF is not performed, completion of the canthoplasty suture is performed by tying down the 5-0 polydioxanone mattress suture creating appropriate tension for eyelid shortening.6.The canthotomy is closed with buried interrupted 5-0 poliglecaprone deep dermal sutures. The lateral canthal angle is re-created with 6-0 fast absorbing gut suture, which is tied beneath interrupted 6-0 silk sutures used to approximate the skin layer of the canthotomy. A less disruptive albeit less powerful lower eyelid tightening procedure is the lateral retinacular suspension.12.Fagien S. Algorithm for canthoplasty: the lateral retinacular suspension: a simplified suture canthopexy.Plast Reconstr Surg. 1999; 103 (discussion 2054-2048): 2042-2053Crossref PubMed Scopus (105) Google Scholar This technique is suited for patients with mild-moderate lower eyelid laxity. 1.A 5-7 mm lateral canthotomy incision is created with a 15-blade through skin and orbicularis muscle sparing the lateral palpebral fissure.2.A freer dissector and cotton-tipped applicators are used to palpate near Whitnall's tubercle.3.A 5-0 polydioxanone suture is then used to perform the lateral retinacular suspension technique, starting from the lateral orbital rim (posterior and superior to Whitnall's tubercle) in a subperiosteal plane through the lower lateral canthal tendon in a horizontal mattress fashion. This suture is tagged and can be tied down after completion of a lateral modified TCF, if planned concurrently (Figure 3).4.The canthopexy suture is cinched down with appropriate tension for adequate eyelid shortening.5.The canthotomy incision is closed with buried interrupted 5-0 polyglactin deep dermal sutures and the skin re-approximated with 6-0 fast absorbing gut. Coupling of the upper and lower eyelids was traditionally completed with a tarsorrhaphy, but the skin edges of the lid were very obvious and obscured the lateral visual field. The lateral modified tarsoconjunctival flap (also known as the mini-Hughes, TCF tarsal transposition) technique was developed to improve the appearance and combat the unopposed effect of upper and lower lid retraction, improving lid malposition and lagophthalmos.13.Sufyan AS Lee HB Shah H et al.Single-stage repair of paralytic ectropion using a novel modification of the tarsoconjunctival flap.JAMA Facial Plast Surg. 2014; 16: 151-152Crossref PubMed Scopus (10) Google Scholar,14.Dedhia RD Shipchandler TZ Tollefson TT. Eyelid Coupling Using a Modified Tarsoconjunctival Flap in Facial Paralysis.Facial Plast Surg Clin North Am. 2021; 29: 447-451Abstract Full Text Full Text PDF PubMed Scopus (1) Google Scholar It provides vertical vector support to a lax lower eyelid and couples dynamic movement of the upper and lower lids to improve tear film distribution. This technique is often performed with either a lateral tarsal strip canthoplasty or canthopexy with lateral retinacular suspension, as described above, to address horizontal lower lid laxity and coupled with upper eyelid loading. 1.This procedure starts with lower eyelid tightening with either a lateral tarsal strip canthoplasty or lateral retinacular suspension as described above. With either tightening technique, the fixation sutures are tagged until completion of the TCF.2.A 4-0 silk traction suture is placed through the upper eyelid gray line and the eyelid is then everted over a Desmarres retractor. Hydrodissection of the posterior lamella is performed with 1% lidocaine 1:100,000 epinephrine, which assists in flap elevation.3.A superiorly based flap is then designed along the lateral upper eyelid. The design is approximately 3 to 8 mm wide, depending on the degree of eyelid laxity and snap test result, ∼4 mm tall, and includes 1 to 2 mm of the superior tarsal plate (Figure 4). The flap design includes 2 mm of the tarsal plate and is cut with a 15C blade to release the TCF for transposition. At least 4 mm of tarsal plate height is preserved above the lid margin to prevent upper lid entropion.4.An incision is made at the gray line of the lower lateral eyelid and a small sliver of lower lid margin is denuded sharply with 15 blade to create a pocket to receive the tarsoconjunctival flap.5.The TCF is then elevated from the overlying orbicularis oculi in standard fashion for a modified Hughes tarsoconjunctival flap (Figure 5).Figure 5Elevation of a modified Hughes tarsoconjunctival flap from the overlying orbicularis oculi.View Large Image Figure ViewerDownload Hi-res image Download (PPT)6.This is secured into the lower eyelid pocket in an interrupted fashion using 4-0 polyglactin suture into each corner as well as at the midpoint portion, with knots facing away from the sclera to prevent ocular irritation.7.The canthopexy or canthoplasty is then tied down and the lateral canthal angle is recreated and canthotomy incision closed. Restoration of the medial eyelid ectropion in facial paralysis is difficult and often leads to early success and fading results. Our preferred technique uses a conservative transcutaneous approach. 1.The medial inferior orbital rim/medial canthal region is exposed via a limited transcutaneous subciliary and/or medial canthal incision. A retrocaruncular approach may be used as an alternative to avoid scar.2.The medial canthal tendon is identified via blunt dissection and the new anchoring point of suspension is planned posterior and superior to the posterior lacrimal crest. To identify the posterior lacrimal crest, a freer dissector is used to palpate the lacrimal fossa during a retrocaruncular approach. A colorado tipped bovie is used to incise the conjunctiva staying posterior to the lacrimal fossa to avoid injuring the lacrimal system with frequent palpation utilizing a freer dissector to ensure safe trajectory.3.A 5-0 polydioxanone suture is placed in mattress fashion through the medial canthal tendon and passed through the posterior lacrimal crest periosteum. Stainless steel wires and bone anchoring systems may be utilized as an alternative which are more durable but have risk of palpation/extrusion and may require greater dissection (Figure 6).15.Kelly CP Cohen AJ Yavuzer R et al.Medial canthopexy: a proven technique.Ophthalmic Plast Reconstr Surg. 2004; 20: 337-341Crossref PubMed Scopus (25) Google Scholar,16.Baek S Chung JH Yoon ES et al.Algorithm for the management of ectropion through medial and lateral canthopexy.Arch Plast Surg. 2018; 45: 525-533Crossref PubMed Scopus (8) Google Scholar4.The skin or conjunctiva is closed with 6-0 fast absorbing gut suture. The scar heals well in this concave facial subunit. When patients have both medial and lateral canthal tendon laxity a lower eyelid sling may be employed to comprehensively address this complete lower lid malposition and laxity.17.Tenzel RR Buffam FV Miller GR. The use of the "lateral canthal sling" in ectropion repair.Can J Ophthalmol. 1977; 12: 199-202PubMed Google Scholar 1.A limited fascia lata graft from the lateral thigh or palmaris longus tendon from ventral forearm is cut to approximately 35 × 10 mm. Incision planning for lateral thigh fascia lata should start 6 cm above the lateral tibial condyle. Orthopedic surgery colleagues assist in harvest of palmaris longus.2.A subciliary approach, lateral canthotomy and/or inferior cantholysis and medial transcutaneous incision is combined for full exposure of the lower eyelid tarsus and medial and lateral canthal tendons.3.Using a thin ribbon of the autologous graft, the tarsal plate is secured medially to the nasal bones and supero-laterally on the orbital rim using techniques described above with 5-0 polydioxanone (Figure 7A-B).4.Routine closure of the canthotomy and canthoplasty is performed followed by closure of the extended subciliary incision with running 5-0 fast gut suture. Paralytic brow ptosis can be addressed with one of a variety of techniques. The goal is to create brow symmetry, reduce associated visual impairment caused by brow ptosis and achieve aesthetic norms for the patient's gender. A nonsurgical option is to treat the contralateral frontalis/corrugator muscles to improve symmetry with chemodenervation. The surgical approach depends on multiple patient factors including the hairline, forehead rhytids, and alopecia. Approaches include coronal, trichophytic and pretrichial, endoscopic, mid-forehead, direct brow, and transblepharoplasty approaches.9.Nahai FR. The varied options in brow lifting.Clin Plast Surg. 2013; 40: 101-104Abstract Full Text Full Text PDF PubMed Scopus (12) Google Scholar In elderly patients with prominent rhytids, a midforehead brow lift will achieve an effective lift concealed within natural forehead creases. 1.The amount of lift is estimated by palpation and measured with a caliper that guides the height of the skin excision.2.A 15 blade is used to excise the mid-forehead brow lift skin, centering the ellipse design over the lateral limbus. For firmer secure fixation, a subgaleal window is created to secure the dermis under the lateral brow to pericranium.3.The scalp is undermined in a subcutaneous plane and re-approximated with buried interrupted 4-0 poliglecaprone suture and the skin is approximated with interrupted 6-0 fast absorbing gut or 6-0 polypropylene or nylon suture. A direct lift can be used in a patient with diminutive rhytids. The incision is concealed 1-2 mm within the brow hairline and the scalpel is beveled away from the hair follicles. The technique is similar to the midforehead lift; however, care is used to preserve hair follicles of the brow. Patients with a high hairline and prominent bangs may benefit from a pretrichial lift. Endoscopic brow lift is the better option in younger patients without rhytids. For patients undergoing upper eyelid loading or canthopexy or canthoplasty procedures, we recommend patients use an ophthalmic antibiotic ointment (bacitracin or erythromycin) three times daily for one week. For patients undergoing modified TCF, we recommend a combination steroid and antibiotic topical treatment (such as ophthalmic drops containing neomycin, polymyxin B, and dexamethasone) three times daily for one week to decrease risk of granulation tissue formation. Patients may use cold compresses for the first few days with head of bed elevation to decrease periorbital edema, bruising and chemosis. It is imperative to emphasize thorough patient education to encourage maintenance of ocular health and protection peri-operatively. Facial nerve paralysis can potentially lead to devastating ophthalmologic complications if not evaluated comprehensively and treated appropriately. Conservative measures may be utilized for short-term treatment, but there are many surgical options for long-term management, the majority of which focus on protecting the ocular surface through a variety of static and dynamic techniques, which can be tailored to a patient's unique anatomy, prognosis, and treatment goals.

Introduction: According to prior literature based on patient self-reporting, olfactory dysfunction (OD) is a specific and prominent symptom in patients with coronavirus-19 (COVID-19) infection. Here we describe olfactory-specific quality of life and objective smell testing in patients with COVID-19, determine if objective measures of OD correlate with a patient's subjective experience, and determine OD recovery rates based on the severity of perceived and tested olfactory loss. Method: The University of Pennsylvania Smell Identification Test (UPSIT), a validated 40-item odorant test instrument, Questionnaire of Olfactory Disorders-Negative Statements (QOD-NS), and Sino-Nasal Outcomes Test (SNOT-22) instruments were administered to 25 polymerase chain reaction-confirmed COVID-19 outpatient subjects to measure the prevalence and severity of OD at diagnosis, and 6 weeks and 6 months postdiagnosis. An analysis of variance, t test, and Pearson correlations were examined. Results: In total, 18 (72%) of 25 patients with positive COVID-19 testing showed some degree of OD (UPSIT score mean: 29.1;standard deviation [SD]: 4.7). Ten patients (40%) had mild microsmia, 6 patients (24%) had moderate microsmia, and 2 patients had severe microsmia (8%) on initial testing. Nine of 25 patients enrolled with OD that reached the 6-week follow-up, and most patients showed objective improvement in OD. There was a difference in QOD-NS scores between patients with normal or mild olfactory OD (mean: 10.2, SD: 7.4) compared with moderate or severe OD (mean: 22.4, SD: 11.6) patients (P = .041) but no trends in mean SNOT scores between groups. There was a significant correlation between QOD-NS score and UPSIT score (Rho =-0.45, P = .027) indicating patients with higher objective measures of OD experienced lower quality of life. Conclusion: There was significant correlation between subjective quality-of-life scores and objective measurements of OD. Most patients improved their OD several weeks after initial diagnosis. The QOD-NS may be an alternative and valuable method to screen for OD in COVID-19 patients.

Introduction: The treatment of traumatic optic neuropathy (TON) is highly controversial with a lack of substantiated evidence to support the use of corticosteroids or surgical decompression of the optic nerve. The aim of the study was to determine if there was a general consensus in the management of TON despite controversy in the literature. Methods: An anonymous survey of members of the American Society of Ophthalmic Plastic and Reconstructive Surgery and the North American Neuro-Ophthalmology Society regarding their practice patterns in the management of patients with TON was performed. Results: The majority of 165 respondents indicated that they treated TON with corticosteroids (60%) while a significant minority (23%) performed surgical interventions (P < 0.0001). Subgroup analysis comparing rates of treatment with steroids among oculoplastic surgeons and neuro-ophthalmologists (67% vs. 47%) was not significant (Fisher's Exact test [FET], P =0.11) while results did suggest that a higher proportion of oculoplastic surgeons (33%) than neuro-ophthalmologists (11%) recommended surgical intervention (FET, P =0.004). In cases where visual acuity exhibited a downward trend treatment with steroids was the most commonly employed management. In general, neuro-ophthalmologists trended toward observation over treatment in TON patients with stable visual acuity while oculoplastic surgeons favored treatment with corticosteroids. Conclusions: In spite of the lack of class I evidence supporting intervention of TON, the majority of respondents were inclined to offer corticosteroid treatment to patients whose visual acuity showed progressive decline following injury.

Purpose of review In the setting of the COVID-19 global pandemic, the demand for and use of telemedicine has surged in facial plastic and reconstructive surgery. This review aims to objectively review and summarize the existing evidence for the use of telemedicine within facial plastic surgery. Recent findings Telemedicine has been successfully implemented among subsets of facial plastic surgery patients, with high patient and provider satisfaction. Although the technology to facilitate telemedicine exists and preliminary studies demonstrate promise, multiple technological, financial, and medical barriers may persist in the postpandemic era. Summary Telemedicine will likely continue to grow and expand within facial plastic surgery moving forward, and we should continue to critically evaluate patient selection, access to care, and strategies for effective implementation to enhance current clinical practices.

Introduction: The use of acellular dermal matrix (ADM) for breast reconstruction continues to change in both single-and two-stage reconstruction. Determining optimal outcomes clinically, aesthetically, financially as well as for the patient's quality of life has become a priority. Methods: A retrospective review of implant-based reconstructions was performed at a single center from 2010 to 2016, with patients blindly matched 1:1:1 into three cohorts based on reconstruction type: 1) single stage direct to implant with ADM, 2) two-stage tissue expander to implant (TE/I) without ADM, and 3) two-stage TE/I with ADM. Relative cost between groups, esthetic outcomes, and quality of life within each group was analyzed. Results: Group 1 was more likely to be older and use intraoperative angiography, but with fewer overall surgeries and postoperative visits ( p < 0.001). There was no statistically significant difference in reconstructive success among all three groups ( p = 0.85). Cost was significantly higher for group 3 relative to groups 1 and 2. Overall appearance was higher in groups 1 and 3 relative to group 2, with radiation therapy the only independent factor. Group 1 had higher scores using Breast-Q for the physical well-being domain ( p = 0.01). Conclusion: This is the first study to incorporate clinical outcomes, esthetic visual grading, and patient-reported quality within the same cohort of individuals, considering both use of ADM and staging. Despite the added ADM cost, it is proven safe, eliminates time and cost associated with tissue expanders, decreases post-operative visits and can lead to equally as functional and aesthetically pleasing outcomes in single-and two-stage breast reconstructions. (c) 2020 Published by Elsevier Ltd on behalf of British Association of Plastic, Reconstructive and Aesthetic Surgeons.

Background The most important purpose of reconstruction is to increase or restore the patient's quality of life (QOL). The purpose of our study was to evaluate the QOL and aesthetic outcomes of patients after autologous versus implant-based breast reconstruction. Methods Patients who underwent breast reconstruction between 2009 and 2011 were included. The Breast-Q, a validated breast reconstruction QOL questionnaire, was used along with postoperative photographs panel analyses using a multiparameter breast-specific aesthetic outcome scale and retrospective evaluation of demographic and treatment data. Results Of 820 patients, 261 complete questionnaires were evaluated. On the multivariable linear regression, the "satisfaction with breasts" was positively influenced by autologous and bilateral reconstructions, whereas radiation therapy (RTx), the time between the reconstruction and the questionnaire, and the number of surgeries due to complications were negative factors (adjusted R-2 = 0.183; P < 0.001). The same factors influenced the "satisfaction with the outcomes." The mean "overall breast appearance" was also positively influenced by autologous and bilateral reconstructions, and RTx and the total number of surgeries were negative predictive factors (adjusted R-2 = 0.311, P < 0.001). Conclusions The aesthetic result and QOL after breast reconstruction for breast cancer treatment are positively influenced by the use of autologous tissue and bilaterality. Factors that negatively influenced the aesthetic result and the QOL include use of RTx, a higher number of surgeries needed for the reconstruction, reoperations due to complications, higher body mass index, and a longer time elapsed between reconstruction and the questionnaire.

AbstractPurpose: Surgical resection of primary tumor with regional lymphadenectomy remains the treatment of choice for patients with advanced human papillomavirus–negative head and neck squamous cell carcinoma. However, even when pathologic disease-free margins can be achieved, locoregional and/or distant disease relapse remains high. Perioperative immunotherapy may improve outcomes, but mechanistic data supporting the use of neoadjuvant or adjuvant treatment clinically are sparse. Experimental Design: Two syngeneic models of oral cavity carcinoma with defined T-cell antigens were treated with programmed death receptor 1 (PD-1) mAb before or after surgical resection of primary tumors, and antigen-specific T-cell responses were explored with functional and in vivo challenge assays. Results: We demonstrated that functional immunodominance developed among T cells targeting multiple independent tumor antigens. T cells specific for subdominant antigens expressed greater levels of PD-1. Neoadjuvant, but not adjuvant, PD-1 immune checkpoint blockade broke immunodominance and induced T-cell responses to dominant and subdominant antigens. Using tumors lacking the immunodominant antigen as a model of antigen escape, neoadjuvant PD-1 immune checkpoint blockade induced effector T-cell immunity against tumor cells lacking immunodominant but retaining subdominant antigen. When combined with complete surgical excision, neoadjuvant PD-1 immune checkpoint blockade led to formation of immunologic memory capable of preventing engraftment of tumors lacking the immunodominant but retaining subdominant antigen. Conclusions: Together, these results implicate PD-1 expression by T cells in the mechanism of functional immunodominance among independent T-cell clones within a progressing tumor and support the use of neoadjuvant PD-1 immune checkpoint blockade in patients with surgically resectable carcinomas.

BACKGROUND:Telemedicine has become increasingly popular in the care of rhinologic patients during the COVID-19 pandemic. This change in practice patterns may place patients at risk of a perceived lower-quality exchange with their healthcare provider, which may in turn impact satisfaction. OBJECTIVE:This study compares patient satisfaction scores between in-person clinic visits and telemedicine video visits in patients with chronic rhinosinusitis (CRS). METHODS:Sixty-nine patients with CRS presenting to an academic rhinology clinic between March to April 2020 were retrospectively divided into video visits (VV) and clinic visits (CV) groups based on mandated state quarantine orders on March 19. Patient demographics, disease severity measures, and Patient Satisfaction Questionnaire-18 (PSQ-18) scores were collected and analyzed. Chi square test and Fisher's exact test were performed. RESULTS:There were no significant differences in age (p = 0.81), gender (p = 0.55), CRS phenotype (p = 0.16), and disease severity measures (Sinonasal Outcomes Test-22 (SNOT-22) (p = 0.92); Lund-Mackay score (p = 0.96)) between the video and clinic visit groups. There were no significant differences in PSQ-18 total scores (VV PSQ-18 mean score = 78.1, CV PSQ-18 mean score = 78.4; p = 0.67) or the following subdomain scores between the two groups: general satisfaction (p = 0.73), technical quality (p = 0.62), interpersonal manner (p = 0.41), communication (p = 0.31), financial aspects (p = 0.89), time spent with doctor (p = 0.88), and accessibility and convenience (p = 0.47). CONCLUSION:Patient satisfaction with telemedicine in the COVID-19 pandemic parallels that of traditional in-person visits. Video visits can serve as a viable alternative to clinic visits, while still maintaining high satisfaction.

Purpose of review Frontal sinus fracture management is evolving. This article will highlight recent literature and provide an evidence-based algorithm in the contemporary management of frontal sinus fractures. Recent findings The role of transnasal endoscopic treatment of frontal sinus fractures has expanded to include fracture reduction and posterior table reconstruction. Evidence continues to support the safety of nonoperative management in select frontal sinus outflow tract fractures. Summary The management of frontal sinus fractures with frontal sinus outflow tract injury continues to evolve with a trend toward observation and minimally invasive approaches. Restoration of the frontal sinus outflow tracts with transnasal endoscopic techniques is being used increasingly in the acute and delayed setting. For severe fractures, the role of conservative treatment paradigms requires further research.

Objective: The objectives of this study are to evaluate incidence, duration, and quality of life (QOL) impact of early tympanostomy tube otorrhea and tube patency when comparing topical ciprofloxacin versus normal saline use in the perioperative period. Methods: Overall, 200 patients undergoing tube placement between November 19, 2015, and September 12, 2016, were randomized to intraoperative plus 5 days of either topical ciprofloxacin or normal saline. Parents or caregivers reported the incidence, duration, and QOL impact of early otorrhea via 4 weekly surveys. In addition, the patient’s otorrhea history and tube patency were evaluated at a 4- to 6-week postoperative visit. Results: Survey and in-office follow-ups were completed on 128 patients. The overall otorrhea incidence was 23.9% for normal saline and 16.7% for ciprofloxacin (P = .32). The week-by-week otorrhea incidence was not statistically different. The percentage of days otorrhea was present, likewise, was not statistically different (normal saline 4.5%, ciprofloxacin 2.8%; P = .74). The QOL impact was not statistically different (normal saline 1.2, ciprofloxacin 1.5; P = .71). Tube patency was not statistically different, with only 1 of 280 ears occluded at follow-up. Conclusion: We find no difference in the incidence, duration, and QOL impact of early tympanostomy tube otorrhea or tube patency between ciprofloxacin and normal saline. This supports the option to substitute normal saline for ciprofloxacin in ears without an active ear infection at the time of tube placement, which would reduce both cost and unnecessary antibiotic use. Level of Evidence: 1b