Social Perception of External Laryngeal Anatomy Related to Gender Expression in a Web-based Survey

OBJECTIVE(S)

To quantify the effect of laryngeal prominence size on socially perceived attributes relating to gender expression. Chondrolaryngoplasty ("tracheal shave") is a common procedure performed for transgender women to feminize neck appearance. The extent of thyroid cartilage resection needed to convey socially-perceived feminine gender expression without destabilizing the voice is incompletely understood.

METHODS

Cross-sectional evaluation of a randomized allocation of images of varying laryngeal prominence to a non-repeated, random sample from November 2021 to December 2021. Photos of laryngeal prominence were isolated against a constant neck baseline with lateral, oblique, and frontal views. The images were embedded into a web-based survey with visual analog scales to capture perceived scaled gender expression (masculinity, femininity) and social traits (e.g., attractiveness, friendliness, leadership). We performed bivariate and multivariate analyses relating the laryngeal prominence to perceived gender expression and social traits.

RESULTS

The analytic sample included 1,026 respondents. Laryngeal grades similar to the demonstrated "grade M" in this study and smaller demonstrated similar perceptions of increased femininity and decreased masculinity. Grades larger than M demonstrate significantly increased perceived masculinity and significantly decreased perceived femininity. The lateral and oblique views of the neck appear to be the most gender-informative.

CONCLUSION

This crowd-sourced analysis of external laryngeal anatomy by a large population of observers provides clear, reproducible insights into social perceptions of gender identity and specifically femininity. These data will meaningfully inform patient counseling and surgical planning for gender-affirming interventions by establishing normative data representing the general public's perceptions.

LEVEL OF EVIDENCE

NA Laryngoscope, 133:2292-2300, 2023.

The Bilobe Flap for Nasal Reconstruction

Repair of nasal defects is technically challenging due to inelastic nasal skin and unforgiving nasal geometry. The bilobe flap is a double transposition flap that can transpose skin from cephalad to caudad to repair defects of the lower third of the nose. However, pincushioning may complicate this flap, yielding untoward aesthetic outcomes. We review our single surgeon series of patients who underwent bilobe flap reconstruction of nasal defects, and describe our surgical technique to minimize pincushioning and poor aesthetic outcomes. This was a retrospective chart review of patients who underwent bilobe flap reconstruction of nasal defects at a tertiary referral facial plastic and reconstructive surgery clinic between January 1, 2010 and February 12, 2019. All postoperative clinic notes were analyzed for complications, reports of unfavorable cosmetic outcome, and rates of revision procedures. Surgical technique is described. In the analysis, 125 patients were included, of whom 84 (67%) patients were women, and the mean (standard deviation) age was 60.7 (12.5) years. Complications were reported in 20 (16%) patients, including scars, pincushioning, and nasal obstruction. Five patients underwent revision surgery (4%), including scar revision and z-plasty. Pincushioning was reported in four patients (3.2%), of whom three underwent scar revision procedures. One patient had alar notching requiring correction. There was no statistically significant association between ear cartilage graft and complications (p = 0.84) or requirement of intervention (p = 1.0). Univariate and multivariate logistic regression did not show statistically significant association between size of the defect and the presence of complications (p > 0.05). The bilobe flap is an excellent transposition flap for the repair of small nasal tip defects. By adequately thinning the transposition flap of excess subcutaneous tissue prior to inset, rates of poor aesthetic outcomes, revision procedures, and pincushioning are minimized.

Analysis of Nasal Obstruction Patterns Following Reductive Rhinoplasty

BACKGROUND

Cosmetic rhinoplasty has been linked to iatrogenic breathing disturbances using clinical tools. However, few studies have evaluated outcomes using validated, patient-centered instruments.

OBJECTIVE

We aim to determine the incidence and severity of nasal obstruction following cosmetic rhinoplasty as measured by patient-centered, disease-specific instruments.

DESIGN

This is a retrospective review of adult patients who underwent cosmetic rhinoplasty at Stanford Hospital between January 2017 and January 2019. General demographic as well as Nasal Obstruction and Symptom Evaluation (NOSE) and the Standardized Cosmesis and Health Nasal Outcomes Survey (SCHNOS) questionnaire data were included. Scores were tracked across postoperative visits and compared to the preoperative state. Patients were subdivided into dorsal hump takedown, correction of the nasal tip, and both.

RESULTS

Of the 68 included patients, 56 were women, and the mean age was 30.6 years. Although mean SCHNOS and NOSE scores increased at the first postoperative interval, mean scores decreased on each subsequent visit. There were no significant increases in SCHNOS or NOSE scores for either dorsal hump takedown, tip correction, or both. There were only two patients who recorded NOSE scores higher than baseline at most recent postoperative visit.

CONCLUSION

Our results indicate reductive rhinoplasty is not associated with a greater risk of breathing obstruction when performed with modern airway preservation techniques. The initial increases in obstructive symptoms we observed on the first postoperative visit likely represent perioperative swelling given the improvement on follow-up visits. Both the NOSE and SCHNOS are patient-centered questionnaires capable of evaluating nasal obstruction following cosmetic rhinoplasty.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Safety of Concurrent Endoscopic Browlift and Blepharoplasty

The objective of the study was to evaluate the clinical safety of endoscopic browlift alone or in combination with blepharoplasty as a treatment for the aging face. This is a retrospective comparative study from 2007 to 2016 at a single tertiary care center. A consecutive sample of patients undergoing surgery for aging of the upper face was included in the study. Surgeries deemed to be inclusive were endoscopic browlift, upper blepharoplasty, and lower blepharoplasty. In total, 46 patients undergoing endoscopic browlift with concurrent blepharoplasty were included. Patient demographics, past medical history, follow-up, and any complications related to their surgery were studied up to 90 months postoperatively. Combination of endoscopic browlift with blepharoplasty did not increase the risk of complications on univariate analysis (p = 0.735). There were no differences in complication rates on univariate analysis of patients with a smoking history, diabetes, or autoimmune disease (p = 0.111, p = 0.575, p > 0.999, respectively). Furthermore, there was no difference between groups in complication rates, smoking history, diabetes, or autoimmune disease (p = 0.735, p = 0.181, p = 0.310, p = 0.218, respectively). Smoking had an insignificant increased risk of complication as compared with nonsmokers on multivariate analysis (odds ratio [OR] = 4.526; p = 0.073). Increasing age was slightly associated with fewer complications on multivariate analysis in this patient cohort (OR = 0.939; p = 0.048). By combining endoscopic browlift with a concomitant blepharoplasty, the goals of the patient and the standards of the surgeon can be effectively and safely achieved. Analysis of complications from 46 combined cases at our institution asserts that this is a safe operation. Smoking status was the only observed predictor for postoperative complications. This was a level of evidence 3, retrospective comparative study.

A Bioabsorbable Lateral Nasal Wall Stent for Dynamic Nasal Valve Collapse: A Review

Nasal obstruction is one of the most common clinical problems encountered by otolaryngologists and facial plastic surgeons. Lateral wall insufficiency (LWI) is a key anatomic contributor to nasal obstruction. Traditional techniques for correcting LWI include alar batten grafts, bone-anchored sutures, and lateral crural strut grafts. Latera is an absorbable nasal implant that can be inserted in the office or the operating room as an adjunctive procedure for LWI. The purpose of this review is to discuss Latera, a novel bioabsorbable implant to improve the nasal airway.

Thermistor-controlled subdermal skin tightening for the aging face: Clinical outcomes and efficacy

Objective

Patients are increasingly seeking nonsurgical treatment for the aging face. The purpose of this study was to evaluate the clinical efficacy and outcomes of a thermistor‐controlled subdermal skin tightening device (ThermiTight) as a treatment modality for the aging face.

Methods

A retrospective analysis of 12 patients was completed on patients having undergone ThermiTight for midface and neck skin tightening. Only five patients had a greater than 1 year follow‐up and were included in the study. Two blinded reviewers assessed photographs taken pre‐procedure and 1 year post‐procedure using a standardized skin laxity scale. Patient charts were reviewed to assess for complications up to 12 months post‐treatment.

Results

The mean age of included patients was 57 years, and all five patients were female. One (20%) patient treated with ThermiTight was also treated with injectables (Botox, Juvéderm) simultaneously. One (20%) patient developed a wound complication. One (20%) patient complained of incisional site pain at her first postoperative visit that subsequently self‐resolved. On a five‐point scale to assess facial skin laxity, there was an average improved score of 0.85 per patient (P < .001) at one year post‐procedure. Two blinded reviewers correctly categorized photographs as either being “baseline” or “post‐procedure” 100% of the time. There was no significant difference between the skin laxity scores by the blinded reviewers (P = .05).

Conclusion

ThermiTight is a new technology used for nonsurgical treatment of the aging face. Long‐term outcomes demonstrate the safety and efficacy of the procedure. Complications are rare, but possible, in the use of ThermiTight.

Level of Evidence: 3

Management of Forehead Scars

This article provides an overview of scar management within the forehead region. It addresses the unique challenges specific to the treatment of forehead wounds. A logical, stepwise approach is used. A subsite based treatment algorithm is provided along with a review of current best practices. Pertinent case examples are included for demonstration purposes.

Topical Therapies for Refractory Chronic Rhinosinusitis

Topical therapy has become an important tool in the otolaryngologist's armamentarium for refractory chronic rhinosinusitis (CRS). Daily high-volume sinonasal saline irrigation and standard metered-dose topical nasal steroid therapy are supported by the most evidence. Nonstandard topical sinonasal steroid therapies are a potential option for refractory CRS. Current evidence recommends against the use of topical antifungal therapy and topical antibiotic therapy delivered using spray and nebulized techniques in routine cases of CRS. Stents are a new modality with preliminary data showing they are an option when traditional treatment has failed. Further research with long-term effects and outcomes studies for refractory CRS are needed.

Rare Parotid Gland Diseases

The differential diagnosis for "rare" parotid gland diseases is broad and encompasses infectious, neoplastic, autoimmune, metabolic, and iatrogenic etiologies. The body of knowledge of parotid gland diseases has grown owing to advances in imaging and pathologic analysis and molecular technology. This article reviews rare parotid diseases, discussing the respective disease's clinical presentation, diagnosis, imaging, pathogenesis, treatment, and prognosis.

Delayed complications after anterior craniofacial resection of malignant skull base tumors

Objective To report complications occurring at least 6 months after completion of treatment for patients with anterior skull base malignancy undergoing anterior craniofacial resection (CFR). Design Retrospective review of medical records of all patients undergoing traditional CFR for treatment of anterior skull base malignancy from 2002 through 2011. Setting Massachusetts General Hospital/Massachusetts Eye and Ear Infirmary Cranial Base Center. Participants Thirty-one consecutive patients who had at least 18 months of follow-up for analysis were reviewed. All patients underwent traditional CFR. A total of 28 patients received postoperative proton beam radiation therapy. Eleven patients received adjuvant chemotherapy. Main Outcome Measures A delayed complication was any complication occurring at least 6 months after the completion of treatment. Results Seventeen patients had delayed complications. Orbital complications were the most common type (13 patients) followed by issues with wound healing (6 patients). The most common orbital complication was epiphora (7 patients). The most common wound complication was a nasocutaneous fistula (5 patients). Conclusions Patients with anterior skull malignancy can develop complications months to years after the completion of treatment. Therefore, it is important to continue to follow and report complications for several years when deciding on the optimal approach for treatment of these patients.

Patient preferences in print advertisement marketing for plastic surgery

BACKGROUND

Plastic surgeons are competing for their share of a growing but still limited market, thus making advertising an important component in a successful plastic surgery practice.

OBJECTIVE

The authors evaluate the variables, characteristics, and presentation features that make print advertisements most effectively pique the interest of individuals selecting a plastic surgeon.

METHODS

An online survey was administered to 404 individuals with active interest in plastic surgery from 10 major metropolitan areas. Participants were presented with 5 different advertisements from plastic surgeons throughout the country and were asked a series of both closed- and open-ended questions to assess verity, quality, and marketability of each advertisement. Reponses to open-ended questions were analyzed using the Wordle program (www.wordle.net).

RESULTS

The most frequent themes identified for all 5 ads were "Being beautiful is possible" (41%), "I could be beautiful" (24%), "Some people need surgery to be beautiful" (16%), and "Being beautiful is important" (14%). Advertisement 1-featuring 3 women and no pre- or posttreatment photography, no physician photography, and a listing of the 3 physicians' credentials but not a list of the services provided-received the highest overall preference rating.

CONCLUSIONS

Factors including emotions felt while reading, unique qualities of the advertisement, list of procedures performed, use of models versus actual patients, and pictures of the plastic surgeons were found to contribute to the respondents' overall perception of advertisements used to market a plastic surgery practice.

The one-piece orbitozygomatic approach: the MacCarty burr hole and the inferior orbital fissure as keys to technique and application

OBJECTIVE

Use of the MacCarty keyhole burr hole and the inferior orbital fissure provides simplicity and safety to perform the one-piece frontotemporal orbitozygomatic (FTOZ1) approach.

METHODS

We performed the FTOZ1 approach with its three subtypes (i.e., total, temporal, and frontal) in cadaveric head specimens in the Goodyear Laboratory and subsequently in surgical cases.

RESULTS

The orbitozygomatic osteotomy, when added to a frontotemporal craniotomy, comprises the frontotemporal orbitozygomatic (FTOZ) approach, provides an expanded exposure to the anterior and middle cranial fossae, and enables the surgeon to create a window to the posterior cranial fossa. The MacCarty burr hole is used to facilitate orbital cuts, and the anterolateral portion of the inferior orbital fissure connects the orbital cuts to the zygomatic cuts. This allows the FTOZ1 craniotomy flap to be "out-fractured" with ease. The three types of FTOZ1 approach, i.e., the total, the temporal, and the frontal, are described step by step.

CONCLUSIONS

Understanding the MacCarty keyhole burr hole and the microsurgical anatomy of the inferior orbital fissure is essential to performing the FTOZ1 approach. The three types of FTOZ1 approach enable the surgeon to tailor the approach according to the surgical exposure needed for each lesion.

Petroclival meningiomas: predictive parameters for transpetrosal approaches

OBJECTIVE

To determine parameters that influence the selection of the proper petrosal approach or combined approaches for the excision of petroclival meningiomas.

METHODS

We dissected 15 cadaver heads, inspected the petroclival region in 50 dry human skulls, and performed a retrospective analysis of the cases of 35 patients with petroclival meningiomas who underwent surgery via transpetrosal approaches.

RESULTS

The petroclival region was divided into three "zones" based on the extent of surgical exposure achieved via the petrosal approaches with microscopic dissection of 15 preserved and silicone-injected cadaveric heads and with the measurements of 50 dry skulls. Zone I, defined as the area from the dorsum sellae to the internal auditory canal, is accessible via the anterior petrosal approach. Zone II, defined as the area from the internal auditory canal to the upper border of the jugular tubercle, is easily accessible in its lateral portion via the posterior petrosal approach. The medial portion of Zone II, the "central clival depression," is accessible only with cochlear resection and posterior facial nerve transposition. Zone III, defined as the area from the upper border of the jugular tubercle to the lower edge of the foramen magnum, is accessible via a suboccipital/transcondylar approach. The retrospective analysis of the cases of 35 patients who underwent transpetrosal resection of petroclival meningiomas between 1991 and 1998 was used to determine the predictive value of these anatomic parameters. The degree of tumor resection was analyzed with a novel grading scale combining the percentage of resection and the percentage of brainstem reexpansion. Total excision was achieved in 37% of the patients and complete brainstem reexpansion was achieved in an additional 40%. Residual tumor was concentrated in the central clival depression in Zone II, as predicted by anatomic parameters, and around infiltrated neurovascular structures. New cranial nerve deficit occurred in 31% of the patients in the early postoperative period and improved to 17% at 6 months. Major morbidity occurred in 9% of the patients, and mortality was 0%. Early Karnofsky scores were reduced in 37% of the patients, but 6-month Karnofsky scores were equal to preoperative baseline scores or improved in 91%.

CONCLUSION

Anatomic parameters can predict the resectability of petroclival meningiomas. Judicious application of cytoreductive surgery in selected patients maintains an acceptable morbidity and achieves adequate brainstem reexpansion.

Microsurgical anatomic features and nomenclature of the paraclinoid region

OBJECTIVE

We describe the detailed microsurgical anatomic features of the clinoid (C5) segment of the internal carotid artery (ICA) and surrounding structures, clarify the anatomic relationships of structures in this region, and emphasize the clinical relevance of these observations. Furthermore, because the nomenclature of the paraclinoid region is confusing and lacks standardization, this report provides a glossary of terms that are commonly used to descibe the anatomic features of the paraclinoid region.

METHODS

The region surrounding the anterior clinoid process was observed in 70 specimens from 35 formalin-fixed cadaveric heads. Detailed microanatomic dissections were performed in 10 specimens. Histological sections of this region were obtained from the formalin-fixed cadaveric specimens.

RESULTS

The clinoid segment of the ICA is the portion that abuts the clinoid process. This portion of the ICA can be directly observed only after removal of the clinoid process. The dura of the cavernous sinus roof separates to enclose the clinoid process. The clinoid segment of the ICA exists only where this separation of dural layers is present. Because the clinoid process does not completely enclose the ICA in most cases, the clinoid segment is shaped more like a wedge than a cylinder. The outer layer of the dura (dura propria) is a thick membrane that fuses with the adventitia of the ICA to form a competent ring that separates the intradural ICA from the extradural ICA. The thin inner membranous layer of the dura loosely surrounds the ICA throughout the entire length of its clinoid segment. The most proximal aspect of this membrane defines the proximal dural ring. The proximal ring is incompetent and admits a variable number of veins from the cavernous plexus that accompany the ICA throughout its clinoid segment.

CONCLUSION

The narrow space between the inner dural layer and the clinoid ICA is continuous with the cavernous sinus via an incompetent proximal dural ring. This space between the clinoid ICA and the inner dural layer contains a variable number of veins that directly communicate with the cavernous plexus. Given the inconstancy of the venous plexus surrounding the clinoid ICA, we think that categorical labeling of the clinoid ICA as intracavernous or extracavernous cannot be justified.

Colored silicone injection for use in neurosurgical dissections: anatomic technical note

OBJECTIVE

The dissection of cadaveric specimens is very important for a more sophisticated understanding of neurosurgical anatomic features and approaches. Teaching known approaches to residents or learning new approaches is best performed in a cadaveric laboratory. The utility of neurosurgical cadaveric dissections can be improved by injecting the intracranial vascular tree with colored silicone. The vascular anatomic features, which are integral to neurosurgical procedures, are much more clearly defined in injected specimens.

METHODS

Self-curing colored silicone rubber is used to inject the arteries and veins (red and blue, respectively) of the head. This process is described in a step-by-step format. Six steps are required and can be summarized as follows: 1) exposure of the great vessels, 2) cannulation of the great vessels, 3) irrigation of the head, 4) preparation of the colored silicone, 5) injection of the colored silicone, and 6) evaluation of the final specimen.

CONCLUSION

Injection of colored silicone into the vascular tree can enhance the educational value of cadaveric head dissections. This report describes the technique of vascular injection that is used in the Goodyear Microsurgical Laboratory, the University of Cincinnati, and the Mayfield Clinic.

The arachnoid and the myth of Arachne

The discovery of the arachnoid membrane is a relatively recent advance. Ancient anatomists noted the presence of the dura mater and pia mater, but the intervening arachnoid membrane was left undescribed. It was not until the 17th century that anatomists discovered a layer separating the pia mater from the dura mater and named this cobweb-like layer the "arachnoid." Arachnoid means "spider-like" and has an interesting etymology that can be traced to the ancient Greek myth of Arachne.

Spinal epidural hematoma and high thromboembolic risk: between Scylla and Charybdis

OBJECTIVE

To determine the optimal time for reinstitution of anticoagulant therapy after evacuation of spinal epidural hematoma in patients who have a high risk for cardiogenic embolization.

MATERIAL AND METHODS

The clinical histories of all patients with a spinal epidural hematoma encountered at Mayo Clinic Rochester between 1975 and 1996 were reviewed. We present three cases of spontaneous spinal epidural hematoma and the management of anticoagulation in each case.

RESULTS

Of the 17 patients identified, 3 received anticoagulant therapy at the onset of the hematoma and were at high risk for cardiogenic embolization. In two patients with a metallic heart valve and one patient with long-standing atrial fibrillation, anticoagulant therapy was discontinued for 5, 13, and 18 days, respectively, after decompressive laminectomy. Systemic embolization occurred in one patient with a previous history of embolization to the femoral artery. No systemic embolization occurred in the two patients with a metallic valve.

CONCLUSION

Early resumption of warfarin therapy is indicated after a spinal surgical procedure; however, discontinuation of anticoagulation for several days seems safe while postoperative hemostasis is monitored.

Ivory osteoma of the cervical spine: case report

OBJECTIVE AND IMPORTANCE

We report a unique case of ivory osteoma of the cervical spine.

CLINICAL PRESENTATION

The clinical presentation was one of polyradicular deficit without myelopathy after trauma. The imaging characteristics and histology of the lesion were those of a classic ivory osteoma.

INTERVENTION

A complete surgical excision of the lesion was accomplished.

CONCLUSION

We think we have recorded the only well-documented case of ivory osteoma affecting the spine.

Repairing holes in the head: a history of cranioplasty

Cranioplasty is almost as ancient as trephination, yet its fascinating history has been neglected. There is strong evidence that Incan surgeons were performing cranioplasty using precious metals and gourds. Interestingly, early surgical authors, such as Hippocrates and Galen, do not discuss cranioplasty and it was not until the 16th century that cranioplasty in the form of a gold plate was mentioned by Fallopius. The first bone graft was recorded by Meekeren, who in 1668 noted that canine bone was used to repair a cranial defect in a Russian man. The next advance in cranioplasty was the experimental groundwork in bone grafting, performed in the late 19th century. The use of autografts for cranioplasty became popular in the early 20th century. The destructive nature of 20th century warfare provided an impetus to search for alternative metals and plastics to cover large cranial defects. The metallic bone substitutes have largely been replaced by modern plastics. Methyl methacrylate was introduced in 1940 and is currently the most common material used. Research in cranioplasty is now directed at improving the ability of the host to regenerate bone. As modern day trephiners, neurosurgeons should be cognizant of how the technique of repairing a hole in the head has evolved.

The history of spinal biomechanics

The history of spinal biomechanics has its origins in antiquity. The Edwin Smith surgical papyrus, an Egyptian document written in the 17th century BC, described the difference between cervical sprain, fracture, and fracture-dislocation. By the time of Hippocrates (4th century BC), physical means such as traction or local pressure were being used to correct spinal deformities but the treatments were based on only a rudimentary knowledge of spinal biomechanics. The Renaissance produced the first serious attempts at understanding spinal biomechanics. Leonardo da Vinci (1452-1519) accurately described the anatomy of the spine and was perhaps the first to investigate spinal stability. The first comprehensive treatise on biomechanics, De Motu Animalium, was published by Giovanni Borelli in 1680, and it contained the first analysis of weight bearing by the spine. In this regard, Borelli can be considered the "Father of Spinal Biomechanics." By the end of the 19th century, the basic biomechanical concepts of spinal alignment and immobilization were well entrenched as therapies for spinal cord injury. Further anatomic delineation of spinal stability was sparked by the anatomic analyses of judicial hangings by Wood-Jones in 1913. By the 1960s, a two-column model of the spine was proposed by Holdsworth. The modern concept of Denis' three-column model of the spine is supported by more sophisticated testing of cadaver spines in modern biomechanical laboratories. The modern explosion of spinal instrumentation stems from a deeper understanding of the load-bearing structures of the spinal column.

Knotted bowel: small-bowel obstruction from coiled peritoneal shunt catheters. Report of two cases

Knotting of a peritoneal catheter around a loop of bowel is a rare occurrence, which may lead to bowel obstruction. The incomplete removal of two ventriculoperitoneal shunts resulted in two cases of iatrogenically knotted peritoneal catheters. One patient underwent a laparotomy for relief of obstruction and the other was successfully treated by uncoiling the catheter by means of a wire passed into its lumen. A plan for management of a knotted peritoneal catheter is outlined.