Faculty Bibliography

Botulinum toxin (Botox) has firmly established itself as one of the premier nonsurgical therapies. Recently, Botox is also being used as an adjuvant to many aesthetic procedures, both surgical and nonsurgical. This combined therapeutic use for Botox may not only create an added benefit toward facial rejuvenation but may create a synergistic one as well. This article examines such uses for Botox and reviews the current medical literature.

The middle vault is a transition zone between the nasal tip and nasal bones and plays an important role in profile, tip projection, tip rotation, and tip support. This report presents an alternative to conventional techniques specific to the middle nasal vault for a patient population with particular nasal features. A narrow middle vault with internal nasal valve collapse is functionally and aesthetically addressed by the insertion of spreader grafts. However, the inverse of this situation is sometimes encountered. A patient with a broad middle vault and without internal nasal valve collapse will benefit from reduction of the horizontal width of the cartilaginous dorsum, which is in effect the reverse of spreader grafts. This effect is achieved by excising a vertical wedge-shaped strip of cartilage that follows the length of the upper lateral cartilage at the junction of the upper lateral cartilage and the dorsal nasal septum.

Endoscopic equipment and specially designed elevators and dissecting instruments provide access to the forehead and scalp region through minimal incisions. This technique is now widely accepted for aesthetic forehead and browlifts. To our knowledge, however, it has not previously been used in reconstructive forehead and scalp surgery. We carried out a retrospective review of 5 cases involving patients who underwent reconstructive scalp and frontal bone defect surgery: 2 patients had frontal defects that were contoured with expanded polytetrafluoroethylene (Gore-Tex; WL Gore & Assoc, Phoenix, Ariz) inserted endoscopically; 2 patients had scalp soft tissue defects that were treated with wide subgaleal undermining and endoscopically guided galeotomies that resulted in primary closure; and 1 patient was treated for facial paralysis to improve the aesthetic result. We conclude that aesthetic endoscopic surgical techniques and equipment can be used in reconstructive therapy for patients with bony and soft tissue defects of the scalp and forehead

OBJECTIVES: Delineation of clinical characteristics affecting the airway in a cohort of craniofacially deformed children. What factors differ between patients requiring and those not requiring surgical airway intervention? What factors predispose to the need for tracheotomy? When can decannulation be expected if tracheotomy is required? What interventions aid decannulation? STUDY DESIGN: Five-year retrospective chart review at tertiary center. METHODS: Two hundred fifty-one patients met the following entry criteria: enrollment in the New York University Institute of Reconstructive and Plastic Surgery's Craniofacial Clinic and admission to Tisch Hospital in Manhattan for surgery from 1990 to 1994. Hospital, clinic, and departmental office records were reviewed. All patients had major craniofacial bony anomalies and underwent administration of general anesthesia at least once. RESULTS: Nearly 20% of all children required tracheotomy (47/251). Craniofacial synostosis patients (Crouzon, Pfeiffer, or Apert syndrome) had the highest rate of tracheotomy (48% [28/59]). Mandibulofacial dysostoses patients (Treacher Collins or Nager syndrome) had the next highest rate (41% [28/59]). Patients with oculo-auriculo-vertebral sequence were less likely to undergo tracheotomy (22% [9/41]). Children with craniosynostosis rarely required a surgical airway, unless there was marked associated facial dysmorphism (1% [1/72]). The duration of cannulation was related to the age at tracheotomy in a bimodal distribution. Generally, tracheotomies required before age 4 years remained for several years, whereas those placed after age 4 were removed after several weeks. The presence of a cleft palate correlated with reduced risk for tracheotomy, but the presence of a ventriculoperitoneal shunt correlated with an increased risk for tracheotomy. Procedures selectively used to improve the airway included midface advancement, mandibular expansion, tonsillectomy and adenoidectomy, uvulopalatopharyngoplasty, anterior tongue reduction, and endoscopic tracheal granuloma excision. CONCLUSIONS: The likelihood for surgical airway management is related to specific craniofacial diagnosis. The length of tracheal cannulation is greatest for infants and young children who manifest severe airway compromise, often because of nasal obstruction in combination with other anatomic factors. Early tracheotomy is advocated for these patients to promote optimal growth and development. Choanal atresia is often misdiagnosed in these infants; nasal obstruction is actually secondary to midface retrusion. Staged surgical interventions can allow eventual successful decannulation in nearly all cases of craniofacial syndromes

Osseointegrated dental implants are a widely used method of replacing lost or missing teeth. Resorption of the alveolar ridge of the edentulous posterior maxilla may necessitate augmentation before osseointegration to provide adequate bone for implant fixation. This can be accomplished through an intraoral approach to the maxillary sinus, with elevation of the mucosa of the sinus floor creating a pocket for graft placement. Disruption of the intact sinus mucosa may result in sinusitis, graft infection, or extrusion with secondary formation of an oroantral communication. To treat these patients effectively, the otolaryngologist must be aware of the techniques of sinus augmentation and osseointegration as well as the etiology of associated complications. We will discuss the management of four patients with significant sinus complications, and evaluate the otolaryngologist's role in the preoperative and postoperative care of these patients

BACKGROUND: Comorbid conditions have a significant impact on the actuarial survival of patients with head and neck cancer. However, no studies have evaluated the impact of comorbidity on tumor- and treatment-specific outcomes. This study was performed to evaluate the impact of comorbidity, graded by the Kaplan-Feinstein comorbidity index (KFI) on the incidence and severity of complications, disease-free interval, and tumor-specific survival in patients undergoing curative treatment for head and neck cancer. METHODS: A multi-institutional, retrospective cohort of 70 patients 45 years of age and under with head and neck squamous cell carcinoma (SCC) presenting over an 11-year period was studied. RESULTS: Advanced comorbidity (KFI grade 2 or 3) was present in 21 patients (30%). Patients with advanced comorbidity did not differ from patients with low-level comorbidity (KFI grades 0 or 1) in sex distribution, race, presence of human immunodeficiency virus (HIV) infection, tobacco use, location of primary lesion, stage at presentation, pathologic differentiation of the tumor, or type of initial treatment. The overall incidence of treatment-associated complications was similar between the groups (57% versus 49%; p > 0.05), but a higher proportion of patients with advanced comorbidity developed high-grade complications (24% versus 6%; p = .04). The median disease-free interval (11.1 months versus 21.6 months; p = .045) and tumor-specific survival (13.7 months versus 57.6 months; p = .03) was poorer for patients with advanced comorbidity. The effects of comorbidity on survival remained significant even after adjusting for the confounding effects of HIV status and tumor stage (p = .05). CONCLUSIONS: The presence of comorbid conditions has a significant impact on tumor- and treatment-specific outcomes. Although the presence of advanced comorbid conditions is not associated with an increase in the rate of treatment-associated complications, complications tend to be more severe in this population. More importantly, advanced comorbidity has a detrimental effect on the disease-free interval and tumor-specific survival in patients with head and neck cancer, independent of other factors. This suggests that comorbidity may impact on tumor behavior, presumably by altering the host's response to cancer. Accordingly, to be more predictive and reliable, the current staging system for head and neck cancer should include a description of the patient's comorbidity