Use of laser-assisted indocyanine green angiography for early division of the forehead flap pedicle

IMPORTANCE

The paramedian forehead flap is used to reconstruct medium to large nasal defects. The staged nature, with its vascular pedicle bridging the medial eyebrow to the nose, results in significant facial deformity. Earlier division lessens this morbidity.

OBJECTIVES

To quantify flap neovascularization 2 weeks after the initial flap transfer and to describe an algorithm for earlier division of the flap pedicle in select patient populations.

DESIGN, SETTING, AND PARTICIPANTS

We performed a prospective and retrospective study at the Ambulatory Surgery Center, Stanford University, Palo Alto, California, from October 14, 2014, through January 21, 2015. Patients with defects appropriate for paramedian forehead flap reconstruction had partial-thickness defects, vascularized tissue in more than 50% of the recipient bed, and no nicotine use. The patients underwent reconstructive surgery by a single surgeon from August 24, 2012, through September 12, 2014. Laser-assisted indocyanine green angiography was used for imaging before and immediately after the initial flap transfer, before pedicle division with the pedicle atraumatically clamped, and immediately after pedicle division and flap inset. Analysis of data and calculation of relative perfusion were performed using a postprocessing analysis toolkit.

MAIN OUTCOMES AND MEASURES

Perfusion was calculated using the analysis toolkit as the percentage of the area of interest relative to a predetermined reference point in normal peripheral tissue.

RESULTS

We enrolled a total of 10 patients. The mean (SD) relative perfusion of the forehead donor site before flap transfer was 61.2% (3.4%); at initial flap transfer, 81.4% (50.2% [range, 31%-214%]) (P = .70 compared with measurement before flap transfer). The mean (SD) relative perfusion of the forehead donor site was 57.5% (21.2% [range, 32%-89%]) at the time of atraumatic pedicle clamping and 58.6% (32.4% [range, 16%-127%]) after pedicle division and flap inset (P = .85 compared with measurement before flap transfer). No flap failures or other complications were observed.

CONCLUSIONS AND RELEVANCE

In select patients (those meeting the inclusion criteria), division of the pedicle at 2 weeks after the initial flap transfer is safe. Earlier pedicle division and flap transfer reduces the duration of facial deformity for the patient.

LEVEL OF EVIDENCE

3.

Complications of rhinoplasty

This article provides a concise description of common complications of rhinoplasty, recommendations for avoidance, and corrective techniques. The surgeon must have a comprehensive understanding of nasal anatomy and effects of surgical maneuvers to help avoid complications. Meticulous history, physical examination, and standardized photographic documentation are central to preoperative evaluation and surgical planning for rhinoplasty. Photographic documentation is useful to illustrate preexisting preoperative asymmetries. Appropriate preoperative counseling regarding appropriate postoperative expectations as well as all risks, benefits, and alternatives is critical. Any complications should be openly discussed with the patient.

A controlled laboratory and clinical evaluation of a three-dimensional endoscope for endonasal sinus and skull base surgery

BACKGROUND

One criticism of current video systems for endoscopic surgery is that two-dimensional (2D) images lack depth perception and may impair surgical dissection. To objectively measure the efficacy of 3D endoscopy, we designed a training model with specific tasks to show potential differences between 2D and 3D endoscopy. Its clinical value was then evaluated during endoscopic sinus and skull base surgical cases.

METHODS

Fifteen subjects were grouped according to endoscopic experience: novices and nonnovices. A training model was constructed to include five tasks: incision manipulation; ring transfer; nerve hook; distance estimation, visual only; and distance estimation, visual and tactile. Each participant was assessed with both a standard 2D endoscope and a 3D endoscope. The clinical value of a 3D endoscope (Visionsense, Ltd., Petach Tikva, Israel) was then examined in four endoscopic sinus cases and four skull base cases.

RESULTS

Of the subjects, six (40%) were novices. Overall, the errors committed during any one task were not significantly different between systems. Novices trended toward more success during the nerve hook task using the 3D system. With size cueing versus visualization alone, distance estimation was significantly more accurate. Novices tended to prefer the 3D system and experienced surgeons disliked the initial learning curve. Advantages were particularly noticed during skull base surgery; subjectively improved depth perception was beneficial during vascular dissection.

CONCLUSION

Three-dimensional endoscopy may improve depth perception and performance for novices. The 3D endoscope is a safe and feasible tool for endoscopic sinus and skull base surgery; it is promising for improving microneurosurgical dissection precision transnasally.

Cytokine amplification by respiratory syncytial virus infection in human nasal epithelial cells

OBJECTIVES

Respiratory syncytial virus (RSV) is an important cause of upper respiratory infections and is known to play a causal role in the pathogenesis of rhinitis, sinusitis, acute otitis media, and pneumonia. RSV appears to prime the respiratory tract to secondary inciting events, such as bacterial or antigen challenges. To study the proinflammatory priming effects of RSV infection, cytokine expression was measured in well-differentiated human nasal epithelial cells (WD-NE) after RSV infection alone or after subsequent tumor necrosis factor (TNF)-alpha stimulation.

STUDY DESIGN

In vitro investigation.

METHODS

Human nasal epithelial cells were obtained from surgical specimens and allowed to differentiate in air-liquid interface cultures until ciliation and mucus production were evident. Two experimental paradigms were used. First, accumulation of cytokines in the media was measured by real-time, quantitative reverse-transcriptase polymerase chain reaction (RT-PCR) and enzyme-linked immunosorbent assay after RSV infection alone. In the second set of experiments, cytokines were also measured after TNF-alpha stimulation in both RSV-infected and uninfected cultures.

RESULTS

RSV infection of WD-NE resulted in significant accumulations of interleukin (IL)-6, IL-8, and RANTES when compared with findings in control samples. Real-time, quantitative RT-PCR demonstrated significant increases in IL-8 gene expression following RSV infection when compared to controls. Secondary TNF-alpha stimulation following well-established (i.e., 72 h) RSV infection induced marked increases in IL-6, IL-8, and RANTES when compared with both RSV infection alone and TNF-alpha stimulation alone.

CONCLUSIONS

These findings suggest that RSV infection primes nasal epithelial cells to secondary proinflammatory challenge, resulting in a hyperimmune response. RSV-induced priming of a hyperimmune response may be important in the pathogenesis of sinusitis, acute otitis media, and pneumonia.