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Background Delayed nonspecific posterior neck pain after pharyngeal instrumentation can be associated with a syndrome of rapidly progressive neurologic embarrassment. We present this cohort to help define the syndrome and aid in early detection. Methods We conducted a retrospective case series of 6 patients presenting from 2003 to 2012 with a history of laryngeal or hypopharyngeal squamous cell carcinoma (SCC) who underwent radiotherapy (RT) or chemoradiotherapy (CRT) followed by salvage laryngectomy. Results Posterior neck and upper back pain developed a mean of 27.5 days after instrumentation of the pharynx (reconstruction after laryngectomy or pharyngeal dilation). Myelopathy developed an average of 21.5 days after the onset of posterior neck pain. Five patients required urgent decompression. Three patients developed quadriplegia. The disease-specific mortality was 50%. Conclusion There is a syndrome of late neurological effects after RT, salvage surgery, and pharyngeal instrumentation that is associated with high morbidity and mortality. © 2015 Wiley Periodicals, Inc. Head Neck, 2015

Background: Postblepharoplasty lower eyelid retraction (PBLER) has been linked to anterior lamellar shortage, unaddressed eyelid laxity, and middle lamellar scarring. The authors believe there are other, less-appreciated physical findings (orbicularis weakness, negative-vector eyelid, and inferior eyelid/orbit volume deficit) that also influence the development and potentially the management of this complex type of eyelid malposition. Objectives: To better understand PBLER, potentially prevent its development, and improve treatment options, the authors determined the incidence of various physical findings present on initial examination of patients referred for PBLER revision. Methods: The medical charts of patients referred for PBLER revision over a 21-month period were reviewed. The presence of anterior lamellar shortage, lower eyelid laxity, and a middle lamellar (internal eyelid) scar was documented. Orbicularis weakness, negative-vector eyelid topography, and volume deficiency of the lower eyelid/inferior orbit also were noted. The incidence of each finding was calculated. Results: Forty-six patients (35 women, 11 men) were included. All patients had undergone primary transcutaneous surgery, which led to the eyelid retraction. Orbicularis weakness, anterior lamellar shortage, inferior eyelid/orbital volume deficit, negative-vector eyelid topography, and eyelid laxity were common. A middle lamellar scar of significance was found in only 17% of eyelids. Conclusions: The data suggest that the aforementioned underappreciated findings are common in patients with PBLER. Evaluating these factors when planning primary blepharoplasty may reduce the incidence of PBLER. Awareness of these findings when planning revisional procedures may improve surgical outcomes. Level of Evidence: 4 ![Graphic][1] [1]: /embed/inline-graphic-1.gif

Chronic facial paralysis is a challenging clinical entity. One of the primary goals is re-establishment of a dynamic smile, which is so important to everyday social interaction. When the facial muscles are denervated for longer than approximately 2 years, they atrophy and fibrose making nerve transfer procedures ineffective. In these cases, regional or free muscle transfer is necessary to achieve dynamic facial movement. Over the past decade, orthodromic temporalis tendon transfer has become a favored facial reanimative procedure. The surgical technique, and important pre- and postoperative factors, are discussed.

Full-thickness nasal deformities are a reconstructive challenge. Restoration of a reliable internal lining is critical for a successful reconstruction. Septal hinge flaps are the workhorse for internal lining defects. However, these and other intranasal mucosal flaps are sometimes unavailable due to prior harvest or previous oncologic resection. We present the two-stage interpolated subcutaneous fat pedicle melolabial flap for lining large defects when traditional intranasal flaps are unavailable. This approach is particularly useful when one forehead flap has already been expended, preserving the patient's remaining forehead tissue for external cover.

The role of maternal experience (i.e., pregnancy and pup exposure) on rats' performance in a foraging task was assessed. Primiparous (P) and nulliparous (N) animals were either exposed to pups for 21 days (+) or received no pup exposure (−). Following habituation trials, all animals were tested in spatial and cued versions of the dry land maze (DLM) for three days (three trials per day). In the spatial DLM, the presence of pups decreased latencies in both N and P groups in Trial 5 and P+ rats exhibited shorter latencies to baited food wells than P− animals on Trial 6. In the subsequent probe trial, P+ animals spent significantly more time in proximity to the previously baited well than P− rats. Pups enhanced performance of both P+ and N+ groups in trial 6 of the cued test. Thus, in the spatial task, the individual components of the maternal experience (e.g., pregnancy, parturition, lactation, and pup exposure) converge to produce behavioral modifications in the DLM spatial and probe tasks that enable the female to care for her offspring, in this case, by enhancing foraging behavior. Further, in one trial of each version of the task, pup exposure enhanced performance in N animals suggesting that, in isolation, pup exposure may be a more important influence on ancillary maternal behavior than the pregnancy itself.

Facial paralysis denervates the orbicularis oculi muscle with important functional and cosmetic deficits. When an intact neural circuit between the brainstem and orbicularis oculi cannot be reestablished, nerve transfer techniques are often utilized. The hypoglossal nerve has been the favored donor nerve for the past 40 years. The past 5 years has witnessed an increased interest in using the masseteric nerve due to its lower incidence of donor deficit and excellent static and dynamic results. We describe the surgical technique for end-to-end masseteric to facial nerve transfer and summarize the published results.

The globe retropulsion and eyelid depression (GRED) technique is described. This involves simultaneous unimanual lower lid depression and globe retropulsion (over the closed upper lid) with two fingers of one hand. The maneuver reliably promotes direct entry to the clearly delineated post-septal fat compartment, obviates the need for an assistant to create this exposure, and does not obscure the globe or lower lid from view.

Endoscopic browlifting techniques have been progressively refined through experience and improvements in equipment. In general, the temporal dissection and temporal fixation have been standardized; however, different options for forehead dissection are available. Subperiosteal dissection with release (elevation, incision, and spread) of the periosteum, or subgaleal dissection and release of brow depressor musculature to the supraorbital rim are both effective techniques used in endoscopic browlifts. Methods of bony fixation remain a controversial topic since there are numerous methods. Some of these methods include absorbable and nonabsorbable screws, bone tunnels with sutures, fixation to soft tissue using absorbable attachment devices such as Endotine or Ultratine (MicroAire, Charlottesville, VA), and fibrin glue. In many, particularly younger patients, we advocate deep temporal fixation only (DTFO) without bone fixation.

The title of this chapter is descriptive in that it reviews a posterior eyelid (conjunctival) approach to cosmetic rejuvenation of the lower eyelid. The designation of the procedure as transconjunctival is important in that it differentiates surgery from the more traditional transcutaneous (through the skin) approach. Transconjunctival blepharoplasty has become the most common approach to cosmetic lower lid surgery over the last decade.1 Since I have been in practice, I have only rarely performed transcutaneous lower blepharoplasty, and not at all in the last 7 years. This is because, in my critical evaluation of this surgery and in my hands, the posterior eyelid approach yields excellent results, with high patient satisfaction and fewer complications.

IMPORTANCE Identifying a procedure to address lower eyelid retraction (LER) in the presence of an orbicularis deficit is a useful tool for aesthetic and reconstructive eyelid surgery. OBJECTIVE To describe and evaluate a surgical technique consisting of a closed canthal suspension and true lower eyelid retractor recession to address LER in the setting of orbicularis weakness. DESIGN, SETTING, AND PARTICIPANTS A retrospective medical record review of patients who underwent the minimally invasive, orbicularis-sparing, lower eyelid recession from January 1, 2010, to October 1, 2012, by one of us (G.G.M.) in an ophthalmic plastic surgical practice. We included 29 patients with reduced orbicularis strength and LER resulting from eyelid paresis related to facial nerve disease, surgical trauma (after blepharoplasty), involutional change, or idiopathic causes. INTERVENTIONS Surgical intervention consisting of closed canthal suspension and lower eyelid retractor recession. MAIN OUTCOMES AND MEASURES Surgical results, complications, and patient satisfaction. RESULTS The 29 patients included 18 women and 11 men. The mean patient age was 52 (range, 6-72) years; mean follow-up, 11 (range, 6-21) months; and mean preoperative orbicularis strength, 2.7 (on a scale of 0-4, where 0 indicates no function and 4, normal function). The causes of orbicularis weakness included eyelid paresis related to facial nerve disease (11 patients), surgical trauma (13 patients), involutional change (4 patients), and an isolated idiopathic finding (1 patient). In 12 patients, the eyelid retraction was unilateral; in 17, bilateral. A small tarsorrhaphy was added to the surgery in 6 patients with facial nerve disease. The mean eyelid elevation after surgery was 1.80 mm, with only minor complications. Patient and surgeon satisfaction were high. CONCLUSIONS AND RELEVANCE Recent publications have demonstrated the utility of closed canthal suspension and true lower eyelid retractor recession as separate procedures. In the setting of LER with reduced orbicularis strength and/or tone, the techniques can be combined to recess the lower eyelid without disturbing the already compromised lower orbicularis muscle (minimally invasive, orbicularis-sparing, lower eyelid recession). The combination technique is safe and effective and yields excellent results. LEVEL OF EVIDENCE 4.

The concept of the ideal female eyebrow has changed over time. Modern studies examining youthful brow aesthetics are reviewed. An analysis of ideal female brow characteristics as depicted in the Western print media between 1945 and 2011 was performed. This analysis provided objective evidence that the ideal youthful brow peak has migrated laterally over time to lie at the lateral canthus. There has been a nonstatistically significant trend toward lower and flatter brows. These findings are discussed in relation to current concepts of female brow aging, with repercussions regarding endoscopic brow lift and aesthetic forehead surgery.

Objective To characterize revision surgery following V-Y subcutaneous tissue pedicle advancement flap repair of large upper lip skin defects. Methods Retrospective review of upper lip skin defects at least 3.0 cm 2 in area that were reconstructed with a V-Y subcutaneous tissue pedicle advancement flap at an academic tertiary care center. Depth and area of the defect, as well as involvement of the vermilion and nasal ala, were recorded as independent variables. Revision techniques were analyzed to identify patterns. Results Thirty patients were identified as having upper lip skin defects with a mean (range) area of 7.0 (3.0-14.0) cm 2 (median, 6.25 cm 2 ). The defect involved the nasal ala in 4 cases and the vermilion in 3 cases. At least 1 revision surgery was performed in 14 patients (47%). Alar or vermilion involvement was a significant factor in revision by χ 2 analysis (P = .03). Larger defect size did not predict a need for revision, even among cases where the defect did not involve the ala or vermilion (P = .68). Conclusions Reconstruction of large upper lip skin defects with a V-Y subcutaneous tissue pedicle advancement flap is associated with a 47% revision rate, and when the defect involves the ala or vermilion, the revision rate is increased. Defect size alone cannot be used to predict the need for revision surgery. Revision techniques are demonstrated.

To compare objective outcomes and complications following temporalis tendon transfer in patients with and without a history of radiation to the parotid bed.Retrospective medical chart review comparing dynamic movement of the oral commissure and resting symmetry achieved in 7 irradiated patients (group R) and 7 nonirradiated patients (group N) after temporalis tendon transfer for unilateral facial paralysis.There were no significant differences between the 2 groups of patients in terms of age, additional facial reanimative procedures, baseline lip position, or follow-up time. Postoperatively, good resting symmetry was achieved in both groups. The mean commissure excursion was significantly inferior in the irradiated group of patients (-1.5 mm in group R vs 2.1 mm in group N; P.05). Two patients in the irradiated group experienced surgical site infections requiring hospital admission and eventual debridement of their tendon transfers.Temporalis tendon transfer seems to produce less dynamic movement in patients who have received radiation to the parotid bed, and these patients may also be at higher risk of postoperative infection. Temporalis tendon transfer can achieve good resting symmetry in both irradiated and nonirradiated patients.