A Review of and Algorithmic Approach to Soft Palate Reconstruction

Importance

The soft palate contributes to deglutition, articulation, and respiration. Current reconstructive techniques focus on restoration of both form and function. The unique challenges of soft palate reconstruction include maintenance of complex upper aerodigestive tract function, with minimal local or donor site morbidity.

Objective

To review the literature on soft palate reconstruction and present an algorithm on how to approach soft palate defects based on this review.

Evidence Review

A review of the literature for articles reporting studies on and that described concepts related to soft palate reconstruction was conducted in March 2017. In all, 1804 candidate titles and abstracts were independently reviewed. English-language articles that discussed acquired soft palate defect reconstruction were included. Non-English language studies without available translations, studies on primary soft palate defect reconstruction (ie, cleft palate repair) and primary cleft palate repair, studies in which the soft palate was not the focus of the article, and studies involving animals were excluded.

Findings

The following observations were made from the review of 92 included articles. Soft palate anatomy is a complex interplay of multiple structures working in a 3-dimensional area. Three of the authors created an initial algorithmic framework based on the selected studies. After this, a round table discussion among 3 authors considered experts was used to refine the algorithm based on their expert opinion. The 4 most important factors were determined to be defect size, defect extension to other subsites, defect thickness, and history of radiotherapy or planned radiotherapy. This algorithm includes both surgical and nonsurgical options. Defects in the soft palate not only affect the size and shape of the organ but, more critically, the function. The reconstructive ladder is used to help maximize the remaining soft palate functional tissue and minimize the effect of nonfunctional implanted tissue. Partial-thickness defects or defects less than one-fourth of the soft palate may not require locoregional tissue transfer. Patients with a history of radiotherapy or defects of up to 75% of the soft palate may require locoregional tissue transfer. Defects greater than 75% of the soft palate, defects that include exposure of the neck vasculature, or defects that include significant portions of the hard palate or adjacent oropharyngeal subsites may require free tissue transfer. Obturation should be considered a second-line option in most cases.

Conclusions and Relevance

Ideal reconstruction of the soft palate relies on a comprehensive understanding of soft palate anatomy, a full consideration of the armamentarium of surgical techniques, consideration for adjacent subsite deficits, and a detailed knowledge of various intrinsic and extrinsic patient factors to optimize speech, swallowing, and airway outcomes. The included algorithm may serve as a useful starting point for the surgeon when considering reconstruction.

Assessment of Casual Observers' Willingness to Pay for Increased Attractiveness Through Rhinoplasty

Importance

Contingent valuation, or willingness to pay, is an established economic concept that has been applied in other areas of medicine and may be useful for understanding the economic forces that determine the cost of cosmetic procedures.

Objective

To determine the monetary value of changes in attractiveness achieved through rhinoplasty, as perceived by society.

Design, Setting, and Participants

Cross-sectional survey administered via public online forums to 228 casual observers.

Main Outcomes and Measures

Participants were shown preoperative and postoperative photographs of 12 patients who underwent cosmetic rhinoplasty and 4 patients who did not undergo any surgery. They were asked to rate (1) the change in overall attractiveness of the patients, and (2) the monetary value they would associate with these changes.

Results

Completed surveys were obtained from 228 casual observers; 144 were female (63.2%); median age, 25 years (median income bracket, $50 000-$75 000). Multilevel, mixed-effects, linear regression was used to characterize the association between monetary value and change in attractiveness. There was a significant association between the change in attractiveness from a rhinoplasty and its monetary value as perceived by society. The baseline value of a rhinoplasty without any change in attractiveness was $3769.98 (95% CI, $3541.59-$4007.10; P < .001). To increase 1 standard deviation in attractiveness was worth an additional $2353.77 (95% CI, $2197.57-$2512.81; P < .001), while increasing 2 standard deviations in attractiveness was worth an additional $5453.07 (95% CI, $5052.57-$5865.51; P < .001).

Conclusions and Relevance

There is a significant association between the societally perceived value of cosmetic rhinoplasty and the change in attractiveness after surgery. The average value of a rhinoplasty in our study approximates the actual average cost of cosmetic rhinoplasty, suggesting that willingness to pay may be a useful concept for studying the value of cosmetic procedures.

Level of Evidence

NA.

The Multivector Gracilis Free Functional Muscle Flap for Facial Reanimation

Importance

A multivector functional muscle flap that closely simulates the biomechanical effects of facial muscle groups is essential for complete smile restoration after facial paralysis.

Objective

To determine the feasibility of a multivector gracilis muscle flap design for reanimation after facial paralysis and to analyze the effect on the smile display zone.

Design, Setting, and Participants

Prospective analysis of patients who underwent a double paddle multivector gracilis flap for complete facial paralysis between June 2015 and December 2016 was carried out in a tertiary hospital.

Interventions

The gracilis muscle was harvested as a double paddle flap and inserted along 2 vectors for facial reanimation.

Main Outcomes and Measures

The primary outcome measures were: (1) dental display (the number of maxillary teeth displayed on paralyzed vs normal sides), (2) exposed maxillary gingival scaffold width, (3) interlabial gap at midline and canine, (4) facial asymmetry index (FAI), and (5) dynamic periorbital wrinkling.

Results

There were 10 women and 2 men between ages 20 and 64 years (mean [SD], 46 [15] years). Five flaps were reinnervated with facial and masseteric nerves, 5 with masseteric nerve only, and 2 with crossfacial nerve only. There was functional muscle recovery in all cases. On average there was additional 3.1 maxillary teeth exposed posttreatment when smiling (5.5 vs 8.6; CI, 7.9 to 16.6; P < .001). The mean exposed maxillary gingival scaffold width improved from 31.5 mm to 43.7 mm (95% CI, 1.9 to 4.3; P < .001). There was no significant difference in interlabial exposure at midline (7.1 mm vs 7.7 mm; CI, -1.5 to 2.7; P = .56) but a 56.4% improvement at the level of the canines (3.9 vs 6.1; CI, 0.1 to 4.3; P = .04). The mean FAI when smiling was reduced from 9.1 mm to 4.5 mm (CI, -8.0 to -1.2; P = .01). Dynamic wrinkling of the periorbital area with smiling was noted in 4 patients.

Conclusions and Relevance

The gracilis flap can be reliably designed as a functional double paddle muscle flap for a multivector facial reanimation. The multivector gracilis flap design is effective in improving all components of the smile display zone and has the potential for producing periorbital-wrinkling characteristic of a Duchenne smile.

Level of Evidence

4.

Analysis of the operative utilization of concurrent rhinoplasty and endoscopic sinus surgery

OBJECTIVES/HYPOTHESIS

To quantify and analyze the concurrent performance of rhinoplasty (RP) (with or without septoplasty) and functional endoscopic sinus surgery (FESS).

STUDY DESIGN

Cross-sectional analysis.

METHODS

Current Procedural Terminology codes were used to extract cases of RP (n = 22,360), FESS (n = 99,173), and concurrent RP with FESS (RP + FESS) (n = 1,321) within the State Ambulatory Surgery Databases of California, Florida, Maryland, and New York from 2009 to 2011. Patient demographics, surgeon volume, charge, concurrent nasal procedures, and operating room (OR) time were compared.

RESULTS

Among the 1,321 RP + FESS combination cases, a majority involved primary rhinoplasty (n = 697, 52.8%), followed by nasal valve repair (n = 563, 42.6%) and revision rhinoplasty (n = 61, 4.6%). High-volume (n > 30), medium-volume (n = 10-30), and low-volume rhinoplasty surgeons (n ≤ 9) were observed to perform a similar number of FESS + RP combination surgeries (153, 152, and 155, respectively). A majority of RP + FESS involved two or fewer sinuses (65%). Mean OR time for RP + FESS was 189.4 ± 4.2 minutes, approximately 50 minutes shorter than the sum of standalone RP performed individually (138.8 ± 1.0 minutes) and standalone FESS (102.9 ± 0.4 minutes).

CONCLUSIONS

RP + FESS more frequently involved fewer sinuses (compared with FESS alone) and was also less likely to involve revision rhinoplasty (compared with rhinoplasty alone); therefore, these cases may be selected for lower sinus disease burden and less complex rhinoplasty compared to standalone procedures. Procedures combining rhinoplasty and sinus surgery had a reduction in OR time compared to the hypothetical sum of two standalone procedures.

LEVEL OF EVIDENCE

NA Laryngoscope, 130:E311-E319, 2020.

Origin and Fate of Vanadium in the Hazeltine Creek Catchment following the 2014 Mount Polley Mine Tailings Spill in British Columbia, Canada

Results from the analysis of aqueous and solid-phase V speciation within samples collected from the Hazeltine Creek catchment affected by the August 2014 Mount Polley mine tailings dam failure in British Columbia, Canada, are presented. Electron microprobe and X-ray absorption near-edge structure (XANES) analysis found that V is present as V³⁺ substituted into magnetite and V³⁺ and V⁴⁺ substituted into titanite, both of which occur in the spilled Mount Polley tailings. Secondary Fe oxyhydroxides forming in inflow waters and on creek beds have V K-edge XANES spectra exhibiting E1/2 positions and pre-edge features consistent with the presence of V⁵⁺ species, suggesting sorption of this species on these secondary phases. PHREEQC modeling suggests that the stream waters mostly contain V⁵⁺ and the inflow and pore waters contain a mixture of V³⁺ and V⁵⁺. These data, and stream, inflow, and pore water chemical data, suggest that dissolution of V(III)-bearing magnetite, V(III)- and V(IV)-bearing titanite, V(V)-bearing Fe(-Al-Si-Mn) oxhydroxides, and V-bearing Al(OH)₃ and/or clay minerals may have occurred. In the circumneutral pH environment of Hazeltine Creek, elevated V concentrations are likely naturally attenuated by formation of V(V)-bearing secondary Fe oxyhydroxide, Al(OH)₃, or clay mineral colloids, suggesting that the V is not bioavailable. A conceptual model describing the origin and fate of V in Hazeltine Creek that is applicable to other river systems is presented.

Environmental risk of severely Pb-contaminated riverbank sediment as a consequence of hydrometeorological perturbation

Metal mining activities have resulted in the widespread metal pollution of soils and sediments and are a worldwide health concern. Pb is often prolific in metal-mining impacted systems and has acute and chronic toxic effects. Environmental factors controlling diffuse pollution from contaminated riverbank sediment are currently seen as a "black box" from a process perspective. This limits our ability to accurately predict and model releases of dissolved Pb. Previous work by the authors uncovered key mechanisms responsible for the mobilisation of dissolved Zn. The current study identifies key mechanisms controlling the mobilisation of dissolved Pb, and the environmental risk these releases pose, in response to various sequences of "riverbank" inundation/drainage. Mesocosm experiments designed to mimic the riverbank environment were run using sediment severely contaminated with Pb, from a mining-impacted site. Results indicated that, although Pb is generally reported as less mobile than Zn, high concentrations of dissolved Pb are released in response to longer or more frequent flood events. Furthermore, the geochemical mechanisms of release for Zn and Pb were different. For Zn, mechanisms were related to reductive dissolution of Mn (hydr)oxides with higher concentrations released, at depth, over prolonged flood periods. For Pb, key mechanisms of release were related to the solubility of anglesite and the oxidation of primary mineral galena, where periodic drainage events serve to keep sediments oxic, particularly at the surface. The results are concerning because climate projections for the UK indicate a rise in the occurrence of localized heavy rainfall events that could increase flood frequency and/or duration. This study is unique in that it is the first to uncover key mechanisms responsible for dissolved Pb mobilisation from riverbank sediments. The mineralogy at the mining-impacted site is common to many sites worldwide and it is likely the mechanisms identified in this study are widespread.

Facial Asymmetry Index: Validation and Applications in Various Smile Restoration Techniques

Consistent and objective evaluation of the paralyzed face is imperative for documenting preoperative findings and assessing postoperative outcomes of reanimation techniques. Static and dynamic facial asymmetry are the key features of the paralyzed face. To date, there is no consensus among surgeons on how best to document facial asymmetry. The authors propose a Facial Asymmetry Index (FAI) as an objective measure of facial asymmetry and validate its use and reliability across numerous reanimation techniques. Frontal photographs of patients with unilateral facial nerve paralysis were analyzed. The length from the medial canthus to the ipsilateral oral commissure was compared between affected and nonaffected sides. The FAI is the difference between the two values, with a higher value reflecting poorer facial symmetry. Validation and reliability testing was then performed. There was a consistent decrease in the FAI with procedural intervention (FAI pre = 10.1, FAI post = 3.17; p < 0.0001). Furthermore, there was excellent inter- and intrarater reliability among independent judges. The FAI is a powerful and accessible tool to quantify operative outcomes for many lower facial nerve reanimation techniques.

Compact DD generator-based in vivo neutron activation analysis (IVNAA) system to determine sodium concentrations in human bone

OBJECTIVE

This study presents the development of a noninvasive method for monitoring Na in human bone. Many diseases, such as hypertension and osteoporosis, are closely associated with sodium (Na) retention in the human body. Na retention is generally evaluated by calculating the difference between dietary intake and excretion. There is currently no method to directly quantify Na retained in the body. Bone is a storage for many elements, including Na, which renders bone Na an ideal biomarker to study Na metabolism and retention.

APPROACH

A customized compact deuterium-deuterium (DD) neutron generator was used to produce neutrons for in vivo neutron activation analysis (IVNAA), with a moderator/reflector/shielding assembly optimized for human hand irradiation in order to maximize the thermal neutron flux inside the irradiation cave and to limit radiation exposure to the hand and the whole body.

MAIN RESULTS

The experimental results show that the system is able to detect sodium levels in the bone as low as 16 µg Na g^-1 dry bone with an effective dose to the body of about 27 µSv. The simulation results agree with the numbers estimated from the experiment.

SIGNIFICANCE

This is expected to be a feasible method for measuring the change of Na in bone. The low detection limit indicates this will be a useful system to study the association between Na retention and related diseases.

Image-Guided Osteoplastic Frontal Sinusotomy

Background

A 6-ft Caldwell radiograph template and transillumination, typically, are used to elucidate the frontal sinus outline for osteoplastic frontal sinusotomy (OFS). These techniques can be fraught with imprecision. The consequences of imprecise OFS may result in significant complications. Computer-aided surgery may offer a safe and accurate alternative to these techniques in selected cases. Several disadvantages were noted with early computer-aided assistance. Current infrared and electromagnetic systems have eliminated many of these disadvantages. We describe our technique and experience with an infrared image-guidance system (The LandmarX Evolution; Medtronic Xomed, Jacksonville, FL) to create a precise OFS that maximizes exposure while minimizing morbidity.

Methods

We describe the use of an infrared image guidance system, the LandmarX Evolution for OFS in three cases.

Results

The LandmarX Evolution allowed for accurate placement of the OFS in each of the three cases and successful treatment of two symptomatic frontal sinus osteomas and a recurrent inverted papilloma. No complications were encountered.

Conclusion

Image-guided OFS results in a confident and accurate entry into the frontal sinus. Image-guided OFS creation should be considered for select cases (i.e., complete opacification and altered anatomy) where performing an OFS by standard techniques may increase the complication rate. More experience with the technique and increased accessibility to image-guided equipment must be made possible before establishing this technique as a standard.

Association Between Patient Value Systems and Physician and Practice Attributes Available Online

IMPORTANCE

The relative value of facial plastic surgeon personal and practice attributes is relevant to the broader health care system because of increasing out-of-pocket expenses to patients.

OBJECTIVE

To determine the relative value of specific facial plastic surgeon personal and practice attributes available online from the perspective of patients.

DESIGN, SETTING, AND PARTICIPANTS

This study consisted of an electronic survey sent to patients by email using choice-based conjoint analysis; surveys were sent between December 2015 and March 2016. Participants had agreed to join email registries to be sent email surveys and promotions at 3 private facial plastic and reconstructive surgery practices. The following surgeon personal and practice attributes and levels were compared: (1) outcome transparency (above average, average, not available); (2) surgical training affiliations (US News and World Reports rankings); (3) online rating site scores (2 [poor], 3, or 4 [excellent] stars); and (4) price ($1×, $2×, and $3× [× = $1500; average cost was set at $2×]).

MAIN OUTCOMES AND MEASURES

The relative importance of outcome transparency, surgical training affiliations, online rating scores, and price to prospective patients.

RESULTS

Overall, 291 patients participated for a completion rate of 68%. Outcome transparency was the most valued attribute (attribute utility range = 141; attribute importance = 35.2%). Price was the least valued attribute (attribute utility range = 58.59; attribute importance = 15.1%). Assuming top-tier affiliations and 4-star ratings, share of market (SOM) was 75.5% for surgeons with above-average outcome transparency priced at $3× compared with those surgeons with no outcomes available priced at $1×. Holding price constant at $2×, surgeons with middle-tier affiliations and 2-star online ratings but above average outcomes achieved 48.4% SOM when compared with those surgeons with top-tier affiliations and 4-star online ratings without available outcomes.

CONCLUSIONS AND RELEVANCE

Facial plastic surgery patients most value surgeons who publish outcomes. Moreover, they are willing to discount poor rating scores and lower-ranked institutional affiliations when outcome transparency is high. This study demonstrates that outcome transparency is crucial in facial plastic surgery markets.

LEVEL OF EVIDENCE

NA.

Prevalence of Body Dysmorphic Disorder and Surgeon Diagnostic Accuracy in Facial Plastic and Oculoplastic Surgery Clinics

Importance

Body dysmorphic disorder (BDD) is a relative contraindication for facial plastic surgery, but formal screening is not common in practice. The prevalence of BDD in patients seeking facial plastic surgery is not well documented.

Objective

To establish the prevalence of BDD across facial plastic and oculoplastic surgery practice settings, and estimate the ability of surgeons to screen for BDD.

Design, Setting, and Participants

This multicenter prospective study recruited a cohort of 597 patients who presented to academic and private facial plastic and oculoplastic surgery practices from March 2015 to February 2016.

Methods

All patients were screened for BDD using the Body Dysmorphic Disorder Questionnaire (BDDQ). After each clinical encounter, surgeons independently evaluated the likelihood that a participating patient had BDD. Validated instruments were used to assess satisfaction with facial appearance including the FACE-Q, Blepharoplasty Outcomes Evaluation (BOE), Facelift Outcomes Evaluation (FOE), Rhinoplasty Outcomes Evaluation (ROE), and Skin Rejuvenation Outcomes Evaluation (SROE).

Results

Across participating practices (9 surgeons, 3 sites), a total of 597 patients were screened for BDD: 342 patients from site 1 (mean [SD] age, 44.2 [16.5] years); 158 patients, site 2 (mean [SD] age, 46.0 [16.2] years), site 3, 97 patients (mean [SD] age, 56.3 [15.5] years). Overall, 58 patients [9.7%] screened positive for BDD by the BDDQ instrument, while only 16 of 402 patients [4.0%] were clinically suspected of BDD by surgeons. A higher percentage of patients presenting for cosmetic surgery (37 of 283 patients [13.1%]) compared with those presenting for reconstructive surgery (21 of 314 patients [6.7%]) screened positive on the BDDQ (odds ratio, 2.10; 95% CI, 1.20-3.68; P = .01). Surgeons were only able to correctly identify 2 of 43 patients (4.7%) who screened positive for BDD on the BDDQ, and the positive likelihood ratio was only 1.19 (95% CI, 0.28-5.07). Patients screening positive for BDD by the BDDQ had lower satisfaction with their appearance as measured by the FACE-Q, ROE, BOE, SROE, and FOE.

Conclusions and Relevance

Body dysmorphic disorder is a relatively common condition across facial plastic and oculoplastic surgery practice settings. Patients who screen positive on the BDDQ have lower satisfaction with their facial appearance at baseline. Surgeons have a poor ability to screen for patients with BDD when compared with validated screening instruments such as the BDDQ. Routine implementation of validated BDD screening instruments may improve patient care.

Level of Evidence

NA.

Synoptic sampling and principal components analysis to identify sources of water and metals to an acid mine drainage stream

Combining the synoptic mass balance approach with principal components analysis (PCA) can be an effective method for discretising the chemistry of inflows and source areas in watersheds where contamination is diffuse in nature and/or complicated by groundwater interactions. This paper presents a field-scale study in which synoptic sampling and PCA are employed in a mineralized watershed (Lion Creek, Colorado, USA) under low flow conditions to (i) quantify the impacts of mining activity on stream water quality; (ii) quantify the spatial pattern of constituent loading; and (iii) identify inflow sources most responsible for observed changes in stream chemistry and constituent loading. Several of the constituents investigated (Al, Cd, Cu, Fe, Mn, Zn) fail to meet chronic aquatic life standards along most of the study reach. The spatial pattern of constituent loading suggests four primary sources of contamination under low flow conditions. Three of these sources are associated with acidic (pH <3.1) seeps that enter along the left bank of Lion Creek. Investigation of inflow water (trace metal and major ion) chemistry using PCA suggests a hydraulic connection between many of the left bank inflows and mine water in the Minnesota Mine shaft located to the north-east of the river channel. In addition, water chemistry data during a rainfall-runoff event suggests the spatial pattern of constituent loading may be modified during rainfall due to dissolution of efflorescent salts or erosion of streamside tailings. These data point to the complexity of contaminant mobilisation processes and constituent loading in mining-affected watersheds but the combined synoptic sampling and PCA approach enables a conceptual model of contaminant dynamics to be developed to inform remediation.

The use of cold coagulation for the treatment of cervical intraepithelial neoplasia

In 2015, Cold Coagulation was introduced as a treatment for cervical intraepithelial neoplasia (CIN) at our colposcopy clinic. We reviewed the 6-month follow up data of the first 200 women who underwent Cold Coagulation using cytology and HPV status as tests of cure (TOC). A random sample of 200 patients treated by Large Loop Excision of the Transformation Zone (LLETZ) during the same period was used to compare treatment outcome. Six months following treatment,173 (86.5%) of the women treated by CC and 167 (83.5%) treated by LLETZ had negative cytology. (x2= P>0.05). 148 (74%) treated by Cold Coagulation and 166 (83%) treated by LLETZ were HPV negative (x2= P<0.05). One hundred and thirty-nine (70%) women treated by Cold Coagulation and 152 (76%) treated with LLETZ had normal cytology and were HPV negative. This audit of our initial experience supports the observation that Cold Coagulation is as effective as LLETZ in the management of CIN when cervical cytology is used as a test of cure.

Transposition of the Intratemporal Facial to Hypoglossal Nerve for Reanimation of the Paralyzed Face: The VII to XII TranspositionTechnique

IMPORTANCE

The hypoglossal nerve has long been an axonal source for reinnervation of the paralyzed face. In this study, we report our experience with transposition of the intratemporal facial nerve to the hypoglossal nerve for facial reanimation.

OBJECTIVES

To determine the feasibility and outcomes of the transposition of the infratemeporal facial nerve for end-to-side coaptation to the hypoglossal nerve for facial reanimation.

DESIGN, SETTINGS, AND PARTICIPANTS

A case series of 20 patients with facial paralysis who underwent mobilization and transposition of the intratemporal segment of the facial nerve for an end-to-side coaptation to the hypoglossal nerve (the VII to XII technique). Participants were treated between January 2007 and December 2014 at a tertiary care center.

MAIN OUTCOMES AND MEASURES

Outcome measures include paralysis duration, facial tone, facial symmetry at rest, and with smile, oral commissure excursion, post-reanimation volitional smile, and synkinesis.

METHODS

Demographic data, the effects of this technique on facial tone, symmetry, oral commissure excursion and smile recovery were evaluated. Preoperative and postoperative photography and videography were reviewed. Facial symmetry was assessed with a facial asymmetry index. Smile outcomes were evaluated with a visual smile recovery scale, and lip excursion was assessed with the MEEI-SMILE system.

RESULTS

All 20 patients had adequate length of facial nerve mobilized for direct end-to-side coaptation to the hypoglossal nerve. The median duration of facial paralysis prior to treatment was 11.4 months. Median follow-up time was 29 months. Three patients were excluded from functional analysis due to lack of follow-up. Facial symmetry at rest and during animation improved in 16 of 17 patients. The median (range) time for return of facial muscle tone was 7.3 (2.0-12.0) months. A significant reduction in facial asymmetry index occurred at rest and with movement. The MEEI FACE-gram software detected a significant increase in horizontal, vertical, overall lip excursion and smile angle. No patient developed significant tongue atrophy, impaired tongue mobility, or speech or swallow dysfunction.

CONCLUSIONS AND RELEVENCE

Mobilization of the intratemporal segment of the facial nerve provides adequate length for direct end-to-end coaptation to the hypoglossal nerve and is effective in restoring facial tone and symmetry after facial paralysis. The resulting smile is symmetric or nearly symmetric in the majority of patients with varying degree of dental show. The additional length provided by utilizing the intratemporal segment of the facial nerve reduces the deficits associated with complete hypoglossal division/splitting, and avoids the need for interposition grafts and multiple coaptation sites.

LEVEL OF EVIDENCE

4.

Nasal Unit Transplantation: A Cadaveric Anatomical Feasibility Study

Background The science and technical acumen in the field of vascularized composite allotransplantation has progressed rapidly over the past 15 years, and transplantation of specialized units of the face, such as the nose, appears possible. No study to date has evaluated the technical feasibility of isolated nasal unit transplantation (NUT). In this study, we explore the anatomy and technical specifics of NUT. Methods In this study, four fresh cadaver heads were studied. Bilateral vascular pedicle dissections were performed in each cadaver. The facial artery was cannulated and injected with food dye under physiologic pressure in two cadavers, and with lead oxide mixture in two cadavers to evaluate perfusion territories supplied by each vascular pedicle. Results The facial artery and vein were found to be adequate pedicles for NUT. Divergent courses of the vein and artery were consistently identified, which made for a bulky pedicle with necessary inclusion of large amounts of subcutaneous tissue. In all cases, the artery remained superficial, while the vein coursed in a deeper plane, and demonstrated consistent anastomoses with the superior transverse orbital arcade. While zinc oxide injection of the facial artery demonstrated filling of the nasal vasculature across the midline, dye perfusion studies suggested that unilateral arterial inflow may be insufficient to perfuse contralateral NUT components. Discrepancies in these two studies underscore the limitations of nondynamic assessment of nutritive perfusion. Conclusion NUT based on the facial artery and facial vein is technically feasible. Angiosome evaluation suggests that bilateral pedicle anastomoses may be required to ensure optimal perfusion.

CT findings in two cats with broncholithiasis

Case series summary

Chronic inflammatory airway disease with secondary broncholithiasis was diagnosed in two cats from CT and bronchoalveolar lavage cytological findings. In one cat with progressively worsening lower respiratory tract signs, more than 80 discrete, highly attenuating endobronchial opacities were detected on thoracic CT. The broncholiths were distributed throughout the right middle, and left and right caudal lung lobes, and the caudal part of the left cranial and accessory lobes. In the other cat broncholithiasis was an incidental finding on thoracic radiographs taken during diagnostic investigation of inappetence. On thoracic CT, 25 calcified endobronchial opacities were detected in the left caudal lung lobe in secondary and tertiary bronchi. CT features of chronic inflammatory airway disease were present in both cases, including bronchiectasis, atelectasis, flattening of the diaphragm and bronchial wall thickening.

Relevance and novel information

This is the first report to document CT features of broncholithiasis in cats. Feline broncholithiasis should be considered as a differential diagnosis in any case where calcified endobronchial material is evident on thoracic radiographs or CT.

Early Nerve Grafting for Facial Paralysis After Cerebellopontine Angle Tumor Resection With Preserved Facial Nerve Continuity

IMPORTANCE

Preserving facial nerve function is a primary goal and a key decision factor in the comprehensive management of vestibular schwannoma and other cerebellopontine angle (CPA) tumors.

OBJECTIVE

To evaluate the use of the pattern of facial paralysis recovery in the early postoperative months as a sole predictor in selecting patients for facial nerve grafting after CPA tumor resection when cranial nerve VII is uninterrupted.

DESIGN, SETTING, AND PARTICIPANTS

Sixty-two patients with facial paralysis and uninterrupted cranial nerve VII who developed facial paralysis after CPA tumor resection at The Johns Hopkins Hospital were followed up prospectively to assess for spontaneous recovery and to determine candidacy for facial reanimation surgery. The study dates and dates of analysis were January 1, 2009, to March 31, 2015.

INTERVENTIONS

After a minimum of 6 months of clinical follow-up and no signs of clinical recovery, patients underwent facial nerve exploration and a masseteric or hypoglossal nerve transfer. Intraoperative direct nerve stimulation was performed to assess for the presence of subclinical reinnervation. Patients were followed up for a minimum of 18 months after surgery to evaluate outcomes.

MAIN OUTCOMES AND MEASURES

Facial function and recovery were studied objectively with a Smile Recovery Scale, Facial Asymmetry Index, and House-Brackmann (HB) grading system. Other outcome measures included the duration of paralysis, time to recovery, and evidence of synkinesis.

RESULTS

Sixty-two patients (33 men, 29 women; mean age 51.8 years) with uninterrupted facial nerves after CPA tumor resection developed HB grade IV, V, or VI facial paralysis. Ten patients underwent nerve grafting by 12 months, 9 patients received grafting after 12 months, and 8 patients had no intervention. Thirty-five patients spontaneously recovered. In all patients who underwent nerve grafting, there were no detectable facial muscle movements or electromyographic response to direct facial nerve stimulation suggestive of occult reinnervation. Overall, early facial reanimation surgery resulted in a shorter total duration of paralysis. Masseteric nerve grafting resulted in earlier recovery compared with hypoglossal nerve grafting (5.6 vs 10.8 months, P = .005). Patients who showed no signs of recovery by 6 months after CPA surgery but declined facial reanimation surgery demonstrated at best HB grade V recovery after 18 months of observation.

CONCLUSIONS AND RELEVANCE

The recovery pattern in the early postoperative period among patients who develop facial paralysis after CPA tumor resection is a useful clinical tool in selecting patients for facial reanimation surgery. Patients can be counseled for facial reanimation surgery as early as 6 months after surgery because satisfactory facial functional recovery is unlikely to occur when there is no clinical evidence of spontaneous nerve regeneration in the first 6 months.

LEVEL OF EVIDENCE

3.

The study of in vivo quantification of aluminum (Al) in human bone with a compact DD generator-based neutron activation analysis (NAA) system

The feasibility and methodology of using a compact DD generator-based neutron activation analysis system to measure aluminum in hand bone has been investigated. Monte Carlo simulations were used to simulate the moderator, reflector, and shielding assembly and to estimate the radiation dose. A high purity germanium (HPGe) detector was used to detect the Al gamma ray signals. The minimum detectable limit (MDL) was found to be 11.13 μg g(-1) dry bone (ppm). An additional HPGe detector would improve the MDL by a factor of 1.4, to 7.9 ppm. The equivalent dose delivered to the irradiated hand was calculated by Monte Carlo to be 11.9 mSv. In vivo bone aluminum measurement with the DD generator was found to be feasible among general population with an acceptable dose to the subject.

Tips for Junior Doctors and Medical Students: Writing and Publishing Undergraduate Textbooks

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