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Agarwal A, Philips R, Fiorella M, Amin DR, Krein H, Heffelfinger R. Complications and Functional Outcomes After Esophageal Reconstruction with an Intact Larynx. Laryngoscope 2024; 134:1227-1233. [PMID: 37712564 DOI: 10.1002/lary.31055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Revised: 07/30/2023] [Accepted: 09/05/2023] [Indexed: 09/16/2023]
Abstract
BACKGROUND Esophageal defects can result from primary pathologies such as malignancy or stricture, or secondary ones such as perforation due to trauma or iatrogenic injury. Techniques, management, and outcomes of reconstruction in this setting are poorly understood. Herein, we aim to highlight surgical outcomes in patients undergoing local and free flap reconstruction of esophageal defects in the setting of an intact larynx. METHODS Retrospective review of patients who underwent esophageal reconstruction with an intact larynx between 2009 and 2022 at our institution was performed. RESULTS Ten patients met inclusion criteria. Esophageal reconstruction was performed for extruded spinal hardware (n = 8), and esophageal stricture (n = 2). Four patients underwent reconstruction with free tissue transfer, and six with local pedicled flaps. There were no cases of flap failure, esophageal fistula, hematoma, or wound dehiscence. One patient had post-operative bleeding requiring return to the operating room. Three patients had a postoperative wound infection, two of whom required washout. There were no unplanned 30-day readmissions. At three months after operation, all patients who were not tube feed-dependent prior to surgery returned to oral intake. Of the four patients who were tube feed-dependent preoperatively, three were tolerating oral intake at nine months postoperatively. Nine patients (90%) had stable flexible laryngoscopy exams pre- and postoperatively with no voice changes. CONCLUSIONS Reconstruction of esophageal defects in the setting of an intact larynx can be challenging. In this series, surgical intervention with free tissue transfer and local pedicled flaps was effective in returning patients to oral intake with low long-term morbidity. LEVEL OF EVIDENCE 4 Laryngoscope, 134:1227-1233, 2024.
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Affiliation(s)
- Aarti Agarwal
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, U.S.A
| | - Ramez Philips
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, U.S.A
| | - Michele Fiorella
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania, U.S.A
| | - Dev R Amin
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, U.S.A
| | - Howard Krein
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, U.S.A
| | - Ryan Heffelfinger
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, U.S.A
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Philips R, Best KA, Agarwal A, Sagheer H, Selman Y, Sweeney L, Wax M, Krein H, Heffelfinger R, Luginbuhl A, Curry J. A Survey of Microvascular Technique Preferences Among American Head Neck Society Members. Laryngoscope 2024; 134:1265-1277. [PMID: 37610286 DOI: 10.1002/lary.30995] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Revised: 06/13/2023] [Accepted: 08/08/2023] [Indexed: 08/24/2023]
Abstract
OBJECTIVE To identify practices in microvascular techniques in routine and challenging scenarios. STUDY DESIGN Cross-sectional study. METHODS A national survey addressing practices related to microvascular free flap reconstruction was distributed to AHNS members between October and November 2021. RESULTS The respondents encompassed 95 microvascular surgeons. Median years of practice was 6 (interquartile range, 2-13) and median flaps per year was 35 (22-50). Common practices in arterial anastomosis included limited cleaning of artery (84.2%), use of a double approximating clamp (64.2%), and use of interrupted suture (88.4%). Common practices in venous anastomosis included limited cleaning (89.5%), downsizing the coupler (53.7%), and coupling to two independent venous systems (47.4%). In arterial anastomosis, respondents felt that kinking (50.5%) and tension (24.2%) were the riskiest challenges. Kinking was handled by loose sutures or native tissue/dissolvable biomaterial to orient pedicle. Excess tension was handled by additional dissection. With regards to associated practices, most surgeons perform anastomosis after partial inset (52.6%), give aspirin immediately postoperatively (66.3%), reserve transfusion for hemodynamic instability (69.5%), and utilize intraoperative pressors when needed (72.6%). More senior surgeons reported placing more suture to address leaks (p = 0.004) and perform end to side anastomosis on larger vein in case of venous mismatch (p = 0.012). In cases of tension, higher volume surgeons perform more extensive dissection (p = 0.035) and end to side coupling (p = 0.029). CONCLUSIONS This survey of AHNS members indicates patterns of microvascular techniques in routine and challenging scenarios. There exists a variation in approaches amongst surgeons based on volume and practice length. LEVEL OF EVIDENCE 5 Laryngoscope, 134:1265-1277, 2024.
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Affiliation(s)
- Ramez Philips
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University Hospitals, Philadelphia, Pennsylvania, U.S.A
| | - Keisha A Best
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University Hospitals, Philadelphia, Pennsylvania, U.S.A
| | - Aarti Agarwal
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University Hospitals, Philadelphia, Pennsylvania, U.S.A
| | - Hamad Sagheer
- Department of Anesthesiology, University of Florida, Gainesville, Florida, U.S.A
| | - Yamil Selman
- Head and Neck Surgical Oncology, Memorial Healthcare System, Hollywood, Florida, U.S.A
| | - Larissa Sweeney
- Department of Otolaryngology-Head and Neck Surgery, University of Miami, Miami, Florida, U.S.A
| | - Mark Wax
- Department of Otolaryngology-Head and Neck Surgery, Oregon Health and Science University, Portland, Oregon, U.S.A
| | - Howard Krein
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University Hospitals, Philadelphia, Pennsylvania, U.S.A
| | - Ryan Heffelfinger
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University Hospitals, Philadelphia, Pennsylvania, U.S.A
| | - Adam Luginbuhl
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University Hospitals, Philadelphia, Pennsylvania, U.S.A
| | - Joseph Curry
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University Hospitals, Philadelphia, Pennsylvania, U.S.A
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Elliot ZT, Lu JS, Campbell D, Xiao KB, Christopher V, Krein H, Heffelfinger R. Evaluating YouTube Videos on Facelift Surgery for Facial Rejuvenation as a Resource for Patients. Ann Otol Rhinol Laryngol 2023; 132:1349-1354. [PMID: 36788443 DOI: 10.1177/00034894231154410] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/16/2023]
Abstract
OBJECTIVES This study evaluated the content and patient educational quality of YouTube videos on facelift surgery for facial rejuvenation. This study investigated the relationship between education quality compared to video content, video metrics, and popularity. METHODS Two hundred videos were identified across 4 search terms: "facelift surgery," "facelift surgery what to expect," "facelift surgery patient education," and "what is facelift surgery." Unrelated videos, operating room recordings, medical professional lectures, non-English, non-audio, and testimonials were excluded from review. Video quality was assessed using the Global Quality Score (GQS) (range: 1-5), modified DISCERN score (range: 5-25), and JAMA Benchmark Criteria (range: 0-4). Secondary outcomes included upload source, video metrics (views, likes, dislikes, duration, days since upload, comments), and Video Power Indexto measure popularity. The first 10 comments on videos were characterized as positive, neutral, or negative. RESULTS One hundred forty-three videos were excluded (43 did not meet criteria, 100 duplicates), and 57 videos were included. Fifty-five videos (96.5%) were uploaded by private medical practices. Overall video quality was poor across all 3 scoring systems: GQS (2.92 ± 1.14), modified DISCERN (13.03 ± 3.64), and JAMA Benchmark Criteria (1.78 ± 0.52). Popularity positively correlated with JAMA Benchmark Criteria (R = .49, P < .05) but did not correlate with other quality criteria. CONCLUSIONS For patients undergoing facelift surgery, there are limited educational videos on YouTube with few videos detailing indications, alternatives, complications, and the postoperative course. YouTube is a growing resource for patient education and opportunities exist for medical institutions to produce higher-quality videos for prospective patients.
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Affiliation(s)
- Zachary T Elliot
- Department of Otolaryngology - Head and Neck Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Joseph S Lu
- Department of Otolaryngology - Head and Neck Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Daniel Campbell
- Department of Otolaryngology - Head and Neck Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Kevin B Xiao
- Department of Otolaryngology - Head and Neck Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Vanessa Christopher
- Department of Otolaryngology - Head and Neck Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Howard Krein
- Department of Otolaryngology - Head and Neck Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Ryan Heffelfinger
- Department of Otolaryngology - Head and Neck Surgery, Thomas Jefferson University, Philadelphia, PA, USA
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Agarwal A, Philips R, Landers K, Savitch S, Barbarite E, Krein H, Heffelfinger R. Functional and Symmetry Outcomes After Forehead Flap Reconstruction of Medial Peri-Ocular Defects. Laryngoscope 2023; 133:2584-2589. [PMID: 36644993 DOI: 10.1002/lary.30566] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Revised: 12/19/2022] [Accepted: 12/29/2022] [Indexed: 01/17/2023]
Abstract
BACKGROUND Orbital defects have a profound impact on orbital function and symmetry of the face and are difficult to reconstruct given the complexity of this area. The paramedian forehead flap (PMFF) has not been well studied in reconstruction of orbital defects. METHODS Retrospective review of patients who underwent reconstruction of periorbital defects with PMFF between 2016 and 2021. Variables were ocular adnexal asymmetry, functional outcomes, and orbital complications. RESULTS Eighteen patients met inclusion criteria. Mean defect size was 11.1 ± 7.5 cm. The most common subsite involved was medial canthus in 88.9% of patients. There was no statistically significant difference between mean medial canthus to midline ratio and mean medial brow to midline ratio when compared to the assumed normal of 1. The medial canthus to pupil ratio and medial canthus to lateral canthus ratio had a statistically significant mean difference from 1.0 (p = 0.003 for both). In 22.2% of patients, the orbit was functional with impairment; the remaining had no impairment. Surgical sequelae occurred in 12/18 (66.7%) of patients, most commonly epiphora in 9/18 (50%) of patients, and ectropion in 5/18 (27.7%). CONCLUSION The PMFF is feasible for medial periorbital reconstruction with acceptable functional and symmetrical outcomes and low morbidity. LEVEL OF EVIDENCE 4 Laryngoscope, 133:2584-2589, 2023.
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Affiliation(s)
- Aarti Agarwal
- Department of Otolaryngology - Head and Neck Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Ramez Philips
- Department of Otolaryngology - Head and Neck Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Kathryn Landers
- Department of Otolaryngology - Head and Neck Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
- Department of Otolaryngology - Head and Neck Surgery, Rush University, Chicago, Illinois, USA
| | - Samantha Savitch
- Department of Otolaryngology - Head and Neck Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
- Department of Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Eric Barbarite
- Department of Otolaryngology - Head and Neck Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Howard Krein
- Department of Otolaryngology - Head and Neck Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Ryan Heffelfinger
- Department of Otolaryngology - Head and Neck Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
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Sagalow ES, Estephan LE, Kumar AT, Hwang M, Krein H, Heffelfinger R. Recovery Benefit With Total Intravenous Anesthesia in Patients Receiving Rhinoplasty. Otolaryngol Head Neck Surg 2023; 169:489-495. [PMID: 36906818 DOI: 10.1002/ohn.319] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Accepted: 02/24/2023] [Indexed: 03/13/2023]
Abstract
OBJECTIVE The aim was to evaluate the difference in recovery when comparing total intravenous anesthesia (TIVA) to inhalational gas anesthesia in patients receiving rhinoplasty. STUDY DESIGN Retrospective review. SETTING Postoperative anesthesia care unit (PACU). METHODS Patients who received a functional or cosmetic rhinoplasty at a single academic institution between April 2017 and November 2020 were included. Inhalational gas anesthesia was in the form of sevoflurane. Phase I recovery time, which was defined as the time it took a patient to reach ≥9/10 on the Aldrete scoring system was recorded, as well as the usage of pain medication in the PACU. The postoperative course and incidence of postoperative nausea and vomiting (PONV) were also collected. RESULTS Two hundred and two patients were identified with 149 (73.76%) who received TIVA and 53 (26.24%) who received sevoflurane. For the patients who received TIVA, the average recovery time was 101.44 minutes (standard deviation [SD]: 34.64) compared to an average recovery time of 121.09 minutes (SD: 50.19) for patients who received sevoflurane leading to a difference of 19.65 minutes (p = 0.002). Patients who received TIVA experienced less PONV (p = 0.001). There were no differences in the postoperative course including surgical or anesthesia complications, postoperative complications, hospital or Emergency Department admissions, or administration of pain medication (p > 0.05 for all). CONCLUSION When utilizing TIVA over inhalational anesthesia, patients undergoing rhinoplasty had significantly increased benefits in terms of reduced phase I recovery times and decreased incidence of PONV. TIVA was demonstrated to be a safe and efficacious method of anesthesia for this patient population.
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Affiliation(s)
- Emily S Sagalow
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Leonard E Estephan
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Ayan T Kumar
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Michelle Hwang
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Howard Krein
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Ryan Heffelfinger
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
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Schlegel L, Malani E, Belko S, Kumar A, Barbarite E, Krein H, Hefelfnger R, Hutchinson M, Pugliese R. Correction to: Design, printing optimization, and material testing of a 3D-printed nasal osteotomy task trainer. 3D Print Med 2023; 9:23. [PMID: 37603078 PMCID: PMC10440856 DOI: 10.1186/s41205-023-00188-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/22/2023] Open
Affiliation(s)
- Lauren Schlegel
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, USA.
- Health Design Lab, Thomas Jefferson University, Philadelphia, PA, USA.
| | - Eric Malani
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, USA
- Health Design Lab, Thomas Jefferson University, Philadelphia, PA, USA
| | - Sara Belko
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, USA
- Health Design Lab, Thomas Jefferson University, Philadelphia, PA, USA
| | - Ayan Kumar
- Department of Otolaryngology, Thomas Jefferson University, Philadelphia, PA, USA
| | - Eric Barbarite
- Department of Otolaryngology, Thomas Jefferson University, Philadelphia, PA, USA
| | - Howard Krein
- Department of Otolaryngology, Thomas Jefferson University, Philadelphia, PA, USA
| | - Ryan Hefelfnger
- Department of Otolaryngology, Thomas Jefferson University, Philadelphia, PA, USA
| | - Morgan Hutchinson
- Health Design Lab, Thomas Jefferson University, Philadelphia, PA, USA
- Department of Emergency Medicine, Thomas Jefferson University, Philadelphia, PA, USA
| | - Robert Pugliese
- Health Design Lab, Thomas Jefferson University, Philadelphia, PA, USA
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Schlegel L, Malani E, Belko S, Kumar A, Barbarite E, Krein H, Heffelfinger R, Hutchinson M, Pugliese R. Design, printing optimization, and material testing of a 3D-printed nasal osteotomy task trainer. 3D Print Med 2023; 9:20. [PMID: 37439899 PMCID: PMC10339601 DOI: 10.1186/s41205-023-00185-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Accepted: 07/01/2023] [Indexed: 07/14/2023] Open
Abstract
BACKGROUND For difficult or rare procedures, simulation offers an opportunity to provide education and training. In developing an adequate model to utilize in simulation, 3D printing has emerged as a useful technology to provide detailed, accessible, and high-fidelity models. Nasal osteotomy is an essential step in many rhinoplasty surgeries, yet it can be challenging to perform and difficult to receive adequate exposure to this nuanced portion of the procedure. As it currently stands, there are limited opportunities to practice nasal osteotomy due to the reliance on cadaveric bones, which are expensive, difficult to obtain, and require appropriate facilities and personnel. While previous designs have been developed, these models leave room for improvement in printing efficiency, cost, and material performance. This manuscript aims to describe the methodology for the design of an updated nasal osteotomy training model derived from anatomic data and optimized for printability, usability, and fidelity. Additionally, an analysis of multiple commercially available 3D printing materials and technologies was conducted to determine which offered superior equivalency to bone. METHODS This model was updated from a first-generation model previously described to include a more usable base and form, reduce irrelevant structures, and optimize geometry for 3D printing, while maintaining the nasal bones with added stabilizers essential for function and fidelity. For the material comparison, this updated model was printed in five materials: Ultimaker Polylactic Acid, 3D Printlife ALGA, 3DXTECH SimuBone, FibreTuff, and FormLabs Durable V2. Facial plastic surgeons tested the models in a blinded, randomized fashion and completed surveys assessing tactile feedback, audio feedback, material limitation, and overall value. RESULTS A model optimizing printability while maintaining quality in the area of interest was developed. In the material comparison, SimuBone emerged as the top choice amongst the evaluating physicians in an experience-based subjective comparison to human bone during a simulated osteotomy procedure using the updated model. CONCLUSION The updated midface model that was user-centered, low-cost, and printable was designed. In material testing, Simubone was rated above other materials to have a more realistic feel.
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Affiliation(s)
- Lauren Schlegel
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, USA.
- Health Design Lab, Thomas Jefferson University, Philadelphia, PA, USA.
| | - Eric Malani
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, USA
- Health Design Lab, Thomas Jefferson University, Philadelphia, PA, USA
| | - Sara Belko
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, USA
- Health Design Lab, Thomas Jefferson University, Philadelphia, PA, USA
| | - Ayan Kumar
- Department of Otolaryngology, Thomas Jefferson University, Philadelphia, PA, USA
| | - Eric Barbarite
- Department of Otolaryngology, Thomas Jefferson University, Philadelphia, PA, USA
| | - Howard Krein
- Department of Otolaryngology, Thomas Jefferson University, Philadelphia, PA, USA
| | - Ryan Heffelfinger
- Department of Otolaryngology, Thomas Jefferson University, Philadelphia, PA, USA
| | - Morgan Hutchinson
- Health Design Lab, Thomas Jefferson University, Philadelphia, PA, USA
- Department of Emergency Medicine, Thomas Jefferson University, Philadelphia, PA, USA
| | - Robert Pugliese
- Health Design Lab, Thomas Jefferson University, Philadelphia, PA, USA
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Elliott ZT, Bheemreddy A, Fiorella M, Martin AM, Christopher V, Krein H, Heffelfinger R. Artificial intelligence for objectively measuring years regained after facial rejuvenation surgery. Am J Otolaryngol 2023; 44:103775. [PMID: 36706713 DOI: 10.1016/j.amjoto.2022.103775] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Accepted: 12/18/2022] [Indexed: 12/27/2022]
Abstract
BACKGROUND Few objective measures are available for assessing the success of facial rejuvenation after face lift surgery. Convolutional neural networks (CNNs) may be used for this type of measurement. The purpose of this investigation is to use artificial intelligence (AI) via CNNs to objectively classify patient photos by age before and after aesthetic surgery. Uniquely, men and patients undergoing deep plane face lifts were included. METHODS A CNN (FaceX) was used for facial age recognition and age estimation. Patient photos were analyzed preoperatively, and at three (PO1) and 12 months (PO2) postoperatively. The study population included male and female patients who underwent facial rejuvenation at our institution from 2017 to 2021. Patient photos were collected with the same camera, distance, and lighting. RESULTS 226 patients were analyzed with a mean true age of 62.2 (SD 6.7) years. The AI estimated the mean preoperative age to be 64.7 (SD 10.4) years. The AI was 96.0 % accurate. Across all subjects, a 3.5-year, 5 % reduction in age (p ≤ 0.001) was attributed at PO1, and a 1.7 year, 3 % age reduction (p = 0.034) at PO2. No single ancillary procedure or technique conferred more benefit than others. The 15 males had a 2.0 year, 4 % age reduction (p = 0.06) at PO1. CONCLUSION AI can be used to objectively measure the success of facelift surgery and compare outcomes among rhytidectomy techniques. Additionally, multiple, different approaches were effective with no single approach being superior. As AI continues to rapidly advance, more accurate models may be developed for multiple applications in facial plastic surgery.
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Affiliation(s)
- Zachary T Elliott
- Thomas Jefferson University, Department of Otolaryngology - Head and Neck Surgery, Philadelphia, PA 19107, United States of America.
| | - Alekya Bheemreddy
- Thomas Jefferson University, Department of Otolaryngology - Head and Neck Surgery, Philadelphia, PA 19107, United States of America
| | - Michele Fiorella
- Thomas Jefferson University, Department of Otolaryngology - Head and Neck Surgery, Philadelphia, PA 19107, United States of America
| | - Ann M Martin
- Thomas Jefferson University, Department of Otolaryngology - Head and Neck Surgery, Philadelphia, PA 19107, United States of America
| | - Vanessa Christopher
- Thomas Jefferson University, Department of Otolaryngology - Head and Neck Surgery, Philadelphia, PA 19107, United States of America
| | - Howard Krein
- Thomas Jefferson University, Department of Otolaryngology - Head and Neck Surgery, Philadelphia, PA 19107, United States of America
| | - Ryan Heffelfinger
- Thomas Jefferson University, Department of Otolaryngology - Head and Neck Surgery, Philadelphia, PA 19107, United States of America
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Schlegel L, Kumar A, Christopher V, Belko S, Barbarite E, Pugliese R, Krein H, Hutchinson M, Heffelfinger R. Tap-Tap: Learning Endonasal and Percutaneous Nasal Osteotomy Techniques on 3D-Printed Midface Models. Otolaryngol Head Neck Surg 2023; 168:1580-1583. [PMID: 36939489 DOI: 10.1002/ohn.260] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Revised: 11/29/2022] [Accepted: 12/17/2022] [Indexed: 02/04/2023]
Abstract
Nasal osteotomy is one of the most challenging steps of rhinoplasty. Lack of hands-on training and confidence with this procedure adds to the complexity for learners and trainees. As three-dimensional (3D) printing becomes increasingly accessible, simulation on 3D printed models has the potential to address this educational need in a safe, reproducible, and clinically realistic manner. The simulation session described in this communication, which utilized our low-cost, 3D-printed nasal osteotomy ($12.37) task trainer, produced both educational and confidence benefits for trainees. Here we describe the design, organization, curriculum, and pilot data for a 3D-printed nasal osteotomy task trainer for the simulation of endonasal and percutaneous nasal osteotomy.
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Affiliation(s)
- Lauren Schlegel
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania, USA.,Health Design Lab, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Ayan Kumar
- Department of Otolaryngology, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Vanessa Christopher
- Department of Otolaryngology, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Sara Belko
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania, USA.,Health Design Lab, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Eric Barbarite
- Department of Otolaryngology, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Robert Pugliese
- Health Design Lab, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Howard Krein
- Department of Otolaryngology, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Morgan Hutchinson
- Health Design Lab, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Ryan Heffelfinger
- Department of Otolaryngology, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
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Sagalow ES, Stewart M, Estephan L, Rodin J, Ananth A, Curcio B, Krein H, Heffelfinger R, Thaler A, Hunt P, Boon M, Huntley C. Assessing Postoperative Recovery With Volatile Gas Versus Total Intravenous Anesthesia in Patients With and Without Obstructive Sleep Apnea. Ann Otol Rhinol Laryngol 2022; 132:667-673. [PMID: 35833578 DOI: 10.1177/00034894221112501] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
INTRODUCTION To determine if there is a recovery time difference between patients with and without obstructive sleep apnea (OSA) when using total intravenous anesthesia (TIVA) compared to volatile gas inhalational anesthesia. PATIENTS AND METHODS OSA and Non-OSA patients were identified at a tertiary institution between January 2019 and November 2020. Non-OSA patients were defined as those who have not been formerly diagnosed with OSA. A modified STOP-BANG score (MSBS) was performed to screen Non-OSA patients for OSA. Recovery was measured by Phase I recovery time, or time it took a patient to reach ≥9/10 on the Aldrete scoring system. RESULTS A total of 334 patients were included with 142 in the OSA cohort (59 TIVA, 83 inhalational anesthesia) and 192 in the Non-OSA cohort (119 TIVA, 73 inhalational anesthesia). In OSA patients, there was a 41.29-minute recovery time reduction when using TIVA versus sevoflurane (P < .0001). Non-OSA patients recovered faster than OSA patients when undergoing inhalational anesthesia by 46.76 minutes and TIVA by 18.58 minutes (P < .0001 and P = .0907, respectively). Non-OSA patients with a MSBS < 3 and ≥3 had a shorter recovery time compared to OSA patients when both underwent sevoflurane anesthesia (57.27 minutes, P < .0001 and 56.23 minutes, P = .040, respectively). Non-OSA patients with a MSBS of <3 had a decrease in recovery time of 26.68 minutes when compared to OSA patients who underwent TIVA (P = .0004). CONCLUSIONS When utilizing TIVA over inhalational anesthesia, patients with OSA have significantly increased benefit in terms of reduced Phase I recovery times as compared to Non-OSA patients.
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Affiliation(s)
- Emily S Sagalow
- Department of Otolaryngology - Head & Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Matthew Stewart
- Department of Otolaryngology - Head & Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Leonard Estephan
- Department of Otolaryngology - Head & Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Julianna Rodin
- Department of Otolaryngology - Head & Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Ashwin Ananth
- Department of Otolaryngology - Head & Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Brian Curcio
- Division of Biostatistics, Department of Pharmacology and Experimental Therapeutics, Thomas Jefferson University, Philadelphia, PA, USA
| | - Howard Krein
- Department of Otolaryngology - Head & Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Ryan Heffelfinger
- Department of Otolaryngology - Head & Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Adam Thaler
- Department of Anesthesiology, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Patrick Hunt
- Department of Anesthesiology, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Maurits Boon
- Department of Otolaryngology - Head & Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Colin Huntley
- Department of Otolaryngology - Head & Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
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11
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Sagalow ES, Givens AK, Gill K, Malkani K, Xu V, Elmer N, Ganti R, Zhan T, Stanek J, Hwang MS, Krein H, Heffelfinger R. Impact of great auricular nerve sacrifice on sensory disturbance after parotidectomy. Am J Otolaryngol 2022; 43:103387. [PMID: 35149344 DOI: 10.1016/j.amjoto.2022.103387] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Accepted: 01/30/2022] [Indexed: 11/01/2022]
Abstract
PURPOSE To investigate the association between great auricular nerve (GAN) sacrifice during parotidectomy and postoperative sensory disturbance. MATERIALS AND METHODS Patients who underwent parotidectomy between November 2016 and May 2020 at a single academic institution were included in this retrospective chart review. Operative notes were reviewed to determine incidence of GAN sacrifice. Prevalence of patient-reported sensory complaints in the GAN distribution and time to spontaneous resolution of symptoms were assessed. RESULTS Of 305 parotidectomy patients, 111 (36.4%) endorsed complaints of postoperative sensory disturbances in the GAN distribution typically characterized by numbness or shooting pains. GAN sacrifice was present in 9 (8.1%) of 111 patients who experienced sensory disturbances compared to 9 (4.6%) who reported no sensory disturbances (p > 0.05). Twenty-five patients (32.5%) experienced spontaneous resolution of symptoms at their most recent follow-up at a mean of 6.2 months after onset of symptoms. Of those that experienced a sensory disturbance, GAN preservation was not significantly associated with likelihood of spontaneous recovery (p > 0.05). CONCLUSIONS We report the largest series to date of post-operative sensory disturbance in parotidectomy patients as it relates to intraoperative GAN sacrifice. Although the relationship between GAN sacrifice and the incidence of postoperative sensory disturbance and its subsequent resolution were not significant, we continue to advocate for GAN preservation to reduce incidence of postoperative sensory disturbances.
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12
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Sussman S, Gill K, Wagoner S, Stanek J, Heffelfinger R, Krein H. A randomized control trial employing infraorbital nerve stimulation as a neural distractor during nasopharyngeal swab. Ear Nose Throat J 2022:1455613211069344. [PMID: 35089070 DOI: 10.1177/01455613211069344] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
INTRODUCTION With the global COVID-19 pandemic, nasopharyngeal swabbing has become commonplace and can occasionally cause discomfort, tearing, and anxiety. OBJECTIVE To evaluate whether using a neural distraction device during nasopharyngeal swabbing can mitigate patient discomfort. METHODS Participants were randomized into nasal swab with vibration first (treatment-control or Tc) or nasal swab without vibration first (control-treatment or Ct). Then the swab was repeated with the opposite technique. The vibration device was used to stimulate the infraorbital nerve at the midpupillary line, while a nasopharyngeal swab was performed according to CDC protocol. After each swab, participants filled out a survey to assess pain, discomfort, and tearing. This procedure was replicated on the contralateral nostril for a total of 4 swabs and 4 surveys. RESULTS Thirty-four subjects were included in the analysis. In the Ct group, there was a median 1.0-point decrease in pain with the use of vibration (95% CI [-1.8, -0.3], P = 0.0117), 2.5-point decrease (95% CI [-3.0, -0.8], P = 00039) in discomfort, and a 1.0-point decrease (95% CI [-2.6, -0.2] P = 0.0303) in tearing when the vibratory device was used. In the Tc group, there was a median 2.0-point decrease in pain with vibration (95% CI [ -2.7, -1.1], P < 0.0001), 2.3-point decrease in discomfort (95% CI [-3.1, -1.5], P < 0.0001), and a 1.5-point decrease in tearing (95% CI [-2.5, -0.5], P = 0.0037) when vibration was used. CONCLUSION Vibratory stimulation of the infraorbital nerve is safe and effectively reduced pain, discomfort, and tearing during nasopharyngeal swab. Vibration is a reasonable option to minimize patient discomfort during COVID-19 or other microbiological testing.
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Affiliation(s)
- Sarah Sussman
- Department of Otolaryngology, 23217Thomas Jefferson University, Philadelphia, PA, USA
| | - Kurren Gill
- Department of Otolaryngology, 23217Thomas Jefferson University, Philadelphia, PA, USA
| | - Sarah Wagoner
- Sidney Kimmel Medical College, 12313Thomas Jefferson University, Philadelphia, PA, USA
| | - Joel Stanek
- Department of Otolaryngology, 23217Thomas Jefferson University, Philadelphia, PA, USA
| | - Ryan Heffelfinger
- Department of Otolaryngology, 23217Thomas Jefferson University, Philadelphia, PA, USA
| | - Howard Krein
- Department of Otolaryngology, 23217Thomas Jefferson University, Philadelphia, PA, USA
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13
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Sagheer SH, Yan BM, Bovenzi CD, Nwagu U, Cognetti D, Krein H, Heffelfinger R. Postoperative Opioid-Prescribing Practices in Nasal Surgery: A Prospective Study. Facial Plast Surg Aesthet Med 2021; 24:266-270. [PMID: 34171976 DOI: 10.1089/fpsam.2020.0532] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Importance: There has been a greater awareness of the opioid epidemic. Studies are needed to better characterize opioid usage after outpatient nasal surgery. Objective: Provide data to guide prescription management for nasal procedures and investigate opioid prescription and subsequent consumption, with the aim of offering analysis to build evidence-based guidelines for postoperative pain management. Design, Setting, and Participants: In this prospective single-center study, morphine milligram equivalents (MME) consumption and pain scores were collected in 69 patients who underwent nasal surgery. Main Measures and Outcomes: Patient demographics, MME use, and pain scores were examined. MME use was compared with patient demographics, surgical procedure type, and postoperative pain scores. Results: In total, 3302 MME were prescribed: 2012 MME (61%) were used, leaving 1290 MME (39%). Patients were prescribed a total average of 47.8 ± 24.0 MME. Four (6%) patients required a second prescription. History of opioid use, benzodiazepine use, and obesity were negative predictors of opioid consumption (p ≤ 0.001). Conclusion and Relevance: Assessing opioid consumption for nasal procedures will guide prescribing practices. Our results indicate that prescription practices can likely be down titrated in patients with a history of certain medication consumption.
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Affiliation(s)
- S Hamad Sagheer
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Brian M Yan
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Cory D Bovenzi
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Uche Nwagu
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - David Cognetti
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Howard Krein
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Ryan Heffelfinger
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
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14
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Xu V, Gill KS, Goldfarb J, Bovenzi C, Moayer R, Krein H, Heffelfinger R. First Bite Syndrome After Parotidectomy: A Case Series and Review of Literature. Ear Nose Throat J 2020; 101:663-667. [PMID: 33314982 DOI: 10.1177/0145561320980179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
Abstract
INTRODUCTION First bite syndrome (FBS) is a rare but potentially debilitating complication observed after surgery involving the upper cervical region. Patients classically complain of severe facial pain in the ipsilateral parotid region with the first few bites of a meal. OBJECTIVE The aim of this study is to shed light on the incidence and potential risk factors of FBS, including a series of cases depicting FBS observed after parotidectomy. METHODS Retrospective review of 419 patients who underwent parotidectomy at a single tertiary care facility between December 2016 and June 2020. RESULTS With a mean follow-up time of 16.5 months, 8 (2%) patients were documented to have symptoms of FBS after parotid gland surgery. Six of these patients underwent partial parotidectomy by dissection of the deep lobe of the parotid (DLP). CONCLUSION Patients undergoing dissection of the DLP are particularly at risk for the development of FBS. All patients should be appropriately counseled during informed consent discussions, especially in high-risk cases.
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Affiliation(s)
- Vivian Xu
- Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA, USA
| | - Kurren S Gill
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Jared Goldfarb
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Cory Bovenzi
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Roxana Moayer
- Department of Otolaryngology-Head and Neck Surgery, Keck Medicine of University of Southern California, Los Angeles, CA, USA
| | - Howard Krein
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Ryan Heffelfinger
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
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15
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Ho M, Goldfarb J, Moayer R, Nwagu U, Ganti R, Krein H, Heffelfinger R, Hutchinson ML. Design and Printing of a Low-Cost 3D-Printed Nasal Osteotomy Training Model: Development and Feasibility Study. JMIR Med Educ 2020; 6:e19792. [PMID: 33200998 PMCID: PMC7708083 DOI: 10.2196/19792] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Revised: 07/26/2020] [Accepted: 10/28/2020] [Indexed: 06/11/2023]
Abstract
BACKGROUND Nasal osteotomy is a commonly performed procedure during rhinoplasty for both functional and cosmetic reasons. Teaching and learning this procedure proves difficult due to the reliance on nuanced tactile feedback. For surgical simulation, trainees are traditionally limited to cadaveric bones, which can be costly and difficult to obtain. OBJECTIVE This study aimed to design and print a low-cost midface model for nasal osteotomy simulation. METHODS A 3D reconstruction of the midface was modified using the free open-source design software Meshmixer (Autodesk Inc). The pyriform aperture was smoothed, and support rods were added to hold the fragments generated from the simulation in place. Several models with various infill densities were printed using a desktop 3D printer to determine which model best mimicked human facial bone. RESULTS A midface simulation set was designed using a desktop 3D printer, polylactic acid filament, and easily accessible tools. A nasal osteotomy procedure was successfully simulated using the model. CONCLUSIONS 3D printing is a low-cost, accessible technology that can be used to create simulation models. With growing restrictions on trainee duty hours, the simulation set can be used by programs to augment surgical training.
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Affiliation(s)
- Michelle Ho
- Health Design Lab, Thomas Jefferson University, Philadelphia, PA, United States
| | - Jared Goldfarb
- Department of Otolaryngology, Thomas Jefferson University, Philadelphia, PA, United States
| | - Roxana Moayer
- Department of Otolaryngology, Thomas Jefferson University, Philadelphia, PA, United States
| | - Uche Nwagu
- Department of Otolaryngology, Thomas Jefferson University, Philadelphia, PA, United States
| | - Rohan Ganti
- Department of Otolaryngology, Thomas Jefferson University, Philadelphia, PA, United States
| | - Howard Krein
- Department of Otolaryngology, Thomas Jefferson University, Philadelphia, PA, United States
| | - Ryan Heffelfinger
- Department of Otolaryngology, Thomas Jefferson University, Philadelphia, PA, United States
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16
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Sweeny L, Curry J, Crawley M, Cave T, Stewart M, Luginbuhl A, Heffelfinger R, Krein H, Petrisor D, Bender-Heine A, Wax MK. Factors impacting successful salvage of the failing free flap. Head Neck 2020; 42:3568-3579. [PMID: 32844522 DOI: 10.1002/hed.26427] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Revised: 06/25/2020] [Accepted: 07/28/2020] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Understanding factors impacting successful salvage of a compromised free flap. METHODS Multi-institutional review of free flap reconstructions for head and neck defects (n = 1764). RESULTS Free flap compromise rate: 9% (n = 162); 46% salvaged (n = 74). Higher salvage rates in initial 48 hours (64%) vs after (30%; P < .001). Greater compromise (14%) and failure (8%) if inset challenging vs straightforward (6% compromise, 4% failure; P = .035). Greater compromise (23%) and failure (17%) following intraoperative anastomosis revision vs no revision (7% compromise, 4% failure; P < .0001). Success following arterial insufficiency was lower (60% failed, 40% salvaged) vs venous congestion (23% failed, 77% salvaged) (P < .0001). Greater flap salvage following thrombectomy (66%) vs no thrombectomy (34%; P < .0001). Greater flap salvage if operative duration ≤8 hours (57%), vs >8 hours (40%) (P = .04). CONCLUSIONS There were higher rates of free flap salvage if the vascular compromise occurred within 48 hours, if due to venous congestion, if operative duration ≤8 hours, and if the anastomosis did not require intraoperative revision.
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Affiliation(s)
- Larissa Sweeny
- Department of Otolaryngology - Head and Neck Surgery, Louisiana State University Health Science Center - New Orleans, New Orleans, Louisiana, USA
| | - Joseph Curry
- Department of Otolaryngology - Head and Neck Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Meghan Crawley
- Department of Otolaryngology - Head and Neck Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Taylor Cave
- Oregon Health and Science University School of Medicine, Portland, Oregon, USA
| | - Matthew Stewart
- Department of Otolaryngology - Head and Neck Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Adam Luginbuhl
- Department of Otolaryngology - Head and Neck Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Ryan Heffelfinger
- Department of Otolaryngology - Head and Neck Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Howard Krein
- Department of Otolaryngology - Head and Neck Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Daniel Petrisor
- Oregon Health and Science University School of Medicine, Portland, Oregon, USA.,Department of Otolaryngology - Head and Neck Surgery, Oregon Health and Science University, Portland, Oregon, USA
| | - Adam Bender-Heine
- Oregon Health and Science University School of Medicine, Portland, Oregon, USA.,Department of Otolaryngology - Head and Neck Surgery, Oregon Health and Science University, Portland, Oregon, USA
| | - Mark K Wax
- Oregon Health and Science University School of Medicine, Portland, Oregon, USA.,Department of Otolaryngology - Head and Neck Surgery, Oregon Health and Science University, Portland, Oregon, USA
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17
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Hjelm N, Goldfarb J, Krein H, Heffelfinger RN, Pribitkin E. Sonic Rhinoplasty: Review and Updated Uses. Facial Plast Surg 2020; 37:107-109. [PMID: 32838439 DOI: 10.1055/s-0040-1714673] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
Abstract
The ultrasonic bone aspirator (UBA) allows for precision and provides ease of use in multiple steps of cosmetic and functional rhinoplasties. Its use has previously been described; however, since the publication of many studies the UBA has been improved and its applications for rhinoplasty have been modified and expanded. Both bony and cartilaginous modifications to the nose can be aided with the use of the UBA. From our experience, patient results have subjectively been found to be more acceptable, if not better, than with the use of other rhinoplasty instruments.
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Affiliation(s)
- Nikolaus Hjelm
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Jared Goldfarb
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Howard Krein
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Ryan N Heffelfinger
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Edmund Pribitkin
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
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18
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Bovenzi CD, Manges KA, Krein H, Heffelfinger R. Online Ratings of Facial Plastic Surgeons: Worthwhile Additions to Conventional Patient Experience Surveys. Facial Plast Surg Aesthet Med 2020; 23:78-89. [PMID: 32716653 DOI: 10.1089/fpsam.2020.0049] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: Physician review websites are now commonly used by patients. However, in facial plastic surgery, the trends and content in these websites are not well studied. We examined online reviews for U.S. facial plastic surgeons, and compared comment content with the most commonly used patient experience survey, the Consumer Assessment of Healthcare Providers and Systems (CAHPS) administered by Press Ganey. Methods: A retrospective mixed method study was employed to quantitatively compare online ratings and comments of 100 randomly selected U.S. facial plastic surgeons on vitals.com, healthgrades.com, google.com and zocdoc.com. Qualitative content analysis was utilized to categorize themes present in 957 patient-generated (unverified) comments, and compare these with CAHPS survey questions and themes. Results: The physician review websites had favorable ratings of facial plastic surgeons with 84.55% five-star reviews on Healthgrades and 78.40% on Vitals. These ratings were similar across surgeon age (p = 0.44), gender (p = 0.85), and geographic region (p = 0.29). Of sites examined, Healthgrades and Vitals were most frequently used. Analysis of patient comments identified themes aligning with CAHPS content (e.g., physician interactions, efficiency, and recommendation likelihood), as well as additional themes such as patient's outcome perception (55.28% of comments) and finances (86% of negatively rated reviews). Conclusions: These exploratory results suggest that facial plastic surgeons are generally rated positively online, and the comments left on these websites provide additional feedback that is not currently included in CAHPS surveys. In evaluating the patient experience with facial plastic surgery practices, these websites may prove to be useful.
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Affiliation(s)
- Cory D Bovenzi
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Kirstin A Manges
- National Clinician Scholar-Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Howard Krein
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Ryan Heffelfinger
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
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19
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Swendseid B, Philips R, Rimmer R, Goldman RA, Luginbuhl AJ, Curry J, Krein H, Heffelfinger R. Postoperative Anatomic Position of Mandibular Free Flap Neocondyles Affects Patient Symptoms. Facial Plast Surg Aesthet Med 2020; 23:36-41. [PMID: 32614617 DOI: 10.1089/fpsam.2020.0110] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Importance: Mandibular condyle reconstruction with vascularized free flaps can re-establish form and function after resection. However, no reports have been published regarding the postoperative anatomic seating of these reconstructions. Objective: To use postoperative axial imaging to determine whether condylar reconstructions migrate and correlate their ultimate location with postoperative symptoms. Design, Setting, and Participants: A prospectively maintained database of free flap cases performed between 2006 and 2019 at a single institution was queried. Twenty-one consecutive patients who underwent reconstructions that involved the mandibular condyle who also had postoperative axial imaging were selected for review. Distances were measured from the reconstructed condyle to the lateral, superior, and posterior aspect of the temporomandibular joint (TMJ), and correlated with postoperative symptoms and jaw function. Main Outcomes and Measures: Condyle displacement, postoperative diet, jaw pain, trismus, and malocclusion. Results: In total, 57% of patients had 1 cm or greater displacement of the condylar reconstruction from the TMJ in at least one vector. Anterior displacement of condyle by >1 cm was associated with jaw misalignment (42.8%) and clicking (14.3%) [odds ratio (OR) 37.3, 95% confidence interval (CI) 1.6-866.9, p = 0.024]. However, 83.3% of these patients were able to return to a normal diet and denied dysphagia. All edentulous patients had acceptable anteroposterior alignment, but 42.8% of dentulous patients had anterior displacement >1 cm (p = 0.12). Inferior displacement >1 cm was associated with dysphagia (OR 23, 95% CI 1.07-494.6, p = 0.04), but not pain or trismus. Eleven patients had multiple postoperative computed tomography scans, on average 21 months apart. The reconstructed location was stable in all 11 patients. Conclusions and Relevance: Patients undergoing free flap reconstruction of the mandibular condyle often return to normal diet, even when their reconstructions do not sit perfectly within the TMJ. Anterior displacement of the neocondyle may be more common in dentulous patients due to stress on the joint from chewing and produces some dysfunction and misalignment. Inferior displacement of the neocondyle may result in dysphagia. The reconstructed condyles are unlikely to migrate over time.
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Affiliation(s)
- Brian Swendseid
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Ramez Philips
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Ryan Rimmer
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Richard A Goldman
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Adam J Luginbuhl
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Joseph Curry
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Howard Krein
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Ryan Heffelfinger
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
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20
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Swendseid B, Kumar A, Sweeny L, Zhan T, Goldman RA, Krein H, Heffelfinger RN, Luginbuhl AJ, Curry JM. Natural History and Consequences of Nonunion in Mandibular and Maxillary Free Flaps. Otolaryngol Head Neck Surg 2020; 163:956-962. [DOI: 10.1177/0194599820931069] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Objective To describe the natural history of bone segment union in head and neck free flap procedures and detail the association of poor segment union with postoperative complications. Study Design Case series with chart review. Setting Single tertiary care referral center. Subjects and Method Patients with mandibular or maxillary defects reconstructed with osseous or osteocutaneous free flaps were analyzed (n = 104). Postoperative computed tomography or positron emission tomography/computed tomography scans were reviewed for signs of osseointegration and nonunion. Postoperative wound complications were correlated with imaging findings. Result Thirty-seven percent of appositions had partial union on nonunion. Appositions between osteotomized free flap segments form complete unions at a higher rate than appositions with native bone (65% vs 53%, P = .0006). If an apposition shows a gap of ≥1 mm, the chances of failing to form a complete union are greatly increated (79% vs 8%, P = .0009). Radiographic nonunion was associated with an increased likelihood of postoperative wound complications (40% vs 19%, P = .025) and in most cases was present before development of complications. Conclusion Radiographic evidence of partial union or nonunion of free flap osseous segments greatly exceeds reported rates of clinically evident nonunion. Unions likely form between free flap appositions before unions to the native bone. If initial bone segments are >1-mm apart, the chance of progression to complete union is low. Incomplete osseointegration appears to be a marker for development of wound complications.
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Affiliation(s)
- Brian Swendseid
- Department of Otolaryngology–Head & Neck Surgery, Thomas Jefferson University Hospitals, Philadelphia, Pennsylvania, USA
| | - Ayan Kumar
- Department of Otolaryngology–Head & Neck Surgery, Thomas Jefferson University Hospitals, Philadelphia, Pennsylvania, USA
| | - Larissa Sweeny
- Department of Otolaryngology–Head & Neck Surgery, Louisiana State University, New Orleans, Louisiana, USA
| | - Tingting Zhan
- Department of Pharmacology, Division of Biostatistics, Thomas Jefferson University Hospitals, Philadelphia, Pennsylvania, USA
| | - Richard A. Goldman
- Department of Otolaryngology–Head & Neck Surgery, Thomas Jefferson University Hospitals, Philadelphia, Pennsylvania, USA
| | - Howard Krein
- Department of Otolaryngology–Head & Neck Surgery, Thomas Jefferson University Hospitals, Philadelphia, Pennsylvania, USA
| | - Ryan N. Heffelfinger
- Department of Otolaryngology–Head & Neck Surgery, Thomas Jefferson University Hospitals, Philadelphia, Pennsylvania, USA
| | - Adam J. Luginbuhl
- Department of Otolaryngology–Head & Neck Surgery, Thomas Jefferson University Hospitals, Philadelphia, Pennsylvania, USA
| | - Joseph M. Curry
- Department of Otolaryngology–Head & Neck Surgery, Thomas Jefferson University Hospitals, Philadelphia, Pennsylvania, USA
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21
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Swendseid B, Kumar A, Sweeny L, Wax MK, Zhan T, Goldman RA, Krein H, Heffelfinger RN, Luginbuhl AJ, Curry JM. Long-Term Complications of Osteocutaneous Free Flaps in Head and Neck Reconstruction. Otolaryngol Head Neck Surg 2020; 162:641-648. [PMID: 32204662 DOI: 10.1177/0194599820912727] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To determine the frequency at which patients with osteocutaneous free flap reconstruction of the head and neck develop long-term complications and identify predisposing perioperative factors. STUDY DESIGN A prospectively maintained database of free flaps performed at a single institution over a 10-year period was queried. SETTING Single tertiary care referral center. SUBJECTS AND METHODS In total, 250 osseous or osteocutaneous free flaps (OCFFs) for mandibular or maxillary reconstruction were analyzed. Data were collected on demographics, preoperative therapy, resection location, adjuvant treatment, complications, and subsequent surgeries, and multivariate analysis was performed. Subgroup analysis based on perioperative factors was performed. RESULTS The median follow-up time was 23 months. In 185 patients with at least 6 months of follow-up, 17.3% had at least 1 long-term complication, most commonly wound breakdown, fistula or plate extrusion (13.5%), osteoradionecrosis or nonunion (6.5%), and infected hardware (5.9%). Prior chemoradiotherapy and cancer diagnosis predisposed patients to long-term complications. At the 5-year follow-up, 21.7% of patients had experienced a long-term complication. CONCLUSIONS Long-term complications after OCFF occurred in 17% of patients. In this series, a preoperative history of chemoradiation and those undergoing maxillary reconstruction were at high risk for the development of long-term complications and thus warrant diligent follow-up. However, OCFFs can often enjoy long-term viability and survival, even in the case of perioperative complications and salvage surgery.
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Affiliation(s)
- Brian Swendseid
- Department of Otolaryngology-Head & Neck Surgery, Thomas Jefferson University Hospitals, Philadelphia, Pennsylvania, USA
| | - Ayan Kumar
- Department of Otolaryngology-Head & Neck Surgery, Thomas Jefferson University Hospitals, Philadelphia, Pennsylvania, USA
| | - Larissa Sweeny
- Department of Otolaryngology-Head & Neck Surgery, Louisiana State University Health Science Center, New Orleans, Louisiana, USA
| | - Mark K Wax
- Department of Otolaryngology-Head & Neck Surgery, Oregon Health and Science University, Portland, Oregon, USA
| | - Tingting Zhan
- Department of Pharmacology, Division of Biostatistics, Thomas Jefferson University Hospitals, Philadelphia, Pennsylvania, USA
| | - Richard A Goldman
- Department of Otolaryngology-Head & Neck Surgery, Thomas Jefferson University Hospitals, Philadelphia, Pennsylvania, USA
| | - Howard Krein
- Department of Otolaryngology-Head & Neck Surgery, Thomas Jefferson University Hospitals, Philadelphia, Pennsylvania, USA
| | - Ryan N Heffelfinger
- Department of Otolaryngology-Head & Neck Surgery, Thomas Jefferson University Hospitals, Philadelphia, Pennsylvania, USA
| | - Adam J Luginbuhl
- Department of Otolaryngology-Head & Neck Surgery, Thomas Jefferson University Hospitals, Philadelphia, Pennsylvania, USA
| | - Joseph M Curry
- Department of Otolaryngology-Head & Neck Surgery, Thomas Jefferson University Hospitals, Philadelphia, Pennsylvania, USA
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Hjelm N, Sanan A, Krein H, Heffelfinger RN. Safety of Concurrent Endoscopic Browlift and Blepharoplasty. Facial Plast Surg 2019; 35:546-548. [PMID: 31505687 DOI: 10.1055/s-0039-1695724] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
Abstract
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.
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Affiliation(s)
- Nikolaus Hjelm
- Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology - Head and Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Akshay Sanan
- Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology - Head and Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Howard Krein
- Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology - Head and Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Ryan N Heffelfinger
- Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology - Head and Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
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Hjelm N, Ortlip TE, Topf M, Luginbuhl A, Curry J, Krein H, Heffelfinger R. Functional outcomes of temporomandibular joint reconstruction with vascularized tissue. Am J Otolaryngol 2019; 40:691-695. [PMID: 31227259 DOI: 10.1016/j.amjoto.2019.06.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2019] [Revised: 06/01/2019] [Accepted: 06/12/2019] [Indexed: 10/26/2022]
Abstract
OBJECTIVE To determine how current temporomandibular joint (TMJ) reconstruction methods affect functional outcomes. METHODS Retrospective review from January 2006 to July 2017 at a single tertiary care center. All patients who underwent mandibulectomy with subsequent reconstruction with vascularized free tissue were included in the study. Condylar segments were reconstructed with vascularized free tissue flap in conjunction with autologous tissue or allograft in the joint space. Preoperative, 3 month, 1 year, and 2 year postoperative records were assessed for trismus, need for tube feeds, and Functional Oral Intake Scale (FOIS). RESULTS Joint space was reconstructed with autologous tissue (n = 10), allograft (n = 15) or both (n = 9). At three months, FOIS scores significantly decreased from 5.4 preoperatively to 4.8 post operatively (P = .024) and need for tube feeds significantly increased from 15.8% preoperatively to 35.1% (P ≤0.027). Trismus significantly decreased from 63.2% to 27% (P = .006). At one-year, there were no significant changes in functional status compared to pre-operative state. Patients who had previous RT had significantly worse FOIS scores preoperatively (p = .002), at three months (p < .001), one year (p < .001), and two years (p = .008). There was no significant difference in postoperative functional status of patients based on the method of TMJ reconstruction. CONCLUSION Reconstruction of the TMJ with vascularized free tissue is a viable option and yields acceptable long-term outcomes. While functional status may improve or worsen in the immediate postoperative period, long term results mirror preoperative function. Preoperative trismus will likely improve. LEVEL OF EVIDENCE Level 3; Retrospective Comparative Study.
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Crawley MB, Sweeny L, Ravipati P, Heffelfinger R, Krein H, Luginbuhl A, Goldman R, Curry J. Factors Associated with Free Flap Failures in Head and Neck Reconstruction. Otolaryngol Head Neck Surg 2019; 161:598-604. [DOI: 10.1177/0194599819860809] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Objective To investigate causes of failure of free flap reconstructions in patients undergoing reconstruction of head and neck defects. Study Design Case series with chart review. Setting Single tertiary care center. Subjects and Methods Patients underwent reconstruction between January 2007 and June 2017 (n = 892). Variables included were clinical characteristics, social history, defect site, donor tissue, ischemia time, and postoperative complications. Statistical methods used include univariable and multivariable analysis of failure. Results The overall failure rate was 4.8% (n = 43). Intraoperative ischemia time was associated with free flap failures (odds ratio [OR], 1.062; 95% confidence interval [CI], 1.019-1.107; P = .004) for each addition of 5 minutes. Free flaps that required pedicle revision at time of initial surgery were 9 times more likely to fail (OR, 9.953; 95% CI, 3.242-27.732; P < .001). Patients who experienced alcohol withdrawal after free flap placement were 3.7 times more likely to experience flap failure (OR, 3.690; 95% CI, 1.141-10.330; P = .031). Ischemia time remained an independent significant risk factor for failure in nonosteocutaneous free flaps (OR, 1.105; 95% CI, 1.031-1.185). Alcohol withdrawal was associated with free flap failure in osteocutaneous reconstructions (OR, 5.046; 95% CI 1.103-19.805) while hypertension was found to be protective (OR, 0.056; 95% CI, 0.000-0.445). Conclusion Prolonged ischemia time, pedicle revision, and alcohol withdrawal were associated with higher rates of flap failure. Employing strategies to minimize ischemic time may have potential to decrease failure rates. Flaps that require pedicle revision and patients with a history of significant alcohol use require closer monitoring.
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Affiliation(s)
- Meghan B. Crawley
- Department of Otolaryngology–Head and Neck Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Larissa Sweeny
- Department of Otolaryngology–Head and Neck Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Prasanti Ravipati
- Drexel University College of Medicine, Philadelphia, Pennsylvania, USA
| | - Ryan Heffelfinger
- Department of Otolaryngology–Head and Neck Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Howard Krein
- Department of Otolaryngology–Head and Neck Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Adam Luginbuhl
- Department of Otolaryngology–Head and Neck Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Richard Goldman
- Department of Otolaryngology–Head and Neck Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Joseph Curry
- Department of Otolaryngology–Head and Neck Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
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Sweeny L, Topf M, Wax MK, Rosenthal EL, Greene BJ, Heffelfinger R, Krein H, Luginbuhl A, Petrisor D, Troob SH, Hughley B, Hong S, Zhan T, Curry J. Shift in the timing of microvascular free tissue transfer failures in head and neck reconstruction. Laryngoscope 2019; 130:347-353. [PMID: 31287566 DOI: 10.1002/lary.28177] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2019] [Revised: 06/06/2019] [Accepted: 06/19/2019] [Indexed: 12/23/2022]
Abstract
OBJECTIVE Analyze the cause and significance of a shift in the timing of free flap failures in head and neck reconstruction. STUDY DESIGN Retrospective multi-institutional review of prospectively collected databases at tertiary care centers. METHODS Included consecutive patients undergoing free flap reconstructions of head and neck defects between 2007 and 2017. Selected variables: demographics, defect location, donor site, free flap failure cause, social and radiation therapy history. RESULTS Overall free flap failure rate was 4.6% (n = 133). Distribution of donor tissue by flap failure: radial forearm (32%, n = 43), osteocutaneous radial forearm (6%, n = 8), anterior lateral thigh (23%, n = 31), fibula (23%, n = 30), rectus abdominis (4%, n = 5), latissimus (11%, n = 14), scapula (1.5%, n = 2). Forty percent of flap failures occurred in the initial 72 hours following reconstruction (n = 53). The mean postoperative day for flap failure attributed to venous congestion was 4.7 days (95% confidence interval [CI], 2.6-6.7) versus 6.8 days (CI 5.3-8.3) for arterial insufficiency and 16.6 days (CI 11.7-21.5) for infection (P < .001). The majority of flap failures were attributed to compromise of the arterial or venous system (84%, n = 112). Factors found to affect the timing of free flap failure included surgical indication (P = .032), defect location (P = .006), cause of the flap failure (P < .001), and use of an osteocutaneous flap (P = .002). CONCLUSION This study is the largest to date on late free flap failures with findings suggesting a paradigm shift in the timing of flap failures. Surgical indication, defect site, cause of flap failure, and use of osteocutaneous free flap were found to impact timing of free flap failures. LEVEL OF EVIDENCE 4 Laryngoscope, 130:347-353, 2020.
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Affiliation(s)
- Larissa Sweeny
- Department of Otolaryngology-Head and Neck Surgery, Louisiana State University Health Science Center-New Orleans, New Orleans, Louisiana
| | - Michael Topf
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Mark K Wax
- Department of Otolaryngology-Head and Neck Surgery, Oregon Health and Science University, Portland, Oregon
| | - Eben L Rosenthal
- Department of Otolaryngology-Head and Neck Surgery, Stanford University, Stanford, California
| | - Benjamin J Greene
- Department of Otolaryngology-Head and Neck Surgery, University of Alabama at Birmingham, Birmingham, Alabama, U.S.A
| | - Ryan Heffelfinger
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Howard Krein
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Adam Luginbuhl
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Daniel Petrisor
- Department of Otolaryngology-Head and Neck Surgery, Oregon Health and Science University, Portland, Oregon
| | - Scott H Troob
- Department of Otolaryngology-Head and Neck Surgery, Oregon Health and Science University, Portland, Oregon
| | - Brian Hughley
- Department of Otolaryngology-Head and Neck Surgery, University of Alabama at Birmingham, Birmingham, Alabama, U.S.A
| | - Steve Hong
- Department of Otolaryngology-Head and Neck Surgery, Stanford University, Stanford, California
| | - Tingting Zhan
- Department of Pharmacology and Experimental Therapeutics, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Joseph Curry
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania
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Sanan A, Hjelm N, Tassone P, Krein H, Heffelfinger RN. Thermistor-controlled subdermal skin tightening for the aging face: Clinical outcomes and efficacy. Laryngoscope Investig Otolaryngol 2018; 4:18-23. [PMID: 30828614 PMCID: PMC6383317 DOI: 10.1002/lio2.228] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2018] [Revised: 10/10/2018] [Accepted: 10/15/2018] [Indexed: 12/04/2022] Open
Abstract
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
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Affiliation(s)
- Akshay Sanan
- Department of Otolaryngology-Head and Neck Surgery Thomas Jefferson University Hospital Philadelphia Pennsylvania U.S.A
| | - Nikolaus Hjelm
- Department of Otolaryngology-Head and Neck Surgery Thomas Jefferson University Hospital Philadelphia Pennsylvania U.S.A
| | - Patrick Tassone
- Department of Otolaryngology-Head and Neck Surgery Thomas Jefferson University Hospital Philadelphia Pennsylvania U.S.A
| | - Howard Krein
- Department of Otolaryngology-Head and Neck Surgery Thomas Jefferson University Hospital Philadelphia Pennsylvania U.S.A
| | - Ryan N Heffelfinger
- Department of Otolaryngology-Head and Neck Surgery Thomas Jefferson University Hospital Philadelphia Pennsylvania U.S.A
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Tassone P, Gill KS, Hsu D, Nyquist G, Krein H, Bilyk JR, Murchison AP, Evans JJ, Heffelfinger RN, Curry JM. Naso- or Orbitocutaneous Fistulas after Free Flap Reconstruction of Orbital Exenteration Defects: Retrospective Study, Systematic Review, and Meta-Analysis. J Neurol Surg B Skull Base 2017; 78:337-345. [PMID: 28725521 DOI: 10.1055/s-0037-1600135] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2016] [Accepted: 02/10/2017] [Indexed: 10/19/2022] Open
Abstract
Objective Naso- or orbitocutaneous fistula (NOF) is a challenging complication of orbital exenteration, and it often requires surgical repair. We sought to identify the incidence and risk factors for NOF after orbital exenteration. Study Design Retrospective chart review, systematic review, meta-analysis. Setting Tertiary care center. Participants Patients undergoing free flap reconstruction following orbital exenteration. Records were reviewed for clinicopathologic data, operative details, and outcomes. Main Outcome Measures Univariate analysis was used to assess risk factors for incidence of postoperative NOF. PubMed and Cochrane databases were searched for published reports on NOF after orbital exenteration. Rates of fistula and odds ratios for predictive factors were compared in a meta-analysis. Results Total 7 of 77 patients (9.1%) developed NOF; fistula formation was associated with ethmoid sinus involvement ( p < 0.05) and minor wound break down ( p < 0.05). On meta-analysis, pooled rates of fistula formation were 5.8% for free flap patients and 12.5% for patients receiving no reconstruction. Conclusion Immediate postoperative wound complications and medial orbital wall resection increased the risk for NOF. On review and meta-analysis, reconstruction of orbital exenteration defects decreased the risk for fistula formation, but published series did not demonstrate a significant decrease in risk with free flaps compared with other methods of reconstruction.
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Affiliation(s)
- Patrick Tassone
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University Philadelphia, Pennsylvania, United States
| | - Kurren S Gill
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University Philadelphia, Pennsylvania, United States
| | - David Hsu
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University Philadelphia, Pennsylvania, United States
| | - Gurston Nyquist
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University Philadelphia, Pennsylvania, United States
| | - Howard Krein
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University Philadelphia, Pennsylvania, United States
| | - Jurij R Bilyk
- Skullbase Division, Neuro-ophthalmology Service, Wills Eye Hospital, Philadelphia, Pennsylvania, United States
| | - Anna P Murchison
- Skullbase Division, Neuro-ophthalmology Service, Wills Eye Hospital, Philadelphia, Pennsylvania, United States
| | - James J Evans
- Department of Neurological Surgery, Division of Neuro-Oncologic Neurosurgery, Thomas Jefferson University Philadelphia, Pennsylvania, United States
| | - Ryan N Heffelfinger
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University Philadelphia, Pennsylvania, United States
| | - Joseph M Curry
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University Philadelphia, Pennsylvania, United States
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28
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Mitchell CA, Goldman RA, Curry JM, Cognetti DM, Krein H, Heffelfinger R, Luginbuhl A. Morbidity and Survival in Elderly Patients Undergoing Free Flap Reconstruction: A Retrospective Cohort Study. Otolaryngol Head Neck Surg 2017; 157:42-47. [DOI: 10.1177/0194599817696301] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objective To review a single institution’s outcomes of free flap reconstruction of the head and neck in patients aged ≥80 years as compared with those <80 years. Study Design Retrospective cohort study. Setting Tertiary academic hospital. Subjects and Methods Patients aged ≥ 80 years who underwent free flap reconstruction of the head and neck between 2007 and 2013 were identified and matched by type of reconstruction with a cohort of younger patients. Outcome measures included flap success, length of stay, discharge disposition, complications, and 2-year mortality. Associations between complications and comorbidities were also evaluated. Results Sixty-six patients aged ≥80 years were identified, and a paired sample <80 years old was selected. There were 3 flap failures per group and 1 perioperative mortality in the elderly group. There was no significant difference in length of stay or major complications between groups. Significantly more elderly patients were discharged to a nursing facility. There was no significant difference in mortality rates at 2 years postoperatively. No associations were seen between level of comorbidity and complications among the elderly group. Conclusion Free flap reconstruction of the head and neck remains a viable option in patients of advanced age. Similar outcomes in terms of flap success, complications, and length of hospitalization can be achieved as compared with younger patients undergoing similar reconstructions. The role of comorbid disease as a predictor of complications remains unclear. There is no significant difference in 2-year mortality for elderly free flap patients versus younger controls.
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Affiliation(s)
- Candace A. Mitchell
- Department of Otolaryngology–Head and Neck Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Richard A. Goldman
- Department of Otolaryngology–Head and Neck Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Joseph M. Curry
- Department of Otolaryngology–Head and Neck Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - David M. Cognetti
- Department of Otolaryngology–Head and Neck Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Howard Krein
- Department of Otolaryngology–Head and Neck Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Ryan Heffelfinger
- Department of Otolaryngology–Head and Neck Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Adam Luginbuhl
- Department of Otolaryngology–Head and Neck Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
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Gill KS, Hsu D, Tassone P, Pluta J, Nyquist G, Krein H, Bilyk J, Murchison AP, Iloreta A, Evans JJ, Heffelfinger RN, Curry JM. Postoperative cerebrospinal fluid leak after microvascular reconstruction of craniofacial defects with orbital exenteration. Laryngoscope 2016; 127:835-841. [DOI: 10.1002/lary.26137] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2015] [Revised: 03/20/2016] [Accepted: 05/17/2016] [Indexed: 11/11/2022]
Affiliation(s)
- Kurren S. Gill
- Department of Otolaryngology-Head and Neck Surgery; Thomas Jefferson University; Philadelphia Pennsylvania U.S.A
| | - David Hsu
- Department of Otolaryngology-Head and Neck Surgery; Thomas Jefferson University; Philadelphia Pennsylvania U.S.A
| | - Patrick Tassone
- Department of Otolaryngology-Head and Neck Surgery; Thomas Jefferson University; Philadelphia Pennsylvania U.S.A
| | - John Pluta
- Department of Radiology; University of Pennsylvania; Philadelphia Pennsylvania U.S.A
| | - Gurston Nyquist
- Department of Otolaryngology-Head and Neck Surgery; Thomas Jefferson University; Philadelphia Pennsylvania U.S.A
| | - Howard Krein
- Department of Otolaryngology-Head and Neck Surgery; Thomas Jefferson University; Philadelphia Pennsylvania U.S.A
| | - Jurij Bilyk
- Department of Ophthalmology, Oculoplastics and Orbital Surgery Service; Thomas Jefferson University Hospital and Wills Eye Institute; Philadelphia Pennsylvania U.S.A
| | - Ann P. Murchison
- Department of Ophthalmology, Oculoplastics and Orbital Surgery Service; Thomas Jefferson University Hospital and Wills Eye Institute; Philadelphia Pennsylvania U.S.A
| | - Alfred Iloreta
- Department of Otolaryngology-Head and Neck Surgery; Thomas Jefferson University; Philadelphia Pennsylvania U.S.A
| | - James J. Evans
- Department of Neurological Surgery, Division of Neuro-Oncologic Neurosurgery; Thomas Jefferson University; Philadelphia Pennsylvania U.S.A
| | - Ryan N. Heffelfinger
- Department of Otolaryngology-Head and Neck Surgery; Thomas Jefferson University; Philadelphia Pennsylvania U.S.A
| | - Joseph M. Curry
- Department of Otolaryngology-Head and Neck Surgery; Thomas Jefferson University; Philadelphia Pennsylvania U.S.A
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30
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Gill K, Hsu D, Tassone P, Krein H, Bilyk J, Murchison A, Lally S, Heffelfinger R, Rosen M, Evans J, Nyquist G, Curry J, Pluta J. Cerebrospinal Fluid Leak after Microvascular Reconstruction of Large Craniofacial Defects with Orbital Exenteration. Skull Base Surg 2016. [DOI: 10.1055/s-0036-1579866] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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31
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Balceniuk MD, Wingate NA, Krein H, Curry J, Cognetti D, Heffelfiner R, Luginbuhl A. Effects of a Fibrin Sealant on Skin Graft Tissue Adhesion in a Rodent Model. Otolaryngol Head Neck Surg 2016; 155:76-80. [PMID: 26932970 DOI: 10.1177/0194599816634616] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2015] [Accepted: 02/03/2016] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To establish a rodent model for skin grafting with fibrin glue and examine the effects of fibrin glue on the adhesive strength of skin grafts without bolsters. STUDY DESIGN Animal cohort. SETTING Academic hospital laboratory. SUBJECTS AND METHODS Three skin grafts were created using a pneumatic microtome on the dorsum of 12 rats. Rats were evenly divided into experimental (n = 6) and control (n = 6) groups. The experimental group received a thin layer of fibrin glue between the graft and wound bed, and the control group was secured with standard bolsters. Adherence strength of the skin graft was tested by measurement of force required to sheer the graft from the recipient wound. Adhesion strength measurements were taken on postoperative days (PODs) 1, 2, and 3. RESULTS The experimental group required an average force of 719 g on POD1, 895 g on POD2, and 676 g on POD3, while the average force in the control group was 161 g on POD1, 257 g on POD2, and 267 g on POD3. On each of the 3 PODs, there was a significant difference in adherence strength between the experimental and control groups (P = .036, P = .029, P = .024). CONCLUSION There is a significant difference in the adhesion strength of skin grafts to the wound bed in the early postoperative period of the 2 groups. In areas of high mobility, using the fibrin sealant can keep the graft immobile during the critical phases of early healing.
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Affiliation(s)
- Mark D Balceniuk
- Department of Otolaryngology-Head & Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Nicholas A Wingate
- Department of Otolaryngology-Head & Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Howard Krein
- Department of Otolaryngology-Head & Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Joseph Curry
- Department of Otolaryngology-Head & Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - David Cognetti
- Department of Otolaryngology-Head & Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Ryan Heffelfiner
- Department of Otolaryngology-Head & Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Adam Luginbuhl
- Department of Otolaryngology-Head & Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
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Bryant LM, Cognetti D, Baker A, Roy S, Johnston DR, Curry J, Krein H. Esthetic and functional reconstruction after parotidectomy in pediatric patients - A case series. Int J Pediatr Otorhinolaryngol 2015; 79:2442-5. [PMID: 26474834 DOI: 10.1016/j.ijporl.2015.09.027] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2014] [Revised: 09/19/2015] [Accepted: 09/21/2015] [Indexed: 01/12/2023]
Abstract
Parotidectomy is a mainstay of treatment for benign and malignant parotid lesions in children and adults. Depending on surgical methods used and tumor size, parotidectomy may result in significant facial disfigurement as well as functional challenges. We describe a series of four pediatric patients, ages 13-16 who presented to our clinic with a parotid mass. All patients underwent parotidectomy with immediate reconstruction by local tissue rearrangement or free fat graft. Esthetic and functional reconstruction after parotidectomy is not well described in pediatric otolaryngology literature. A review of current literature and description of reconstructive methods is included.
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Affiliation(s)
- Lucas M Bryant
- Department of Otolaryngology, Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE, United States; Department of Otolaryngology, Thomas Jefferson Hospital, Philadelphia, PA, United States.
| | - David Cognetti
- Department of Otolaryngology, Thomas Jefferson Hospital, Philadelphia, PA, United States
| | - Adam Baker
- Department of Otolaryngology, Thomas Jefferson Hospital, Philadelphia, PA, United States
| | - Sudeep Roy
- Department of Otolaryngology, Thomas Jefferson Hospital, Philadelphia, PA, United States
| | - Douglas R Johnston
- Department of Otolaryngology, Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE, United States
| | - Joseph Curry
- Department of Otolaryngology, Thomas Jefferson Hospital, Philadelphia, PA, United States
| | - Howard Krein
- Department of Otolaryngology, Thomas Jefferson Hospital, Philadelphia, PA, United States
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Affiliation(s)
- Eli A. Gordin
- Department of Otolaryngology–Head and Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Adam L. Luginbuhl
- Department of Otolaryngology–Head and Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Timothy Ortlip
- Jefferson Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Ryan N. Heffelfinger
- Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology–Head and Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Howard Krein
- Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology–Head and Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
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Iloreta A, Rosen M, Nyquist G, Parkes W, Heffelfinger R, Krein H, Curry J, Cognetti D, Farrell C, DeSouza J, Evans J. Microvascular Free Flap Reconstruction of Dural Defects. Skull Base Surg 2014. [DOI: 10.1055/s-0034-1370481] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Parkes WJ, Greywoode J, O'Hara BJ, Heffelfinger RN, Krein H. A preliminary report of percutaneous craniofacial osteoplasty in a rat calvarium. Laryngoscope 2013; 124:1550-3. [DOI: 10.1002/lary.24459] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2013] [Accepted: 10/07/2013] [Indexed: 11/08/2022]
Affiliation(s)
- William J. Parkes
- Department of Otolaryngology-Head and Neck Surgery; Thomas Jefferson University Hospital; Philadelphia Pennsylvania U.S.A
| | - Jewel Greywoode
- Department of Otolaryngology-Head and Neck Surgery; Thomas Jefferson University Hospital; Philadelphia Pennsylvania U.S.A
| | - Brian J. O'Hara
- Department of Pathology; Anatomy and Cell Biology, Thomas Jefferson University Hospital; Philadelphia Pennsylvania U.S.A
| | - Ryan N. Heffelfinger
- Department of Otolaryngology-Head and Neck Surgery; Thomas Jefferson University Hospital; Philadelphia Pennsylvania U.S.A
| | - Howard Krein
- Department of Otolaryngology-Head and Neck Surgery; Thomas Jefferson University Hospital; Philadelphia Pennsylvania U.S.A
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Abstract
PURPOSE To examine the etiology, surgical extent and techniques, complications, and outcomes of microvascular free flaps (MFF) in the reconstruction of orbitocraniofacial defects. DESIGN A retrospective, institutional review board approved study was performed of all patients undergoing MFF to repair orbitocraniofacial defects over 51 months. PARTICIPANTS Fifty-eight patients undergoing MFF to repair orbitocraniofacial defects were included. MATERIAL AND METHODS Variables analyzed included demographics, etiology, resection area(s), donor site, flap size, duration of surgery, complications, length of hospital stay, flap survival, and mortality. RESULTS Fifty-eight patients underwent 61 MFFs from June 2007 to September 2011. The majority of patients were white (79.3%) and male (72.4%). The mean age was 64.1 years. The most common etiology was intraorbital and skull base extension of cutaneous squamous cell carcinoma (29.3%) followed by sinonasal squamous cell carcinoma (13.8%). Dura and/or brain were exposed in 44.8% of cases. MFFs were harvested from the anteriolateral thigh in 71.4% of cases with a 180.9 cm(2) mean flap area. The mean length of hospital stay was 15.3 days and mean length of surgical time was 11 h and 17 min. CONCLUSIONS Complex orbitocraniofacial defects require a multi-disciplinary team skilled in surgical extirpation and advanced reconstructive techniques. MFF should be considered in the management of large defects, especially when there is dura or brain exposure. Intensive postoperative monitoring is indicated for both systemic and flap-related complications. MMFs provide excellent coverage of large areas of exposed critical skull base structures, including dura and brain, and may allow for earlier adjuvant treatment.
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Affiliation(s)
- Ryan Heffelfinger
- Department of Otolaryngology-Head & Neck Surgery, Jefferson Medical College, Philadelphia, Pennsylvania, USA
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William John CM, Schaheen B, Krein H, Curry J, Heffelfinger R. Free Tissue Transfer for Cranio-orbitofacial Defects. Otolaryngol Head Neck Surg 2011. [DOI: 10.1177/0194599811416318a22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objective: 1) Examine the outcomes and complications from a single institution experience with free tissue transfer for craniofacial defects involving the orbit. 2) Discuss an algorithm for free flap reconstruction of the orbit and peri-orbital structures. Method: A review of 42 patients who underwent free flap reconstruction for orbital or peri-orbital defects between September 2006 and January 2011 was performed at a tertiary care facility. Data reviewed included demographics, defect characteristics, free flap used, additional reconstructive techniques employed, length of stay, complications, and follow-up. Results: Forty-four cases were identified; thirty-five required orbital exenteration. Periorbital defects included those resulting from significant soft tissue or bony removal from the midface, scalp, or skullbase. We present an algorithm for management of such defects. Free flaps used included anterolateral thigh (31), radial forearm (10), latissimus (2), and rectus abdominus (1). Additional reconstructive techniques were performed concurrently in 23 cases, and 4 patients required revision procedures. Fifteen (36%) patients experienced a complication with flap loss occurring in 2 (4.8%). Mean hospital stay and duration of follow-up were 9.9 days and 13 months, respectively. Conclusion: Free tissue transfer allows for the safe and effective reconstruction of complex defects of the orbit and periorbital structures. Reconstructive choice is dependent upon the extent of soft tissue loss, midfacial bone loss, and skullbase involvement. The anterolateral thigh provides a versatile option to reconstruct the many cranio-orbitofacial defects encountered.
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Luginbuhl A, Pribitkin E, Krein H, Heffelfinger R. Assessment of Microvascular Anastomosis Training in Otolaryngology Residencies: Survey of United States Program Directors. Laryngoscope 2011; 120 Suppl 4:S233. [DOI: 10.1002/lary.21700] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Ezzat WH, Dahl JP, Luginbuhl A, Gordin E, Krein H, Heffelfinger RN. Recombinant human tissue factor pathway inhibitor prevents thrombosis in a venous tuck model. Laryngoscope 2011; 120:2172-6. [PMID: 20939073 DOI: 10.1002/lary.20898] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVES/HYPOTHESIS Microvascular free tissue transfer has become a mainstay of reconstruction after resections for head and neck cancer. With current techniques, free flap failure is typically low; however, failure rates have been reported as high as 10%. Most thrombotic failures occur within the first few days postoperatively and tend to involve the venous anastomoses. We evaluated the efficacy of recombinant human tissue factor pathway inhibitor (rhTFPI), an anticoagulant that directly inhibits the extrinsic coagulation pathway, using a rat model of microvenous thrombosis. STUDY DESIGN Prospective, randomized. METHODS Sprague-Dawley rats were randomly assigned to either rhTFPI or saline groups. We performed a venous tuck procedure in the common femoral vein. Prior to closure, the anastamosis was irrigated with either rhTPFI (20 μg/mL) or normal saline. Survival of the anastomosis was measured via clinical assessment at regular postoperative intervals. After a postoperative period of 48 hours, sites were intraoperatively assessed and the vessels harvested. RESULTS There was a significant increase in vessel patency in rats treated topically with rhTFPI compared to controls receiving saline. There was no increase in bleeding complications in the treated group versus controls. CONCLUSIONS Our data suggests that the use of topical rhTPFI increases venous anastomotic patency rates in vivo. The topical means of administration is attractive, as there seems to be a low percentage of systemic complications as is often seen with anticoagulation therapies. Future studies will investigate the potential efficacy in patients undergoing microvascular free tissue transfer.
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Affiliation(s)
- Waleed H Ezzat
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
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Murray RC, Gordin EA, Saigal K, Leventhal D, Krein H, Heffelfinger RN. Reconstruction of the radial forearm free flap donor site using integra artificial dermis. Microsurgery 2010; 31:104-8. [PMID: 20939003 DOI: 10.1002/micr.20833] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2010] [Revised: 08/01/2010] [Accepted: 08/09/2010] [Indexed: 11/09/2022]
Abstract
Autologous skin grafting to the donor site in patients who undergo radial forearm free flap reconstruction (RFFF) is associated with cosmetic and functional morbidity. Integra artificial dermis (Integra Lifesciences, Plainsboro, NJ) is a bovine collagen based dermal substitute that can be used as an alternative to primary autologous skin transplantation of the donor site. We describe a staged reconstruction using Integra followed by ultrathin skin grafting that results in highly aesthetic and functional outcomes for these defects. A retrospective review of 29 patients undergoing extirpative head and neck oncologic resection were examined. Integra graft placement was performed at the time of RFFF harvest followed by autologous split thickness skin grafting at 1 to 5 weeks postoperatively. Healing fully occurred within 4-6 weeks with negligible donor site complications, excellent cosmesis, and minimal scar contracture. Composite reconstruction with Integra artificial dermis offers advantages over traditional methods of coverage for select cases of radial forearm free flap donor site closures.
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Affiliation(s)
- Ryan C Murray
- Department of Otolaryngology - Head & Neck Surgery, Thomas Jefferson University, Philadelphia, PA 19107, USA.
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Krauthamer GM, Grunwerg BS, Krein H. Putative cholinergic neurons of the pedunculopontine tegmental nucleus projecting to the superior colliculus consist of sensory responsive and unresponsive populations which are functionally distinct from other mesopontine neurons. Neuroscience 1995; 69:507-17. [PMID: 8552245 DOI: 10.1016/0306-4522(95)00265-k] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
We examined the sensory properties of putative cholinergic neurons of the pedunculopontine tegmental nucleus projecting to the superior colliculus. Projection neurons were identified by antidromic activation from the contralateral posterior superior colliculus; stimulation of the anterior half was essentially ineffective. Identified neurons fell into two groups, one with a somatosensory input (39%) and one without a sensory input. Somatosensory responsive projection neurons were low threshold and rapidly adapting. Receptive fields were contralateral (94%) and predominantly orofacial (57%). Sensory responsive and unresponsive projection neurons were intermingled within the pedunculopontine tegmental nucleus as identified histologically by reduced nicotinamide adenine dinucleotide phosphate diaphorase or acetylcholinesterase. The properties of neurons outside the nucleus differed significantly. They could not be activated antidromically from the superior colliculus; many had ipsi- or bilateral receptive fields (75%) and wide dynamic range or nociceptive response patterns (52%). The presence of two functionally distinct groups of projection neurons implies a dual or more complex modulation of tectal neurons by the pedunculopontine tegmental nucleus. The pedunculopontine tegmental nucleus has been implicated in a multiplicity of behaviors and, in particular, in rapid eye movement sleep and alerting or arousal functions. By virtue of its many connections with the basal ganglia, limbic system and reticular structures, the projection to the superior colliculus of two distinct groups may provide an important differentiating element of the tectal organization of orienting and spatial cognitive behavior.
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Affiliation(s)
- G M Krauthamer
- Department of Neuroscience and Cell Biology, University of Medicine and Dentistry of New Jersey, Robert Wood Johnson Medical School, Piscataway 08854, USA
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Abstract
The cholinergic pedunculopontine tegmental area of the anesthetized rat was explored for single units responsive to somatosensory stimulation. Units projecting to the intralaminar thalamus were identified by antidromic stimulation. Approximately one half of the somatosensory units consisted of low threshold units responsive to light tapping and stroking; the others were high threshold mechanoreceptive units. Most receptive fields were trigeminal and contralateral. These results suggest that somatosensory information is an important element in a subcortical system linking this area with the basal ganglia, superior colliculus and thalamus.
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Affiliation(s)
- B S Grunwerg
- Department of Neuroscience, University of Medicine and Dentistry of New Jersey, Robert Wood Johnson Medical School, Piscataway 08854
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