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Significant nasal septal deviation may require complex reconstruction to achieve complete correction. Subtotal septal reconstruction is a method for addressing deviations in the L-strut.To review the long-term outcomes of subtotal septal reconstruction and provide objective evidence of functional and aesthetic improvement.This medical record review obtained data on 144 patients who underwent subtotal septal reconstruction from September 1, 2008, to September 1, 2013. Data analysis was performed from September 1, 2013, to September 1, 2014.Functional outcomes were measured using the Nasal Obstruction Symptom Evaluation (NOSE) questionnaire, and objective aesthetic outcomes were measured using 3-dimensional (3-D) stereophotogrammetry. Follow-up times were classified as time point 1 (TP1; preoperative), time point 2 (TP2; early postoperative), and time point 3 (TP3; final postoperative).Of the 144 patients who underwent subtotal septal reconstruction, 104 (72.2%) were female; the mean (SD) age was 37.3 (13.7) years; 57 underwent primary septorhinoplasty; and 87 (60.5%) underwent revision septorhinoplasty. The NOSE scores improved in all 5 categories of nasal obstruction, with mean (SD) survey completion at 270 (260.1) days. Aesthetic results were measured with 3-D imaging after a mean (SD) follow-up of 613.5 (434.4) days postoperatively. No statistically significant loss was found in mean (SD) nasal length over time (TP2 to TP 3, -0.16 [1.36] mm; 95% CI, -0.54 to 0.22 mm; P = .41) or between mean (SD) postoperative loss of projection (TP2 and TP3, -0.19 [0.92] mm, 95% CI, -0.45 to 0.07 mm; P = .17). An increase in mean (SD) rotation (nasolabial angle) generated with septorhinoplasty (4.24° [11.08°]; 95% CI, 1.14°-7.34°; P = .01) and a mean (SD) decrease in rotation detected during postoperative healing (-2.63° [6.96°]; 95% CI, -4.63° to -0.63°; P = .01) were found. Although measurement of symmetry was improved in the early postoperative period (TP1 to TP2, -0.16 [1.26] mm; 95% CI, -0.52 to 0.20 mm; P = .40), this finding did not become statistically significant until the final measurement (TP1 to TP3, -0.43 [1.07] mm; 95% CI, -0.73 to -0.13 mm; P = .007; TP2 to TP3, -0.28 [0.87] mm; 95% CI, -0.53 to -0.03 mm; P = .03). A mean (SD) decrease in columellar show was achieved with surgery (-0.66 [1.37] mm; 95% CI, -1.05 to -0.27 mm; P = .001). No statistically significant change was found in the alar-columellar association from TP2 to TP3 in this patient population, confirming no unwanted alar or columellar retraction over time (0.10 [0.61] mm; 95% CI, -0.07 to 0.27 mm; P = .25). A total of 114 patients (79.2%) required costal cartilage harvest for adequate reconstruction.Subtotal septal reconstruction yields improved functional and aesthetic outcomes and has the potential to be a useful tool for the rhinoplasty surgeon in the treatment of severe septal deviation.4.

After completion of this article, the reader should be able to describe the indications for lateral crural repositioning, understand the key steps to performing the procedure, and be able to manage the complications associated with this treatment strategy.

IMPORTANCE Negative pressure wound therapy has been shown to accelerate healing. There is a paucity of literature reporting its use as a tool to promote wound healing in head and neck reconstruction. OBJECTIVE To review 1 institution's experience with negative pressure dressings to further describe the indications, safety, and efficacy of this technique in the head and neck. DESIGN, SETTING, AND PARTICIPANTS Retrospective case series at a tertiary care academic hospital. One hundred fifteen patients had negative pressure dressings applied between April 2005 and December 2011. Data were gathered, including indications, details of negative pressure dressing use, adverse events, wound healing results, potential risk factors for compromised wound healing (defined as previous radiation therapy, hypothyroidism, or diabetes mellitus), and wound characteristics (complex wounds included those with salivary contamination, bone exposure, great vessel exposure, in the field of previous microvascular free tissue transfer, or in the case of peristomal application in laryngectomy). EXPOSURE Negative pressure wound therapy utilized after head and neck reconstruction. MAIN OUTCOMES AND MEASURES Indications for therapy, length and number of dressing applications, identification of wound healing risk factors, classification of wound complexity, wound healing results, and adverse events related to the use of the device. RESULTS Negative pressure wound therapy was used primarily for wounds of the neck (94 of 115 patients [81.7%]) in addition to other head and neck locations (14 of 115 patients [12.2%]), and free tissue transfer donor sites (7 of 115 patients [6.1%]). The mean (SD) wound size was 5.6 (5.0) cm. The mean number of negative pressure dressing applications was 1.7 (1.2), with an application length of 3.7 (1.4) days. Potential risk factors for compromised wound healing were present in 82 of 115 patients (71.3%). Ninety-one of 115 patients (79.1%) had complex wounds. Negative pressure dressings were used in wounds with salivary contamination (n = 64), bone exposure (n = 40), great vessel exposure (n = 25), previous free tissue transfer (n = 55), and peristomal application after laryngectomy (n = 32). Adverse events occurred in 4 of 115 patients (3.5%). CONCLUSIONS AND RELEVANCE Negative pressure wound therapy in head and neck surgery is safe and has potential to be a useful tool for complex wounds in patients with a compromised ability to heal. LEVEL OF EVIDENCE 4.

An increasing number of head and neck surgeons have begun using transoral robotic-assisted surgery. Our objective was to examine the postoperative bleeding complications we have encountered to determine risk factors and to discuss the topic of hemorrhage control.Case series with chart review.Medical records were reviewed in 147 consecutive patients undergoing transoral robotic-assisted surgery for any indication at one tertiary academic medical center between March 2007 and September 2011.Eleven of 147 (7.5%) patients undergoing transoral robotic-assisted surgery experienced some degree of postoperative hemorrhage, with 9 patients requiring reoperation for examination and/or control of bleeding. Bleeding occurred at a mean of 11.1 ± 9.2 days after initial operation. Eight of 11 (72%) patients who bled were on antithrombotic medication (anticoagulants or antiplatelet agents) for other medical comorbidities. The postoperative hemorrhage rate in patients taking antithrombotic medication (8/48 patients = 17%) was significantly higher than in those not taking antithrombotics (3/99 patients = 3%), P = .0057. While the bleeding rate in salvage surgery (3/29 = 10.3%) was slightly higher than in primary surgery (8/118 = 6.8%), this difference did not reach statistical significance.Potential for postoperative bleeding in association with antithrombotic medications in patients undergoing transoral robotic-assisted surgery should be recognized. Various effective techniques for management of these patients without robotic assistance were demonstrated.

Despite recent consensus definitions, lack of specific biomarkers remains a hurdle towards a more accurate and efficient diagnosis of cancer cachexia, distinguishing cachexia as a separate entity from other wasting syndromes. In a previous pilot study, we have shown that cancer-cachectic mice have a unique metabolic fingerprint with distinct glucose and lipid alterations compared to healthy controls. Further metabolomics studies were carried out to investigate differences in metabolic profiles of cancer-cachectic mice to tumor-bearing non-cachectic mice, calorie-restricted mice, and surgically treated cancer-cachectic mice. CD2F1 mice were divided into: (1) Cachexia Group received cachexia-inducing C26 undifferentiated colon carcinoma cells; (2) Tumor-Burden Group received, non-cachectic, P388 lymphoma cells; (3) Caloric-Restriction Group, remaining cancer-free, but subjected to caloric-restriction; (4) Surgery Group, similar to Cachexia Group, but tumors resected mid-experiment; and (5) Control Group aged intact. Baseline, mid-experiment and final serum samples were collected for 1H NMR spectroscopic analysis. After data reduction, unsupervised principal component analysis and orthogonal projections to latent structures analyses demonstrate that the unique metabolic fingerprint is independent of tumor-burden and distinct from profiles of caloric-restriction and aging. Hyperlipidemia, hyperglycemia, and reduced branched-chain amino acids distinguish cachexia from other groups. Furthermore, the profile of surgically treated mice differs from that of cachectic mice, reverting to a profile more congruent with healthy controls indicating cachexia is amenable to correction where surgical cure is possible. That metabolomic analysis of murine serum is able to differentiate cachexia from tumor-burden and caloric-restriction warrants similar translational investigations in patients to explore cancer cachexia’s unique biomarkers.

Spreader grafts are used for aesthetic and functional enhancement of the middle nasal vault in rhinoplasty. The spreader graft was originally described by Sheen as an endonasal (closed) rhinoplasty technique.1 More recently, most variations of the spreader graft have been described as anadjunct in theexternal rhinoplasty approach.2-4 The external approach allows improved visualization and access to the middle vault, which aids in accurately positioning and securing spreader grafts. In endonasal rhinoplasty, the correct placement and fixationof spreader grafts is typicallymorechallenging.4Knotless, “barbed” suture is a relativelynew technology that eliminates the need to tie knotswhile securing tissue. To our knowledge, we provide the first description of securing spreader grafts using barbed suture in endonasal rhinoplasty (Figure). The technique can be viewed in the Video.

Cancer cachexia is a severe wasting syndrome characterized by the progressive loss of lean body mass and systemic inflammation, which is seen in as many as 80% of patients with advanced malignancy. It accounts for an estimated 20-30% of all cancer-related deaths. The mechanism by which cancer induces skeletal muscle atrophy in cachexia involves tumor-derived cytokines, including TNF?, IL-1, and IL-6. Upon interaction with their unique receptors on skeletal muscle, these cytokines activate NF-kappaB, a transcription factor crucial for atrophy related sarcomere proteolysis to occur. The significance of NF-?B is highlighted in studies demonstrating that genetic inhibition of NF-?B ameliorates cancer-induced muscle loss in vivo. In the present study, we evaluate a selective NF-kappaB inhibitor (NBD peptide) which targets the IkappaB complex to prevent cancer-induced skeletal muscle atrophy in an established mouse model (C26 adenocarcinoma). We identified for the first time that NBD peptide can directly inhibit tumor-induced NFkappaB activation in skeletal muscle, resulting in a decrease loss of lean muscle. We also identified that NBD peptide reduces the expression of the tumor induced ubiquitin ligases MuRF-1 and MAFbx/Atrogin-1 necessary for atrophy. These findings highlight that NBD peptide may be a potential selective therapeutic agent for the treatment of cancer cachexia.

Objective: Anatomic identification of parathyroid glands during surgery is challenging and time consuming. We sought to determine whether 5-aminolevulinic acid (5-ALA) could produce parathyroid gland fluorescence to improve their detection in a preclinical model. Methods: Thirty-two rats were administered 0 to 700 mg/kg of 5-ALA by intraperitoneal injection prior to neck exploration under the illumination of a blue light (380–440 nm). Tissue fluorescence was assessed at 1, 2, or 4 hours postinjection and then removed for histologic confirmation of parathyroid tissue. Results: Rat parathyroid glands could not be visualized under ambient light. At dosages of 300 mg/kg or greater, bilateral parathyroid glands were visualized in 18 of 19 rats using blue light illumination. At dosages less than 300 mg/kg, parathyroid gland fluorescence was detected in only 1 of 13 rats. At 2 hours after 5-ALA administration, the net mean intensity of parathyroid gland fluorescence was optimal with a dose of 500 mg/kg. At both 1 and 4 hours after 5-ALA injection, the net mean intensity of parathyroid gland fluorescence was optimal at the highest dose (700 mg/kg) and positively correlated with dosage increases. Conclusion: 5-ALA can be used to selectively detect parathyroid tissue from surrounding tissue in a preclinical model. Our data support the use of this technique in the clinical setting.

Objective To assess the role of high-resolution ultrasonography in the preoperative evaluation of patients with hyperparathyroidism. Design Retrospective cohort. Setting Tertiary care university hospital. Patients Three hundred seventeen patients with hyperparathyroidism who underwent preoperative assessment with ultrasonography and/or sestamibi scan and surgical treatment between October 2003 and October 2006. Main Outcome Measures Descriptive statistics of localization imaging studies and detection of concomitant thyroid disease in patients presenting with hyperparathyroidism. Results Ultrasonography correctly localized the parathyroid adenoma(s) in 148 (69.4%) of the 229 patients with these lesions. Sestamibi scans correctly localized the parathyroid adenoma(s) in 133 (58.1%) of the 229 patients. The agreement between the 2 imaging procedures was moderate (κ = 0.23; 95% confidence interval, 0.12-0.36). Of 317 patients with hyperparathyroidism, 96 (30.3%) had clinically significant concomitant thyroid disease requiring partial or total thyroidectomy. Histopathologic examination revealed benign thyroid disease in 80 (83.0%) of the 96 patients and thyroid carcinoma in 16 (16.6%). Conclusion Ultrasonography is a useful tool in the preoperative evaluation of patients with hyperparathyroidism both for localization of parathyroid adenomas and for the diagnosis of concomitant thyroid disease.