No abstract available
Editorial: The changing face of adult surgical education: a positive ‘disruption’ for more than just millennials
01-08-2019 – Tollefson, Travis T.
No abstract available
Facial reanimation: an update on nerve transfers in facial paralysis
01-08-2019 – Jandali, Danny; Revenaugh, Peter C.
Purpose of review The aim of this article is to review the recent literature on nerve transfers in facial paralysis. The discussion focuses on direct nerve repair and three types of nerve transfers, cross facial nerve graft, hypoglossal, and masseter nerve transfers.
Recent findings Masseteric nerve transfers have a high probability of creating significant movement, although tone is poor. The hypoglossal to facial nerve transfer is reliable in affording facial tone and has been updated to involve a transposition technique that offers good results with minimal morbidity. Combination nerve transfer techniques using multiple cranial nerves or cross-face nerves are increasingly described.
Summary Reinnervation of the facial nerve and neural regeneration in general are areas of intense research and novel surgical approaches continue to be explored. Although direct nerve repair is the most ideal, other nerve transfers can be performed with good results. More specifically, the masseteric nerve transfer can provide excellent movement and the hypoglossal transfer good tone. Combination transfers may afford the benefits of multiple nerves.
Update on empty nose syndrome: disease mechanisms, diagnostic tools, and treatment strategies
01-08-2019 – Gill, Amarbir S.; Said, Mena; Tollefson, Travis T.; Steele, Toby O.
Purpose of review To discuss the proposed pathophysiology of empty nose syndrome (ENS), summarize and evaluate the role of validated diagnostic tools in the diagnosis of ENS, and review the medical and surgical treatment strategies for patients with ENS.
Recent findings Historically, ENS has been associated with a reduction in nasal turbinate size; new data suggest that impaired trigeminal nerve function may also play a role in the pathophysiology of the disease. The newly validated empty nose syndrome 6 item questionnaires and Cotton test are steps forward to standardize the diagnosis of ENS. Finally, there has been a marked increase in surgical treatment strategies to reconstitute turbinate volume with various implant materials.
Summary The diagnosis of ENS remains controversial but the last several years have seen a rejuvenation of interest in this disease entity. The validated empty nose syndrome 6 item questionnaires and Cotton test provide a standardized and objective means by which to characterize ENS. Prevention of iatrogenic ENS through avoidance of excessive turbinate reduction remains critical in preventing paradoxical nasal obstruction. Nasal humidification, patient education, and treatment of possible concomitant medical conditions (e.g., depression) constitute first lines of treatment. We support the cautious use of these screening tools as adjuncts to clinical decision-making. Although injectable implants to augment turbinate volume show promise as a therapeutic surgical technique, there is insufficient data to fully support their use at this time.
An update in facial gender confirming surgery
01-08-2019 – Juszczak, Hailey M.; Fridirici, Zachary; Knott, P. Daniel; Park, Andrea M.; Seth, Rahul
Purpose of review To summarize current surgical and nonsurgical approaches to facial gender confirming surgery (FGCS) and highlight standards of care and areas of future research.
Recent findings Gender nonconforming individuals may encounter considerable internal coping and external social stressors that may contribute to gender-associated dysphoria. FGCS provides patients the ability to align facial appearance with gender identity, using recently described advances in surgical and nonsurgical techniques. The majority of FGCS is performed on transwomen (individuals identifying as female), yielding the more common term of facial feminization surgery (FFS). Although no set protocols or standards are in place, certain procedures are commonly performed to alter sex-determining characteristics of the face, and further research may help define guidelines. As many training programs have minimal exposure to FGCS, promotion of transgender health awareness is paramount for diverse and inclusive surgical training.
Summary Although demand for FGCS is increasing, there remains a need for improving surgical approaches, developing evidence-based care guidelines, and implementing education and awareness in training programs.
Contemporary management of frontal sinus fractures
01-08-2019 – Dedhia, Raj D.; Morisada, Megan V.; Tollefson, Travis T.; Strong, E. Bradley
Purpose of review Frontal sinus fracture management is evolving. This article will highlight recent literature and provide an evidence-based algorithm in the contemporary management of frontal sinus fractures.
Recent findings The role of transnasal endoscopic treatment of frontal sinus fractures has expanded to include fracture reduction and posterior table reconstruction. Evidence continues to support the safety of nonoperative management in select frontal sinus outflow tract fractures.
Summary The management of frontal sinus fractures with frontal sinus outflow tract injury continues to evolve with a trend toward observation and minimally invasive approaches. Restoration of the frontal sinus outflow tracts with transnasal endoscopic techniques is being used increasingly in the acute and delayed setting. For severe fractures, the role of conservative treatment paradigms requires further research.
Rib cartilage in Asian rhinoplasty: new trends
01-08-2019 – Yoo, Shin Hyuk; Jang, Yong Ju
Purpose of review Costal cartilage has many advantages over other grafting materials because of its large quantity and high biocompatibility. As a result, it has been considered as a good option for Asian rhinoplasty. However, costal cartilage is difficult to use and is associated with a high complication rate. To avoid the disadvantages and complications of costal cartilage graft, several techniques have been proposed in the literature. This review addresses the conventional uses of costal cartilage in Asian rhinoplasty and recent updates.
Recent findings Different techniques have been reported for Asian rhinoplasty using costal cartilage. Solid-block costal cartilage and diced cartilage with or without wrapping materials are widely used for dorsal augmentation. Many different grafting techniques for the tip and septal reconstruction have been reported by numerous surgeons. When using costal cartilage graft, surgeons should pay attention to both graft complications, such as warping or infection, and donor-site morbidity. Several strategies have recently been developed to avoid these complications.
Summary This article summarises grafting options for Asian rhinoplasty using costal cartilage and possible complications. This information may assist with proper selection of appropriate techniques for harvesting, carving and grafting costal cartilage.
The evolving roles of computer-based technology and smartphone applications in facial plastic surgery
01-08-2019 – Kayastha, Darpan; Vakharia, Kalpesh T.
Purpose of review This article aims to provide a comprehensive review of the established and emerging applications of various computer-based technologies and smartphone applications in the field of facial plastic surgery.
Recent findings Computer-based technologies and smartphone applications have widespread utility across various domains of facial plastic surgery; these include preoperative consultation, surgical planning, intraoperative navigation, custom implant creation, postoperative assessment, physician productivity, communication, and education. Smartphone applications are being utilized for assessment of patients such as those with facial paralysis. Three-dimensional (3D) imaging and 3D printing has influenced preoperative counseling, surgical planning, and execution. The incorporation of intraoperative navigation has the potential to improve the accuracy and precision of facial reconstruction.
Summary Current advances in computer-based technology have made a significant impact on the practice of facial plastic and reconstructive surgery. These technological advances have influenced how we counsel patients, perform procedures, assess outcomes, and learn new techniques.
Update on the management of craniomaxillofacial trauma in low-resource settings
01-08-2019 – Shah, Irfan; Gadkaree, Shekhar K.; Tollefson, Travis T.; Shaye, David A.
Purpose of review Craniomaxillofacial (CMF) trauma is a common cause of global morbidity and mortality. Although in high resource settings the management of CMF trauma has improved substantially over the past several decades with internal rigid fixation technology; these advancements have remained economically unviable and have not yet reached low and middle-income countries (LMICs) en masse. The purpose of this review is to discuss the current management of CMF injuries in low-resource settings.
Recent findings Trauma injuries remain a global epidemic with head and neck injuries among the most common. CMF trauma injuries largely occur in LMICs, with motor vehicle trauma being a common cause. Patients present in a delayed fashion which increases complications. Diagnostic methods are often limited to plain radiographs as computed tomography is not always available. In low-resource settings, CMF trauma continues to be treated primarily by closed reduction, maxillomandibular fixation, and transosseous wiring, yielding acceptable results through affordable methods. With the advent of less expensive plating systems, internal fixation with plates and screws are gradually finding their place in the management of facial trauma in low-resource settings. A shortage of CMF surgeons in LMICs is a recognized problem and is being addressed by targeted curricula.
Summary CMF trauma is a major cause of morbidity and mortality globally that remains poorly addressed. Currently, conventional methods of treating CMF trauma in low-resource settings have evolved to meet resource constraints. The education of CMF surgeons remains a key leverage point in improving CMF trauma care globally.
Rhinoplasty outcomes and trends
01-08-2019 – Ho, Osan Y.M.; Ku, Peter K.M.; Tong, Michael C.F.
Purpose of review This article reviewed studies that support the use of implants for nasal valve surgery and augmentation rhinoplasty.
Recent findings For nasal valve collapse, there is a trend for rhinoplasty surgeons to use Monarch nasal implant, absorbable valve implant and titanium butterfly implant rather than traditional cartilaginous grafts. For augmentation rhinoplasty, it is still a gold standard to use autologous cartilage. However, alloplastic implants are still very popular for Asian rhinoplasty. A combination of implant materials for augmentation rhinoplasty can improve outcomes while minimizing complications.
Summary Application of implants and newer techniques in nasal valve surgery and augmentation rhinoplasty are important to enhance the outcome in rhinoplasty.
Current approaches to cleft lip revision
01-08-2019 – Garland, Katie; Matic, Damir
Purpose of review Cleft lip repair requires multidisciplinary follow-up throughout a childs life and often requires lip revision surgery in adolescence to restore function and symmetry of the lip. There is significant variability in the approaches taken for lip repair and therefore a review of current techniques and subsequent guidance to secondary cleft lip repair is warranted.
Recent findings New methods of secondary reconstruction can be divided into superficial or muscle related. Recent suggestions for superficial reconstruction include botulinum toxin injection, silicone gel sheeting, local flap reconstruction, fat grafting, and CO2 laser ablation. Suggestions for muscular reconstruction include pedicled prolabial flaps, modified Abbe flap, and orbicularis oris eversion.
Summary Secondary cleft lip deformities can be classified as superficial or muscle related. Superficial problems require relatively minor treatments such as laser, local scar revisions, small local flaps, mucosal excision, or fat grafting. Muscle deformities generally require total lip revision and rerepair as a first step to achieving longstanding improvements in lip esthetics and function. Cleft lip revision should only be considered in concert with the patient, be based on the patients concerns and desires, and offered at the appropriate timeline to improve social integration and/or psychosocial wellbeing.
Malignant maxillofacial bone tumors
01-08-2019 – Lopez, Joseph; Tufaro, Anthony P.
Purpose of review Malignant bone tumors of the head and neck region are rare. Due to the paucity of studies on these tumors, patients with these maxillofacial malignancies can suffer from high morbidity and mortality.
Recent findings Currently, mainstay management of these tumors includes wide surgical resection with margins followed by radiotherapy and/or adjuvant chemotherapy. Although much progress has been made over the last few decades regarding the prognosis of many of these tumors, large multicenter trials are needed to better determine their optimal management.
Summary The current review will provide a broad review of the most current epidemiology, pathogenesis, prognosis, and management of the most common bone malignancies of the maxillofacial skeleton.
Management of the protuberant premaxilla: where does it fit in?
01-08-2019 – Morris, Lisa
Purpose of review To discuss multidisciplinary treatment options for the protuberant premaxilla associated with bilateral cleft lip and palate. Lessons have been learned throughout the years regarding the effect of growth restriction after early and aggressive therapy. Multiple surgical and orthodontic interventions are discussed. Recent literature will be highlighted and discussed.
Recent findings A paucity of long-term studies was noted. Recent literature revealed numerous studies introducing innovative presurgical orthopedic devices as less expensive and easier to use alternatives to nasoalveolar molding. Multiple approaches to premaxillary setback were presented, offering multiple approaches to improve success rates and minimize burden to the patient. Novel orthodontic and advanced microvascular procedures were discussed as additional tools for treatment of the malpositioned premaxilla once skeletal maturity is reached.
Summary Multidisciplinary team management of the protuberant premaxilla and bilateral cleft lip and palate is becoming increasingly embraced worldwide. Numerous surgical procedures and orthodontic treatments are required to optimally reposition the premaxilla; however, these interventions can inhibit growth, resulting in maxillary retrusion. Long-term follow-up studies are needed to determine what protocol is best. Studies should also include ways to overcome barriers to treatment success, such as late intervention, resource disparity, and limited access to care.
Contemporary management of orbital blowout fractures
01-08-2019 – Homer, Natalie; Huggins, Alison; Durairaj, Vikram D.
Purpose of review Orbital floor blowout fractures may lead to significant morbidity, including debilitating double vision and globe malposition. Thorough evaluation and timely surgical intervention may prevent long-term sequelae.
Recent findings New studies have demonstrated certain patients with orbital floor fractures to do well when managed conservatively. In those necessitating operative repair, precise surgical dissection and adequate fracture reduction are essential to restoring orbital anatomy and function. Novel surgical techniques and orbital floor reconstruction materials, described in this review, will further optimize patient outcomes.
Summary A knowledgeable evaluation, thoughtful management strategy and modernized surgical technique can prevent long-term disability in patients with orbital floor blowout fractures.
Risk factors for velopharyngeal dysfunction following orthognathic surgery in the cleft population
01-08-2019 – Vella, Joseph B.; Tatum, Sherard A.
Purpose of review This article highlights important trends in speech outcomes following orthognathic surgery in the cleft lip and palate populations. The geometric changes in the velopharyngeal port caused by maxillary advancement by standard means and distraction are only one consideration in predicting speech outcomes. Myriad and variable preoperative risk factors, both anatomic and functional, have been identified in the literature because of weaknesses in experimental design and small patient populations. Therefore, elucidating risk factors for postoperative velopharyngeal dysfunction remains a challenge in our field.
Recent findings Recent pharyngeal morphologic studies using computed tomography demonstrate volumetric discrepancies in the unilateral and bilateral cleft lip and palate populations before and after orthognathic surgery, suggesting differing requirements of velar adaptation among these two populations. Perceptual and instrumental speech evaluation studies and cephalometric correlates revisit ‘borderline’ velopharyngeal insufficiency and isolate preoperative velar length as a risk factor for velopharyngeal dysfunction following orthognathic surgery.
Summary Research design heterogeneity, small patient populations, and inherent risk of bias of retrospective reviews obscure velopharyngeal dysfunction risk factor identification prior to orthognathic surgery. However, recent reports on the volumetric changes in the pharyngeal airway and preoperative ‘borderline’ velopharyngeal insufficiency and velar length offer improved predictive value in anticipating postoperative velopharyngeal dysfunction.