Optimizing Wound Care after Surgery of the Head and Neck: A Review of Dressing Materials

Wound healing is a complex biological process subject to complications that might jeopardize the patient's postoperative care. Appropriately approaching surgical wounds after head and neck surgery positively influences the quality and speed of wound healing and increases patient comfort. A large variety of dressing materials currently exist that allow the care of different types of wounds. Nevertheless, there is limited literature on the most suitable types of dressings after head and neck surgery. The objective of the present article is to review the most commonly used wound dressings, their benefits, indications, and disadvantages, and to provide a systematic approach for wound care within the head and neck. The Woundcare Consultant Society distinguishes wounds into three groups: black, yellow, and red. Each type of wound represents distinctive underlying pathophysiological processes with unique needs. Utilizing this classification along with the TIME model allows a proper characterization of wounds and the identification of potential healing barriers. This evidence-based and systematic approach can facilitate and guide the head and neck surgeon in selecting a wound dressing upon acknowledging their properties, which are herein reviewed and exemplified with representative cases.

Clinical Benefits of the Utrecht Questionnaire for Aesthetic Outcome Assessment in Rhinoplasty: An Update

Presently, there is no consensus on which patient-reported outcome measurement (PROM) instrument is best suited to assess the aesthetic outcomes of rhinoplasty. In this regard, at least seven different validated PROMs are available from the literature, each one with advantages and disadvantages.In this article, we review the development, validation, international translation, and clinical application of the Utrecht Questionnaire (UQ). The UQ was developed in 2009 with the idea to be a short and practical tool for the rhinoplasty surgeon to assess the aesthetic outcomes of rhinoplasty. The questionnaire was then validated in 2013. Body image in relation to nasal appearance is quantified with five simple questions on a 5-point Likert scale and a Visual Analogue Scale score. We discuss how the UQ can easily be incorporated and become an important asset in a rhinoplasty practice. Practical benefits, such as its role in the shared decision-making process, patient expectations management, identification of unsuitable patients, avoiding revision surgery, and the evaluation of the surgeon's personal performance curve, are exemplified. Currently, the UQ has been translated and validated in four languages, providing scientific opportunities to generate and compare international data for advances in rhinoplasty. We describe some of the significant scientific contributions of leaders in the field of rhinoplasty that used the UQ.

Functional and Aesthetic Outcomes of Septal Reconstructions: Results of a Prospective Longitudinal Outcome Study

In order to correct severe septal deformities, complete septal reconstruction is often required to achieve the desired functional and aesthetic results. Several different techniques have been described. Systematic evaluation of the long-term results is crucial to assess and improve the quality of these surgical techniques. A custom-built dashboard (the rhinoplasty health care monitor [RHM]) was used for prospective and longitudinal outcome evaluation of the septal reconstruction. The RHM includes the Nasal Obstruction Symptom Evaluation (NOSE) scale for nasal obstruction and the Utrecht Questionnaire (UQ) for aesthetic outcome results. In total, 58 patients were included for septal reconstructive surgery. The mean preoperative NOSE scale scores decreased from 67.8 ± 19.1 to 12.2 ± 17.5, 1 year after surgery. Mean preoperative UQ scores went from 12.3 ± 6.4 to 6.2 ± 2.7. The beneficial functional and aesthetic effects of the techniques that we currently use to reconstruct the septum are efficient in terms of function and aesthetics.

A cohort analysis of surgically treated primary head and neck lentigo maligna (melanoma): Prognostic value of melanoma subtype and new insights in the clinical value of guideline adherence

BACKGROUND

Knowledge about lentigo maligna (melanoma) (LM/LMM) and its associated prognostic clinicopathological characteristics are limited compared to that of non-LM/LMM subtypes. The current study aimed to determine the clinical relevance of the LM/LMM subtype and its influence on recurrence and survival outcomes.

METHODS

All consecutive cases of primary cutaneous head and neck LM/LMM treated by wide local excision over a ten-year period were retrospectively reviewed and compared to non-LM/LMM. Clinical outcome and prognostic factors were assessed by cumulative incidence and competing risk analyses.

RESULTS

A total of 345 patients were identified. Specific clinicopathological characteristics such as lower median Breslow thickness (1.6 mm versus 2.1 mm; P = 0.013), association with diagnostic sampling errors (17.3% versus 5.2%; P = 0.01), and increased risk of local recurrences due to incomplete resection (18.7% versus 2.3%; P < 0.001), were significantly associated with LM/LMM. Guideline adherence was similar between the two study groups. The positive nodal status at baseline for LMM was low compared to non-LM/LMM (4.2% vs 17.9%; P = 0.037). The LMM subtype, facial localization, and reduced surgical margins (i.e., guideline non-adherence) were not shown to be independent prognostic factors for disease-free, melanoma-specific, or overall survival after correction for competing risks such as patient age and Breslow thickness.

CONCLUSIONS

The LMM subtype was not shown to be prognostically different from non-LM/LMM when corrected for other variables of influence such as patient age and Breslow thickness. Reduced resection margins did not seem to affect disease-free, and melanoma-specific survival and warrant LM/LMM-specific guidelines. Further research is needed to evaluate the value of SLNB in LMM patients.

The Rhinoplasty Health Care Monitor: Using Validated Questionnaires and a Web-Based Outcome Dashboard to Evaluate Personal Surgical Performance

Background: Self-assessment provides valuable feedback in the life-long process of mastering rhinoplasty. This study presents a method to measure and evaluate data-based performance of a single surgeon using a web-based dashboard. Methods: In this prospective analytic cohort study, all patients referred to the senior author for functional-aesthetic (revision) rhinoplasty between April 2014 and September 2020 are included. Patients completed the Nasal Obstruction Symptom Evaluation (NOSE) scale, Utrecht Questionnaire (UQ), and visual analog scales before and after rhinoplasty. Questionnaire scores were exported to a customized web-based dashboard: the rhinoplasty health care monitor. Supported by real-time graphic output, this monitor automatically analyzes functional and aesthetic outcomes. Results: Of 603 referred patients, 363 were eligible for rhinoplasty. Mean NOSE scale scores decreased from 66.6 ± 23.5 to 23.2 ± 24.0 (p < 0.001), and mean UQ scores decreased from 12.2 ± 6.3 to 7.1 ± 3.9 (p < 0.001) 1 year after surgery. The rhinoplasty health care monitor visualizes numerous outcome parameters that help the surgeon to analyze results, identify learning needs, and detect trends in performance development. Conclusions: This automated outcome dashboard transparently measures individual surgeon performance. Gauging performance provides means to enhance surgical development and, consequently, patient satisfaction.

The Value of Averageness in Aesthetic Rhinoplasty: Humans Like Average Noses

BACKGROUND

The aesthetic ideal of the nose eludes clear definition. Averageness may be an important determinant of ideal nasal shape: research has shown that averageness plays an important role in the human perception of facial attractiveness.

OBJECTIVES

The aim of this study was to test whether an averaged nasal shape is attractive, and whether deviation away from average is associated with decreased attractiveness.

METHODS

Photographic series of the face were obtained from 80 Caucasian female volunteers aged 25-40 years. A mathematically averaged composite image was created from the first 40 volunteers. Forty-one panel members were recruited to judge the attractiveness of the nose of each original image and the composite, based on a 5-point Likert scale ranging from 1 (very ugly) to 5 (very pretty). Deviation of nasal shape from average was calculated by principal components analysis of standardized nasal landmarks.

RESULTS

Twenty-one respondents were male (51%). The mean age of the respondents was 35.3 [15.6] years. The rating of the composite was significantly higher than the distribution of ratings for the 80 original nose images (4.2 vs 2.8, t = 31.24, P < 0.001). The rating of the original nose images correlated negatively with deviation from average shape (r = -0.40, n = 80, P < 0.001).

CONCLUSIONS

In Caucasian females, a mathematically averaged nose is an attractive nose. Furthermore, the more an individual nose shape resembles the average shape, the more attractive it is rated. Calculating deviation from average before and after rhinoplasty may aid in objectively measuring aesthetic rhinoplasty outcome.

Treatment of Frontal Secondary Headache Attributed to Supratrochlear and Supraorbital Nerve Entrapment With Oral Medication or Botulinum Toxin Type A vs Endoscopic Decompression Surgery

Importance

Endoscopic surgical decompression of the supratrochlear nerve (STN) and supraorbital nerve (SON) is a new treatment for patients with frontal chronic headache who are refractory to standard treatment options.

Objective

To evaluate and compare treatment outcomes of oral medication, botulinum toxin type A (BoNT/A) injections, and endoscopic decompression surgery in frontal secondary headache attributed to STN and supraorbital SON entrapment.

Design, Setting, and Participants

Prospective cohort study of 22 patients from a single institution (Diakonessen Hospital Utrecht) with frontal headache of moderate-to-severe intensity (visual analog scale [VAS] score, 7-10), frontally located, experienced more than 15 days per month, and described as pressure or tension that intensifies with pressure on the area of STN and SON. A screening algorithm was used that included examination, questionnaire, computed tomography of the sinus, injections of local anesthetic, and BoNT/A in the corrugator muscle.

Interventions

Different oral medication therapy for headache encountered in the study cohort, as well as BoNT/A injections (15 IU) into the corrugator muscle. Surgical procedures were performed by a single surgeon using an endoscopic surgical approach to release the supraorbital ridge periosteum and to bluntly dissect the glabellar muscle group.

Main Outcomes and Measures

Headache VAS intensity after oral medication and BoNT/A injections. Additionally, early postoperative follow-up consisted of a daily headache questionnaire that was evaluated after 1 year.

Results

In total, 22 patients (mean [SD] age, 42.0 [15.3] years; 7 men and 15 women) were included in this cohort study. Oral medication therapy reduced the headache intensity significantly (mean [standard error of the mean {SEM}] VAS score, 6.45 [0.20] [95% CI, 0.34-3.02; P < .001] compared with mean [SEM] pretreatment VAS score, 8.13 [0.22]). Botulinum toxin type A decreased the mean (SEM) headache intensity VAS scores significantly as well (pretreatment, 8.1 [0.22] vs posttreatment, 2.9 [0.42]; 95% CI, 3.89-6.56; P < .001). The mean (SEM) pretreatment headache intensity VAS score (8.10 [0.22]) decreased significantly after surgery at 3 months (1.30 [0.55]; 95% CI, 5.48-8.16; P < .001) and 12 months (1.09 [0.50]; 95% CI, 5.71-8.38; P < .001). There was a significant decrease of headache intensity VAS score in the surgical group over the BoNT/A group (mean [SEM] VAS score, 2.90 [0.42]) after 3 months (mean [SEM] VAS score, 1.30 [0.55]; 95% CI, 0.25-2.93; P < .001) and 12 months (mean [SEM] VAS score, 1.09 [0.50]; 95% CI, 0.48-3.16; P < .001) after surgery.

Conclusions and Relevance

Endoscopic decompression surgery had a long-lasting successful outcome in this type of frontal secondary headache. Even though BoNT/A had a positive effect, the effect of surgery was significantly higher.

Level of Evidence

3.

Oncodermatology of the Head and Neck

The European Academy of Facial Plastic Surgery celebrates its 40th anniversary. We aimed to describe innovations in the diagnostics and treatment in head and neck skin cancer over the past 40 years as well as future perspectives. Landmark events, developments, and highlights over the past decades for basal cell carcinoma, cutaneous squamous cell carcinoma, and melanoma are discussed.

Sensorineural Hearing Loss After Adoptive Cell Immunotherapy for Melanoma Using MART-1 Specific T Cells: A Case Report and Its Pathophysiology

OBJECTIVE

To illustrate a case of sensorineural hearing loss (SNHL) after immunotherapy based on T cell receptor (TCR) gene therapy using modified T cells recognizing melanoma antigen recognized by T cells 1 for disseminated melanoma.

PATIENT

We present a 59-year-old woman with profound subacute bilateral SNHL including unilateral deafness after immunotherapy based on TCR gene therapy using modified T cells recognizing melanoma antigen recognized by T cells 1 for disseminated melanoma. Ten days after treatment, the patient developed hearing loss of 57 dB hearing loss air conduction at pure-tone average 0.5-1-2-4 kHz in the right ear, and >100 dB hearing loss air conduction at pure-tone average 0.5-1-2-4 in the left ear. The right ear recovered partially, while the left ear remained deaf, despite oral prednisolone (1.0 mg/kg) and salvage treatment with three transtympanic injections of 0.5 ml dexamethasone (4.0 mg/ml).

CONCLUSION

Based on our presented case and a vast amount of literature there is circumstantial evidence that TCR gene therapy for melanoma targets the perivascular macrophage-like melanocytes in the stria vascularis, resulting in SNHL. We suggest that SNHL after TCR gene therapy may be caused by a disruption of the blood-labyrinth-barrier and the endolymphatic potential and/or a sterile inflammation of the stria vascularis. In severe cases like our subject, we posit that endolymphatic hydrops or hair cell loss may cause irreversible and asymmetrical deafness. Steroid prophylaxis via transtympanic application is debatable.

The Portuguese version of “The Utrecht questionnaire for outcome assessment in aesthetic rhinoplasty”: validation and clinical application

Introduction

The evaluation of surgical outcomes measured by patient satisfaction or quality of life is very important, especially in plastic surgery. There is increasing interest in self-reporting outcomes evaluation in plastic surgery.

Objective

The aim of this study was to perform the translation, cross-cultural adaptation and validation of “The Utrecht questionnaire for outcome assessment in aesthetic rhinoplasty” from English to Portuguese.

Methods

Retrospective study involving 50 patients undergoing to rhinoplasty comparing the preoperative period with the current postoperative situation (minimum 6 months and maximum 24 months postoperatively). Statistical analysis was performed to assess internal consistency, test–retest reliability, validity and responsiveness.

Results

No patients received a negative score on the visual analogue scale comparing preoperative and postoperative appearance. The postoperative improvement on the visual analogue scale revealed a Gaussian curve of normal distribution with a mean improvement of 4.44 points. The test–retest reliability showed a positive correlation between the postoperative response and the same questionnaire repeated ninety-six hours later. The internal consistency was high (Cronbach's alpha value: Preoperative = 0.88; Postoperative = 0.86). The authors observed a significant improvement in response for all individual questions in the postoperative phase as compared with preoperative situation (t-student test – p < 0.05).

Conclusion

The Portuguese version of “The Utrecht questionnaire for outcome assessment in aesthetic rhinoplasty” is a valid instrument to assess patients’ outcomes following rhinoplasty surgery.

Surgical Treatment of Chronic Parotitis

Introduction  chronic parotitis (CP) is a hindering, recurring inflammatory ailment that eventually leads to the destruction of the parotid gland. When conservative measures and sialendoscopy fail, parotidectomy can be indicated.

Objective  to evaluate the efficacy and safety of parotidectomy as a treatment for CP unresponsive to conservative therapy, and to compare superficial and near-total parotidectomy (SP and NTP).

Methods  retrospective consecutive case series of patients who underwent parotidectomy for CP between January 1999 and May 2012. The primary outcome variables were recurrence, patient contentment, transient and permanent facial nerve palsy and Frey syndrome. The categorical variables were analyzed using the two-sided Fisher exact test. Alongside, an elaborate review of the current literature was conducted.

Results  a total of 46 parotidectomies were performed on 37 patients with CP. Near-total parotidectomy was performed in 41 and SP in 5 cases. Eighty-four percent of patients was available for the telephone questionnaire (31 patients, 40 parotidectomies) with a mean follow-up period of 6,2 years. Treatment was successful in 40/46 parotidectomies (87%) and 95% of the patients were content with the result. The incidence of permanent and transient facial nerve palsy was 0 (0%) and 12 (26.1%), respectively. Frey syndrome manifested in 20 (43.5%) patients. Neither this study nor careful review of the current literature resulted in evident difference between SP and NTP regarding the primary outcome variables.

Conclusion  parotidectomy is a safe and effective treatment for CP in case conservative therapy fails. There is no evidence of a distinct difference between SP and NTP regarding efficiency, facial nerve palsy or Frey syndrome.

Salvage Surgery for Recurrence after Radiotherapy for Squamous Cell Carcinoma of the Head and Neck

OBJECTIVE

Most studies that report on salvage surgery after primary radiotherapy for head and neck squamous cell carcinoma (HNSCC) are small and heterogeneous. Subsequently, some relevant questions remain unanswered. We specifically focused on (1) difference in prognosis per tumor subsite, corrected for disease stage, and (2) differences in prognosis after salvage surgery for local, regional, and locoregional recurrences.

STUDY DESIGN

Retrospective analysis.

SETTING

Single-center study (2000-2016).

SUBJECTS AND METHODS

Patients treated with salvage surgery for HNSCC recurrence after (chemo)radiotherapy.

RESULTS

In total, 189 patients were included. Five-year overall survival (OS) was 33%, and median OS was 18 (95% confidence interval [CI], 11-26) months. Treatment-related mortality was 2%. Larynx carcinoma was associated with more favorable local (adjusted hazard ratio [HR] = 4.02; 95% CI, 1.46-11.10; P = .007) and locoregional control (adjusted HR = 5.34; 95% CI, 1.83-15.61; P = .002) than pharyngeal carcinoma. American Society of Anesthesiologists (ASA) score (≥3 vs 1-2: adjusted HR = 3.04; 95% CI, 1.17-7.91; P = .023), pT stage (3-4 vs 1-2: adjusted HR = 4.41; 95% CI, 1.65-11.82; P = .003), and salvage surgery for locoregional recurrences (locoregional vs local: adjusted HR = 3.81; 95% CI, 1.13-11.82; P = .021) were independent predictors for disease-free survival (DFS).

CONCLUSION

Salvage surgery for larynx carcinoma, regardless of disease stage and other prognostic factors, results in more favorable loco(regional) control but not favorable DFS than pharyngeal carcinoma. The observed difference in DFS between salvage surgery for local and regional recurrences was not significant after correction for confounders. However, survival following salvage surgery for locoregional disease is significantly worse. For this subgroup, we propose to consider T status and comorbidity for clinical decision making, as high pT stage and ASA score are independent predictors for worse DFS.

Salivary duct carcinoma: evaluation of treatment and outcome in a tertiary referral institute

PURPOSE

The aggressive behavior of salivary duct carcinoma (SDC) necessitates an aggressive treatment strategy, including surgery and radiotherapy (RT). We evaluated practice patterns and treatment outcomes in patients with SDC treated in our Institute.

METHODS

Patients with SDC of the parotid or submandibular gland treated with curative intention in our Institute from 1998 until 2016 were reviewed. Our diagnostic workup and treatment strategy were evaluated together with treatment outcomes.

RESULTS

Fifteen patients with SDC were included. Staging included MRI and ultrasound-guided fine needle aspiration cytology. Only in a minority (20%) of patients, the preoperative diagnosis of SDC was raised due to positive immunohistochemical staining for the androgen receptor (AR) on cytology. All patients were treated with (sub)total resection of the salivary gland and 53% underwent a therapeutic neck dissection. All patients except one received postoperative RT. Immunohistochemical staining was found positive for AR (100%) and human epidermal growth factor receptor 2 (HER2/neu) (13%). No local recurrences occurred. Regional and distant failure rates were 20% and 40%, respectively.

CONCLUSIONS

Excellent local control rates can be achieved with extensive (local) surgical treatment and postoperative RT. In case of lymph node metastases, a neck dissection with adjuvant postoperative RT is warranted. In patients with node-negative disease, a less aggressive approach for the neck seems feasible to reduce treatment-related morbidity.

Dermatography (Medical Tattooing) for Scars and Skin Grafts in Head and Neck Patients to Improve Appearance and Quality of Life

Importance

Dermatography (medical tattooing) is often overlooked as an adjuvant procedure to improve color mismatch in the head and neck area, and its effect on patient satisfaction and quality of life has not been evaluated, to our knowledge.

Objective

To analyze the effect of dermatography on the subjective perception of the appearance of scars and skin grafts and the quality of life in head and neck patients.

Design, Setting, and Participants

Case series of patients undergoing dermatography at the Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, between July 1, 2007, and April 1, 2015. Participants were invited to respond to 2 questionnaires measuring their scar or graft appearance and their quality of life before and after dermatography as an adjuvant treatment for benign or malignant head and neck tumors.

Intervention

Use of dermatography.

Main Outcomes and Measures

Two questionnaires evaluating a visual analog scale score (range, 0-10) and multiple questions on a 5-point scale focusing on satisfaction with the appearance and the quality of life.

Results

Among 76 patients, 56 (74%) were included in the study. The mean (SD) age of the study cohort was 56.5 (16.0) years, and 42 (75%) were female. The mean improvement in scar or skin graft perception on the visual analog scale of the modified Utrecht Questionnaire for Outcome Assessment in Aesthetic Rhinoplasty before and after dermatography was 4 points. On the modified Patient Scar Assessment Questionnaire, uniform improvement of approximately 1 point across 9 questions was observed. The answers to all patient satisfaction and quality-of-life questions on both questionnaires improved significantly after dermatography.

Conclusions and Relevance

Dermatography is an effectual adjuvant procedure to improve the subjective perception of scar and skin graft appearance and the quality of life in head and neck patients.

Level of Evidence

4.

[Pain as the primary symptom of a malignant parotid tumour]

The differential diagnosis of peri-auricular pain is comprehensive and arriving at a correct diagnosis is not always easy, which may result in a delay of treatment or even malpractice. Two patients presented themselves with facial peri-auricular pain. After a period of follow-up and control this pain turned out to be related to a malignant tumor in the glandula parotidea. These two cases show the importance for the dentist to refer patients with peri-auricular pain, with or without concomitant facial nerve palsy, to a specialist in a timely manner.

The Tongue-in-Groove Technique in Primary and Revision Rhinoplasty

The tongue-in-groove (TIG) is a conservative but powerful surgical suture technique to control tip rotation and projection, to set an appropriate alar-columellar relationship, to straighten a caudal septal deviation, and to stabilize the nasal base. TIG is suitable in primary and most revision cases and is easily combined with other surgical techniques. Seventeen years after its popularization, the TIG technique is embedded in modern-day rhinoplasty literature and teaching material. This article describes indications and considerations during external primary and revision rhinoplasty, based on clinical experience and the available literature.

Aggressive basal cell carcinoma of the head and neck: challenges in surgical management

With exponentially increasing numbers of basal cell carcinoma (BCC) of the head and neck region, also the locally advanced BCCs are increasing in number. These tumours are associated with aggressive biological behaviour with invasion of soft tissues, organs or bone and present with wide variation in management strategies. The objectives of the study was to describe the biological behaviour of aggressive BCCs and their clinical presentation in the head and neck region with a series of cases treated in our tertiary hospital, discuss management plans of such complex cases in terms of surgical planning and reconstruction. A series of five cases of aggressive BCC in the head and neck region with involvement of organs such as nose, orbit, temporal bone, facial nerve, paranasal sinuses and mandible was studied. Locally advanced, aggressive BCC should be evaluated and treated as head and neck tumours. Multidisciplinary team (MDT) discussion is advisable wherein the strategies on surgical excision, reconstruction options, facial nerve rehabilitation, indications for prosthesis and further adjuvant treatment such as radiotherapy and chemotherapy are carefully planned.

Orthovoltage for basal cell carcinoma of the head and neck: Excellent local control and low toxicity profile

OBJECTIVES/HYPOTHESIS

Evaluation of treatment results of orthovoltage X-rays for a selection of previously untreated favorable basal cell carcinomas (BCC) in the head and neck area concerning local control, cosmetic and functional outcome, and toxicity profile.

METHODS

A consecutive series of patients with primarily treated BCCs who were irradiated by means of orthovoltage X-rays in the Netherlands Cancer Institute in Amsterdam between January 2000 and February 2015 were retrospectively evaluated.

RESULTS

Two hundred fifty-three BCCs in 232 patients were primarily treated with orthovoltage X-rays. The local control rates at 1, 3, and 5 years for this selection of basal cell carcinomas were 98.9%, 97.5%, and 96.3%, respectively. Tumor size was the only significant predictor for local control because BCCs < 20 mm had a significantly higher 5-year local control rate than lesions ≥ 20 mm (96.8% vs. 89.4%, P = 0.041). Acute toxicity healed spontaneously without medical intervention, and late toxicity rates were low. Functional impairments were negligible, and the cosmetic outcome was excellent.

CONCLUSION

Orthovoltage therapy for well-selected favorable BCCs in the head and neck area resulted in excellent local control rates, a low toxicity profile, and apparently satisfactory functional and cosmetic outcomes. Orthovoltage irradiation is a good alternative for surgery for BCCs with favorable histologic prognosis at locations that are at risk for postoperative functional or cosmetic changes, such as the nose or canthus.

LEVEL OF EVIDENCE

4. Laryngoscope, 126:1796-1802, 2016.

Patients' satisfaction with facial prostheses

We assessed the "impact on wellbeing" and "satisfaction" of patients who had a facial prosthesis (of the ear, nose, or orbit) fitted in The Netherlands Cancer Institute. Patients had either an adhesive-retained or an implant-retained facial prosthesis between 1951 and 2011. We did a cross-sectional survey of 104 patients, then gave a questionnaire to the final study group of 71 (68%), a year or more later. All were satisfied with their prostheses (visual analogue scale (VAS): mean (SD) 8.1(1.5). The implant-retained group were the most satisfied (p=0.022), and the adhesive-retained group felt more self-conscious (p=0.013). Three-quarters of all patients said that the prosthesis was not painful and there were no problems with the way it functioned. A well-designed facial prosthesis has obvious benefits, but there were no appreciable differences between the two groups. Each patient must make a careful decision about which type of prosthesis to choose, taking into account the quality of their remaining tissue, the site of the defect, and their general health.

Tongue-in-Groove Setback of the Medial Crura to Control Nasal Tip Deprojection in Open Rhinoplasty

BACKGROUND

Overprojection of the nasal tip is a common problem in aesthetic Caucasian and Mediterranean rhinoplasty patients. In these patients, shortening of the conjoined medial crura frequently plays an important part in deprojection of the nasal tip. The combination of vertical incision maneuvers of the medial crura and tongue-in-groove (TIG) allows the surgeon to achieve significant control over projection, rotation and shape of the nasal tip. In this article we present our graduated approach towards nasal tip deprojection in aesthetic Caucasian and Mediterranean rhinoplasty together with a statistical analysis of overall success.

METHODS

This retrospective study based on 22 consecutive Caucasian or Mediterranean patients who had aesthetic, open deprojection rhinoplasty combining TIG with either footplate resection or medial crural overlay by one surgeon between 2009 and 2011. Aesthetical success was determined by statistical analysis of change in subjective body image in relation to nasal appearance, scored on five aesthetic 5-point Likert Scale questions and a 10 cm visual analog scale. Change in projection was calculated using a modified Goode method, applied on standardized pre- and postoperative photographs which were also used to measure change in rotation.

RESULTS

Subjective body image in relation to nasal appearance improved from 15.14 to 6.55 (p < 0.01). The mean aesthetic VAS score improved from 3.32 to 7.91 (p < 0.01). Substantial deprojection was measured in 19 patients (86.4 %) with a mean deprojection ratio of 0.06 [range 0.02-0.16]. An increased projection ratio of 0.03 was encountered in one patient and in two patients projection was unchanged.

CONCLUSIONS

Analysis of objective and subjective aesthetic outcome data suggest that our deprojection algorithm helps to deliver consistently good results in Caucasian and Mediterranean patients who require open deprojection rhinoplasty.

Patient satisfaction in Caucasian and Mediterranean open rhinoplasty using the tongue-in-groove technique: prospective statistical analysis of change in subjective body image in relation to nasal appearance following aesthetic rhinoplasty

OBJECTIVES/HYPOTHESIS

Tongue-in-groove (TIG) is a conservative but powerful surgical suture technique to control shape, rotation, and projection of the nasal tip. In this study, statistical analyses were performed to determine the aesthetical and functional effectiveness of TIG rhinoplasty.

STUDY DESIGN

Prospective cohort study including 110 Caucasian or Mediterranean aesthetic rhinoplasty patients treated by one surgeon between 2007 and 2012, with a 1-year follow-up.

METHODS

Data were collected using the Utrecht Questionnaire, a validated instrument routinely offered to our patients before and 1 year after surgery. Aesthetic results were reflected by change in subjective body image in relation to nasal appearance, scored on five aesthetic questions and a 10-cm visual analog scale (VAS). Functional results were determined by change in subjective nasal airway patency, scored on a 10-cm VAS for both sides.

RESULTS

The mean aesthetic sum score (5, low burden-25, high burden) significantly improved from 14.01 to 6.54 (P <.01). The mean aesthetic VAS score (0, very ugly-10, very nice) significantly improved from 3.35 to 7.78 (P < .01). The mean functional VAS score (0, very bad-10, very good) showed a small but significant improvement on both sides (left, 6.83-7.96; right, 6.88-7.80; P <.01).

CONCLUSION

Statistical analysis of quantified subjective data on nasal aesthetics and function show that TIG is a reliable technique that can help to deliver consistently good results in Caucasian and Mediterranean patients seeking aesthetic rhinoplasty. A small additional functional improvement can be expected.

Cadaver study on the location of suboccipital lymph nodes: Guidance for suboccipital node dissection

BACKGROUND

The purpose of this study was to provide anatomic guidance for the extent (technique) of suboccipital node dissection.

METHODS

Five human cadaver necks (9 sides) were studied. Boundaries were the superior nuchal line and external occipital protuberance (cranial), the nuchal ligament (medial), an imaginary line through C7 (caudal), and the posterior wall of the auditory channel (anterior). The overlying skin and complete thickness of the cranial part of the trapezius muscle and fascia sheath was included (deep).

RESULTS

An average number of 4 lymph nodes per suboccipital side were found. Diameters ranged from 1 to 6 mm. Twenty nodes (63%) were located in the subcutaneous tissue, 12 (37%) were found just underneath the superficial fascia of the trapezius muscle.

CONCLUSION

Suboccipital nodes are small and mainly located in the subcutaneous layer, with a minority just underneath the superficial fascia of the trapezius muscle. This anatomic knowledge was used to refine the suboccipital dissection.

Cervical osteomyelitis after carbon dioxide laser excision of recurrent carcinoma of the posterior pharyngeal wall

Two patients with recurrent carcinoma of the posterior pharyngeal wall, previously treated with carbon dioxide (CO2) laser excision and (chemo)radiotherapy, presented with neck pain due to cervical osteomyelitis. In one patient this led to cervical spine instability, for which a haloframe was applied. Our working hypothesis was that cervical osteomyelitis was caused by an infected wound bed induced by CO2 laser excision of the tumor in the already vascular-compromised area of the irradiated posterior pharyngeal wall. We discuss the risks of leaving a wound for secondary granulation after CO2 laser excision of the posterior pharyngeal wall and prophylactic antibiotic treatment.

The lateral crural underlay spring graft

The objective of this study is to evaluate the functional and aesthetic results obtained from the use of the lateral crural underlay spring (LCUS) graft for the treatment of internal and external nasal valve collapse. In this retrospective study, preoperative and postoperative functional and aesthetic results were compared in patients undergoing treatment for internal or external nasal valve collapse. Results were scored by means of a questionnaire and visual analog scale completed by the patients. Eight patients were recruited and included in this study: 6 (75%) had an improvement in their functional scores, 1 (12%) remained unchanged, and 1 (12%) scored worse. The mean difference in functional scores after the intervention was 9.4 points (p < 0.005). There was no significant difference in aesthetic scores. We found evidence that the LCUS graft is effective for relieving nasal obstruction in patients with internal, external, or combined nasal valve collapse. The amount of increased sidewall tension and rigidity as well as the increase in nasal valve angle and cross-sectional area are determined by the length of the graft, which can be varied according to need.

Split hump technique for reduction of the overprojected nasal dorsum: a statistical analysis on subjective body image in relation to nasal appearance and nasal patency in 97 patients undergoing aesthetic rhinoplasty

OBJECTIVES

To describe the split hump technique (SHT) and to examine its effectiveness for correction of an overprojected nasal dorsum in patients undergoing aesthetic rhinoplasty.

METHODS

This prospective study included 97 patients. Objective assessment was performed using a short, practical questionnaire. Investigation focused on nasal patency and the patient perception of body image in relation to nasal appearance using 5-point Likert scale questions and visual analog scales.

RESULTS

Use of the SHT resulted in a significant improvement in nasal patency and aesthetic nasal perception. Sum functional question scores decreased from 9.154 to 6.351 and aesthetic question scores from 13.897 to 6.825 (P < .001 for both). Mean aesthetic visual analog scale scores improved in all patients, from 3.346 to 7.782 (P < .001). Graphic illustration of this improvement revealed a gaussian curve of normal distribution around a mean (SD) improvement of 4.48 (1.93).

CONCLUSIONS

Traditional en bloc humpectomy maneuvers are frequently combined with spreader graft use to avoid postoperative inferomedial repositioning of the upper lateral cartilages and inverted-V deformity. The SHT for correction of the overprojected dorsum creates a paradigm change in this patient group. The transverse segments of the upper lateral cartilages are saved and repositioned instead of being resected as a part of an en bloc osseocartilaginous composite hump resection in a transverse plane. Several modifications of the SHT enable the surgeon to deproject the nose while keeping sufficient strength in the keystone area and augmenting dorsal width. Using statistical analysis of subjective patient data, we could prove a broad acceptance and appreciation for the SHT.

Free-Flap Reconstruction of Large Full-Thickness Lip and Chin Defects

Objectives:

We describe our experience in the reconstruction of large 3-layer lip defects using free revascularized lower-arm and fibula flaps.

Methods:

Between 2005 and 2009, nine patients underwent free-flap reconstruction after oncological surgery involving the lip and chin with or without mandibular involvement. The flap techniques are described, and postoperative functional and aesthetic results were recorded.

Results:

There were no flap failures. All patients showed intact oral function and good aesthetic results. Two patients died of distant metastases, 8 months and 17 months after surgery.

Conclusions:

Three-layer defects of the lip ideally require free-flap reconstruction, which has a high probability of achieving good functional and aesthetic results.

Lymphatic drainage patterns from melanomas on the shoulder or upper trunk to cervical lymph nodes and implications for the extent of neck dissection

Purpose

To determine the incidence and pattern of cervical lymphatic drainage in patients with melanomas located on the upper limb or trunk, and to evaluate our current neck dissection protocol for those patients with a N+ neck.

Methods

Of 1192 melanoma patients who underwent sentinel node biopsy, 631 were selected with a primary tumor on the upper limb or trunk. All lymphoscintigrams, SPECT/CT images and operative reports were reviewed to determine the exact locations of sentinel nodes visualized preoperatively and dissected during operation.

Results

Thirty-nine (6.2 %) of 631 patients with a melanoma on the upper limb or trunk showing cervical lymph node drainage were identified. In 34 (87 %) of 39 patients, sentinel nodes were excised from level IV or Vb, and in 30 of those 39 patients simultaneous from the axilla. In the remaining five patients (13 %), sentinel nodes were collected from level IIb, level III or the suboccipital region. All collected sentinel nodes were located in the intended dissection area for N+ patients. Thirteen patients (33 %) had a total of 22 tumor-positive sentinel nodes in either the axilla (n = 10), level IV (n = 2), Vb (n = 9) or suboccipital (n = 1).

Conclusions

Only a minority of the patients with upper limb or trunk melanomas demonstrated lymphatic drainage to cervical lymph node basins, with preferential drainage to levels IV and Vb. Our current dissection protocol of levels II–V, with or without extension to the suboccipital region, in those patients with involved cervical sentinel nodes seems sufficient.

Control of tip rotation

Rotating the nasal tip is an integral and challenging aspect of rhinoplasty. This article describes ways of measuring tip rotation, coming to an agreement with the patient regarding desired tip rotation and psychological implications of tip rotation. Based on the tripod theory of the nasal tip, various techniques for changing tip rotation and projection are detailed and illustrated with clinical cases. The authors review the literature and present their personal preferences.

10th International Symposium on Head And Neck Skin Cancer

Since 1993, ten multidisciplinary symposia were organized at The Netherlands Cancer Institute on the diagnosis and treatment of malignancies of the head and neck. The symposia are meant to provide up-to-date teaching for physicians by world-renowned speakers. The previous symposia dealt with sarcomas, reconstruction, cancer in young patients, salivary glands, melanoma, unknown primaries, as well as several other topics. This 10th symposium focused on skin cancer of the head and neck. There are many types of skin cancer and the differential diagnosis can often be difficult. In this symposium, diagnosis, molecular biology, epidemiology, staging and the treatment of various skin cancers were discussed by leaders in the field. There were over 200 participants from many different countries in Europe and overseas, representing specialties in the fields of dermatology, maxillofacial surgery, otolaryngology, head and neck surgery, general surgery, plastic and reconstructive surgery, and radiotherapy.

Transposition flaps in nasal reconstruction

The aim of reconstructive nasal surgery is not only to rebuild all or part of the nose but also to blend and tailor the new and old tissues in such a way as to create the best possible result. Although a variety of reconstructive options exist, local or regional skin flaps are one of the most powerful reconstructive tools for the reconstruction of cutaneous nasal defects. This article discusses the fundamentals of nasal reconstruction and describes the local and regional transposition flaps for the reconstruction of nasal defects.

Eighteen years of experience in Mohs micrographic surgery and conventional excision for nonmelanoma skin cancer treated by a single facial plastic surgeon and pathologist

OBJECTIVES/HYPOTHESIS

To determine and compare the efficacy of Mohs micrographic surgery (MMS)- and conventional excision (CE)-confirmed resection of nonmelanoma skin cancers (NMSCs).

STUDY DESIGN

Retrospective cohort study.

METHODS

A retrospective cohort study of NMSCs treated in a tertiary referral center by a single facial plastic surgeon and a group of five histopathologists over an 18-year period. The treatment modality was either MMS or CE. The primary outcome measure was recurrence of disease. The secondary outcome measure was the size of resulting surgical excision defect.

RESULTS

Between 1990 and 2008, 795 patients were treated with MMS and 709 with CE. The median follow-up period for MMS was 24 months and for CE 16 months. Disease recurred in 6/795 and 7/709 patients, respectively (P = .78). Analysis of the resection defects with general linear models adjusted for localization and primary or recurrent disease showed significantly smaller defects after MMS (P = .008).

CONCLUSIONS

This study demonstrates that: 1) MMS and CE are safe in terms of recurrence rates in NMSCs; 2) MMS can be performed adequately by an experienced facial plastic surgeon in close collaboration with a group of pathologists; and 3) the advantage of MMS is that resection defects can be minimized in important aesthetic and functional areas, such as the nose and eyelid, possibly facilitating the reconstruction.

Novel insights into pathological changes in muscular arteries of radiotherapy patients

BACKGROUND AND PURPOSE

Vascular disease is increased after radiotherapy and is an important determinant of late treatment-induced morbidity and excess mortality. This study evaluates the nature of underlying pathologic changes occurring in medium-sized muscular arteries following irradiation.

MATERIALS AND METHODS

Biopsies of irradiated medium-sized arteries and unirradiated control arteries were taken from 147 patients undergoing reconstructive surgery with a vascularised free flap following treatment for head and neck (H&N) or breast cancer (BC). Relative intimal thickening was derived from the ratio of the thickness of the intima to the thickness of the media (IMR) on histological sections. Proteoglycan, collagen and inflammatory cell content were also scored.

RESULTS

Intimal thickness was significantly increased in irradiated vessels: in the H&N group the IMR was 1.5-fold greater without correction for the control artery (p=0.018); in the BC group the IMR increased 1.4-fold after correction for the control artery (p=0.056) at a mean of 4 years following irradiation. There was an increase in the proteoglycan content of the intima of the irradiated IMA vessels, from 65% to 73% (p=0.024). Inflammatory cell content was increased in the intima of the irradiated H&N vessels (p=0.014).

CONCLUSIONS

Radiation-induced vascular pathology differs quantitatively and qualitatively from age-related atherosclerosis.

Superficial Parotidectomy via Facelift Incision

The stigma of a visually prominent facial scar following parotid surgery can be distressing to a young patient. The surgical technique of parotidectomy via a facelift incision is described and evaluated. Thirty patients with a benign lesion of the parotid gland underwent a partial superficial parotidectomy via a modified facelift incision. After operation, all patients had excellent cosmesis and complete function of the facial nerve. The facelift incision provides adequate exposure of the parotid gland for (partial) superficial parotidectomy. It can be offered as an alternative to a select group of patients who present with a small, mobile tumor in the tail of the parotid gland and an explicit request for an invisible postoperative scar.

Optimizing exposure of the posterolateral maxillary and pterygoid region: the lower cheek flap

AIM

Description of an alternative surgical approach to the posterolateral maxillary and pterygoid region.

PATIENTS AND METHOD

Three patients with posterior maxillary/pterygoid lesions are described in whom a lower cheek flap was used to achieve optimal surgical exposure. After midline division of the soft tissues of the lower lip and chin, the incision is extended posteriorly in the inferior gingivobuccal sulcus and continued lateral from the retromolar trigone in the upward direction lateral from the maxillary tuberosity. The flap is elevated under the periosteum towards the angle of the mandible with detachment of the masseter muscle. By marginal resection of the anterior part of the ascending mandible, visualisation of the posterolateral maxillary and pterygoid region can be optimized.

CONCLUSION

As compared to the transoral approach, the lower cheek flap creates an optimal surgical exposure of the posterolateral maxillary sinus wall and pterygoid plates and should be considered for maxillary lesions extending into the pterygoid plate and pterygoid muscles.

Nasal septum perforation repair using differently designed, bilateral intranasal flaps, with nonopposing suture lines

In this article, we briefly review the aetiology and symptoms of nasal septal perforations, and focus on a surgical reconstruction technique of which the results were retrospectively studied. The technique described, involves the interposition of a connective tissue graft between differently designed local mucoperichondrial and/or mucoperiosteal flaps on each side of the perforation, thereby preventing opposing suture lines. On one side a rotation/advancement flap is derived from the septum, the nasal floor and lateral nasal wall while in the opposite nasal passage, bipedicled flaps from the septum and nasal floor and/or from the superior septum and under-surface of the upper lateral cartilage are created. Of the 43 patients included in this study, 40 had their perforation permanently closed, while three experienced a non-symptomatic recurrence. We conclude that the use of differently designed, mucoperichondrial or mucoperiosteal bilateral intranasal flaps with non-opposing suture lines, and interposition of Alloderm or autogenous connective tissue with cartilage, especially with adequate exposure through an external approach, can lead to excellent results in the majority of cases.

Reconstructive surgery of the leprosy nose: a new approach

There has still been no reduction in the detection rate worldwide for leprosy, despite supervised multi-drug therapy. In time, leprosy can result in a severe saddle-nose deformity leading to functional problems, disfiguration and stigmatization. In severe cases, only the nasal skin tissue and the lower lateral cartilages are preserved. In such cases, the ideal would be to restore the cartilaginous skeleton but, by contrast with other causes of saddle-nose deformities, this is complicated by the quantity and the poor quality of the remaining nasal mucosa. Leprosy-related saddle-nose deformities are therefore challenging and difficult to reconstruct with the techniques that have been proposed in the past. In this study, 24 patients underwent rhinoplastic surgery involving the use of autogenous costal and/or auricular cartilage or composite grafts. The nasal septum, the upper laterals and the anterior nasal spine were reconstructed with a dorsal onlay attached to a columellar strut with an extension on the proximal side. Before surgery, the saddle-nose deformities were classified according to severity with a new system based on clinical symptoms and signs. Postoperative evaluation was performed at least two years after surgery (N=17). Functional and aesthetic improvement, resorption rate, warping, infection and extrusion were analysed. Functional and aesthetic improvements were achieved in 15/17 patients. None of the patients developed an infection and extrusion or warping of the implants was not observed. The resorption rate depended on the localization and the type of cartilage implant. In general, auricular conchal cartilage implant grafts resulted in less resorption than costal cartilage. Least resorption (4/17 patients) was observed in the dorsal onlay grafts of both conchal (1/6) and costal cartilage grafts (3/11). Resorption of columellar strut implants and shield grafts was observed in 7/17 patients. No resorption was seen of composite grafts (0/4) and alar battens (0/7). Autogenous cartilage implants can be used to reconstruct saddle-nose deformities in leprosy with a minimum risk of complications. The preoperative grade of severity was used as a basis for the development of guidelines for optimal long-term functional and aesthetic outcome.

Postoperative management of nasal vestibular stenosis: the custom-made vestibular device

OBJECTIVE

To evaluate the effect of a custom-made postoperative vestibular device on the occurrence and severity of restenosis.

DESIGN

This was a retrospective study conducted at the Department of Otorhinolaryngology/Head and Neck Surgery, Center for Facial Plastic and Reconstructive Surgery of the Academic Medical Center. In this tertiary care center between January 1994 and December 2000, 52 patients treated for nasal vestibular stenosis received a vestibular device directly postoperatively, with the intention to decrease the risk of restenosis. The vestibular device was composed of thermoplastic acrylic material and had a lumen to facilitate breathing. The shape of the device was custom-made within 1 week after surgery and was subsequently worn by the patient for 12 weeks (6 weeks continuously and 6 weeks only during the night). After this period, the occurrence and severity of restenosis of the nasal vestibule were evaluated and the necessity for a potential adjuvant operation was assessed.

RESULTS

Preoperatively, of the 52 patients, 38 (73%) had severe stenosis, 13 (25%) had moderate stenosis, and 1 (2%) had mild stenosis. Postoperatively, 15 (29%) of the patients had mild restenosis, 1 had a case of moderate stenosis, and 1 had a case of severe stenosis. Only the latter patient required a subsequent revision. Functional improvement was noticed in 51 (98%) of the patients, whereas 49 (94%) of the patients showed aesthetic improvement after the initial procedure.

CONCLUSIONS

In case of surgical treatment of vestibular stenosis, the use of a custom-made vestibular device may help prevent restenosis. In addition to functional improvement, the device may also improve the aesthetic result. The device does not seem to have any negative adverse effects, was easy to make, and was comfortable for the patient to wear.

Objective computerized determination of the minimum cross-sectional area of the nasal passage on computed tomography

OBJECTIVES/HYPOTHESIS

Current methods that measure cross-sectional areas of the nasal passage on computed tomography (CT) do not determine the minimum cross-sectional area that may be an important factor in nasal airway resistance. Objective measurement of the dimensions of the nasal passage may help in the diagnosis, as well as the choice and evaluation of surgical treatment for upper airway insufficiencies.

STUDY DESIGN

Retrospective and clinical study.

METHODS

Software was developed that automatically calculates the minimum cross-sectional area of the nasal passage on CT.

RESULTS

Evaluation shows that the minimization algorithm in the software reliably calculates the position and orientation of the oblique plane on which the minimum cross-section lies.

CONCLUSION

The developed method may be used for objective and observer-independent evaluation of surgical treatment options.

Surgical technique—unwrapping the neck node levels around a sternocleidomastoid muscle bar: A systematic way of performing (modified) radical neck dissection

AIM

Description of a systematic approach to the neck for removal of lymph node bearing tissues in levels I-V.

METHOD

A (modified) radical neck dissection is divided in three steps: (1) Dissection of levels I-IV, (2) dissection of level V and (3) transection of SCM bar and finalisation of the dissection. The sternocleidomastoid muscle (SCM) is used as a "bar", around which the different neck levels can be systematically unwrapped, warranting permanent cranio-caudal tension of the neck specimen, while anatomical relations remain intact.

RESULTS

In a group of 115 (modified) radical en bloc neck dissections with or without post-operative radiotherapy 10% regional recurrences, 2% post-operative chylous fistulas and < 5% post-operative wound infections occurred. The overall 5 years survival was 45% (95% confidence interval: 36-54%).

CONCLUSION

A systematic unwrapping of lymph node levels around the sternocleidomastoid bar provides a reliable systematic method for performing (modified) radical neck dissections without a negative influence on clinical outcome.

Interest in Facial Plastic and Reconstructive Surgery Among Otorhinolaryngologists

OBJECTIVE

To assess the interest of Dutch otorhinolaryngologists in facial plastic and reconstructive surgery (FPRS).

METHODS

We conducted a 22-question survey among otorhinolaryngology physicians and residents concerning their experience with and interest in FPRS. The response rate was 71% (335/475; 275 physicians and 60 residents).

RESULTS

Most respondents associated FPRS with rhinoplasty, otoplasty, and the reconstruction of skin cancer defects. Of the physicians, 81% said that 1% to 33% of their practice involves FPRS; 62% were satisfied with this percentage, whereas 36% would like it to be higher. Approximately 70% of physicians regarded their training in FPRS as insufficient, although most (70%) had taken supplementary courses. Moreover, 73% of the otorhinolaryngology physicians and 72% of all respondents said that FPRS should be taught during and after residency, with a preference for hands-on courses. Finally, 84% of all respondents thought that FPRS should be part of the field of otorhinolaryngology, whereas 48% thought that it should become a subspecialty.

CONCLUSION

There is interest in integrating FPRS training into the Dutch otorhinolaryngology residency program, as it is in the United States.

Effectiveness of therapeutic (N1, N2) selective neck dissection (levels II to V) in patients with laryngeal and hypopharyngeal squamous cell carcinoma

BACKGROUND

The use of selective neck dissection (SND) in the treatment of clinically node-positive necks remains controversial.

METHODS

A total of 48 patients with laryngeal and hypopharyngeal carcinoma underwent 53 primary, therapeutic SNDs (levels II-V) and were retrospectively evaluated.

RESULTS

Regional metastases were staged as pN1 in 8 patients, pN2a in 3, pN2b in 29, and pN2c in 8. Of the primarily treated necks 45 of 53 (85%) were irradiated postoperatively. Extracapsular spread was found in 27 neck specimens (51%). Regional recurrences in level I occurred in one patient (1.8%) and in level II-V in 5 patients (9.4%). The actuarial overall survival at 4 years was 36.5%.

CONCLUSIONS

In selected cases therapeutic SND (levels II-V) in node positive (N1,2) patients with laryngeal or hypopharyngeal carcinoma does not lead to increased risk for recurrence in level I or other levels of the neck and is therefore a safe procedure.

Treatment of chondrodermatitis nodularis with removal of the underlying cartilage alone: retrospective analysis of experience in 37 lesions

Most otolaryngologists treat patients with chondrodermatitis nodularis (CDN) by wedge excision. Although the results of this technique are generally good, it can leave the patient with an asymmetric, deformed ear. In the dermatological literature, a relatively straightforward technique has been described for the treatment of CDN by smoothing only the underlying cartilage. This is based on the assumption that CDN is caused by pressure necrosis of protuberant cartilage, and thus is primarily not a skin disease. Reports on this technique claim excellent cosmetic results with only a small chance of recurrence. In the present study we analyse the application of this technique to 34 patients with 37 CDN lesions. All patients were symptom-free with a minimum follow-up of three months according to their medical reports. Seventeen patients with 19 lesions were interviewed later by telephone. In a mean follow-up of 30.7 months, 34 of these patients remained symptom-free and only one required revision surgery. The authors recommend this safe and simple technique to other physicians who treat patients with CDN.

Bone resorption after alloplastic augmentation of the mandible

Augmentation mentoplasty is a commonly performed operation especially in conjunction with rhinoplasty. While various materials have previously been used for this procedure, silastic has been the implant of choice for the last three decades. Concerns have been raised due to the occurrence of bone resorption beneath these implants. Controversy prevails as to the cause and the long-term effects of the resorption. It has been suggested by some that the resorption is self-limiting although this has not been confirmed in clinical studies. In total, 40 patients with silastic implants, who had a mean follow-up of 20 months (8-60 months), were studied radiologically. In 21 of them (52%), a degree of resorption from 0.5 to 2 mm was observed. Spearman's rank correlation showed a statistically significant relationship between the degree of resorption and the time lapse since surgery (P = 0.048).