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BackgroundThere is significant interest in treatment de-escalation for human papillomavirus-associated (HPV+) oropharyngeal squamous cell carcinoma (OPSCC) patients given the generally favourable prognosis. However, 15-30% of patients recur after primary treatment, reflecting a need for improved risk-stratification tools. We sought to develop a molecular test to risk stratify HPV+ OPSCC patients.MethodsWe created an immune score (UWO3) associated with survival outcomes in six independent cohorts comprising 906 patients, including blinded retrospective and prospective external validations. Two aggressive radiation de-escalation cohorts were used to assess the ability of UWO3 to identify patients who recur. Multivariate Cox models were used to assess the associations between the UWO3 immune class and outcomes.FindingsA three-gene immune score classified patients into three immune classes (immune rich, mixed, or immune desert) and was strongly associated with disease-free survival in six datasets, including large retrospective and prospective datasets. Pooled analysis demonstrated that the immune rich group had superior disease-free survival compared to the immune desert (HR = 9.0, 95% CI: 3.2-25.5, P = 3.6 × 10-5) and mixed (HR = 6.4, 95% CI: 2.2-18.7, P = 0.006) groups after adjusting for age, sex, smoking status, and AJCC8 clinical stage. Finally, UWO3 was able to identify patients from two small treatment de-escalation cohorts who remain disease-free after aggressive de-escalation to 30 Gy radiation.InterpretationWith additional prospective validation, the UWO3 score could enable biomarker-driven clinical decision-making for patients with HPV+ OPSCC based on robust outcome prediction across six independent cohorts. Prospective de-escalation and intensification clinical trials are currently being planned.FundingCIHR, European Union, and the NIH.

Platelet-rich plasma has been increasingly used for facial rejuvenation in conjunction with other modalities such as microneedling or on its own. Nanofat grafting to the face has also been utilized for skin quality improvements. Our group previously described the novel combined Platelet Hybridized Adipose Transplant (PHAT) technique for hair restoration. In this series, we describe our experience with the PHAT technique for lip and facial rejuvenation to improve the quality of facial skin and superficial musculoaponeurotic system, and enhancing surgical results. [ABSTRACT FROM AUTHOR]

The fundamental goal of modern face and neck lifting is to enhance and restore a more youthful facial appearance by addressing soft tissue descent. There are variations in described facelift technique including superficial musculoaponeurotic system (SMAS) flaps, composite flaps, deep plane, skin flaps, and subperiosteal facelifts, among others. The term "deep plane rhytidectomy" was originally described by Hamra. This term has since been linked with facelift surgery with recent advances including incision placement, treatments of SMAS–platysma complex, and mastoid crevasse among others. In the lead authors' experience, using deep plane techniques have demonstrated superior facial surgical rejuvenation results with less dependence on ancillary measures such as fat grafting or implantation for midface volumization. In order to successfully perform any face or neck lift, it is key to understand the relationship of the skin, the fat compartments, and the ligamentous attachments. This chapter details the anatomy of the deep plane of the face and neck and explains some nuances as it relates to surgical lifting. We also describe recent anatomical revelations of the mandibular ligament and its management in deep plane face lifting. In this chapter, given this opportunity to share personal experiences and preferences, the authors hope to describe relevant anatomy for the deep plane and provide some clarity on the merits of deep plane face and neck lift technique. [ABSTRACT FROM AUTHOR]

This article seeks to expand on our understanding of lifting by utilizing the benefits of deep plane release and repositioning. The deep plane is a more logical and natural approach to lifting of the face and neck, lifting along the natural anatomic glide planes. Deep plane face and neck lifting have demonstrated superior results in the authors' experience with less dependence on ancillary measures such as fat grafting or implantation for midface volumization. The deep plane technique allows for the face and neck to be treated and lifted as a single composite unit, providing a more natural and long-lasting result and less distortion of underlying structures (i.e., mimetic muscle function). Among facelift surgeons, there is still debate and discussion over treatment of various regions including submandibular gland prominence, jowling and deepened prejowl sulcus, anterior digastric prominence, and a low hyoid. In this article, given the opportunity to share personal experiences, we seek to provide additional insight on the merits of deep plane release in rhytidectomy and our novel approaches to avoiding surgical failures. [ABSTRACT FROM AUTHOR]

The exact relationship between the jowl and the mandibular ligament and causes for jowling remain unclear in the literature. The anatomic basis for the jowl is multifactorial and disparities in descriptions of the mandibular ligament and prejowl sulcus have resulted in variations in its management. The aim of this paper was to clarify the anatomy and aging around the prejowl sulcus and the mandibular ligament and review our experience with its management in facial rejuvenation. We performed a retrospective blinded review of patients in a high-volume private practice comparing patients who underwent mandibular ligament release in a subdermal plane during facelift with those who solely underwent fat grafting of the prejowl sulcus with facelift. Blinded surgeons graded 25 patients who had undergone mandibular ligament release and 25 patients who did not. Patient photographs were scored on a 1 to 4 graded scale of correction on the degree of jowling and prejowl sulcus depth and color. We also performed a literature review to describe the anatomy of the mandibular ligament and its implications for jowls, and techniques to address it in facial rejuvenation. Patients who had fat grafting with minimal or no release of the skin around the prejowl sulcus or mandibular ligament had a greater degree of correction of their jowls in their postoperative photographs than those who had a mandibular ligament release without fat grafting (P =.046). Adverse sequelae were also lower in the group with less skin dissection around the mandibular ligament. Our findings support the theory that the appearance of tethering and depression in the prejowl sulcus is more likely the cause of atrophy in the subdermal soft tissues than a consequence of ligamentous contracture. Volumetric replenishment with fat grafting provides a more direct solution to the cause of the issue, providing more universal improvements with less risk. Surgeons should consider volumetric fat grafting with or without subsequent subdermal release if needed. Level of Evidence: 4 [ABSTRACT FROM AUTHOR]

Background The vector of aging and consequently the vector of lift in rhytidectomy has aided surgeons in improving movement of tissues during facial rejuvenation procedures. Objectives The goal was to analyze the vector of lift in patients undergoing primary and revisional facelift to achieve proper vectorial lifting. Methods Patients undergoing deep-plane facelift surgery were included for analysis. Intraoperative photographs and measurements were taken of the skin, superficial musculoaponeurotic system (SMAS), and platysmal suture suspension with mastoid crevasse inset. Measurements were compared between patients who were undergoing primary vs secondary surgery, site of lift, age, and gender. Results Seventy-one patients (90% female, mean age 57.8) with a total of 142 hemifaces were analyzed, 57 (73%) of which were primary and 14 (27%) secondary facelifts. The average vector of SMAS lifting was 70.8°. Females had a more vertical vector than males (71.3° vs 65.4°; P <.01). The average vectors of platysmal and skin lift were 87.0° and 58.2°, respectively. There was intrapatient difference between hemifaces. Despite there being more intersuture disparity in secondary cases than primary cases (16.9° vs 4.5°; P <.05), the mean vector of lifting was similar between them. Conclusions Proper release of the deep plane helps determine the appropriate vectors of lift, without relying on guidelines based on population averages. Each patient presents with a unique vector required to correct their descent. This technique provides an optimal result by directly suspending against the vectors of greatest descent. Level of Evidence: 3 [ABSTRACT FROM AUTHOR]

Facial synkinesis is characterized by unintentional contractions of facial musculature secondary to aberrant facial nerve healing. The associated impairment in facial functioning results in a significant decrease in patients' quality of life. The mainstay treatment for postfacial paralysis synkinesis (PFPS) is chemodenervation and physiotherapy, which requires long-term maintenance neurotoxin injections. This can lead to treatment resistance. Selective neurectomy of the distal branches of the facial nerve has been suggested as an effective surgical treatment of PFPS. This study aims to provide a comprehensive systematic review evaluating the efficacy of selective neurectomy for patients presenting with PFPS. Ovid MEDLINE, Ovid Embase, PubMed, Web of Science, and CINAHL were searched from inception until July 2022. Studies that investigated postoperative outcomes of pediatric and/or adult patients who underwent selective neurectomy as a treatment for PFPS were included. The database search identified 1,967 studies, and 11 were ultimately included based on inclusion and exclusion criteria. These 11 studies represented 363 patients. Studies reported on outcomes following selective neurectomy with or without adjuvant therapies for patients with PFPS. The main outcome categories identified were clinician-reported outcomes and patient-reported outcomes. The studies that used clinician-reported outcomes found an improvement in both synkinesis and facial nerve paralysis (FNP) outcomes following selective neurectomy according to their respective grading systems. Three studies looked at patient-reported outcomes and found increased patient-reported quality of life and satisfaction following selective neurectomy. The most reported complications were upper lip contracture, uneven cheek surface, lagophthalmos, and temporary oral incompetence. Selective neurectomy has demonstrated stable or improved synkinesis, FNP, and quality of life outcomes in patients with PFPS. This approach should be considered for patients with PFPS, particularly for patients with refractory symptoms or those who are unable to undergo continued medical management. [ABSTRACT FROM AUTHOR]

Objective: Several cases of facial nerve paralysis (FNP) post‐COVID‐19 infection have been reported with varying presentations and management. This study aims to identify FNP clinical characteristics and recovery outcomes among patients acutely infected with COVID‐19. We hypothesize that FNP is a potentially unique sequalae associated with COVID‐19 infections. Methods: A systematic review of PubMed‐Medline, OVID Embase, and Web of Science databases from inception to November 2021 was conducted following the Preferred Reporting Items for Systematic Reviews and Meta‐Analyses guidelines. Results: This search identified 630 studies with 53 meeting inclusion criteria. This resulted in 72 patients, of which 30 (42%) were diagnosed with Guillain‐Barré Syndrome (GBS). Non‐GBS patients were on average younger (36 vs. 53 years) and more likely to present with unilateral FNP (88%) compared to GBS patients who presented predominantly with bilateral FNP (74%). Among non‐GBS patients, majority (70%) of FNP presented a median of 8 [IQR 10] days after the onset of initial COVID‐19 symptom(s). Treatment for non‐GBS patients consisted of steroids (60%), antivirals (29%), antibiotics (21%), and no treatment (21%). Complete FNP recovery in non‐GBS patients was achieved in 67% patients within a median of 11 [IQR 24] days. Conclusion: FNP is a possible presentation post COVID‐19 infections, associated with both GBS and non‐GBS patients. Although no causation can be assumed, the clinical course of isolated FNP associated with COVID‐19 raises the possibility of a unique presentation differing from Bell's palsy, seen with higher proportion of patients developing bilateral FNP and a shorter duration to complete recovery. Laryngoscope, 133:1007–1013, 2023 [ABSTRACT FROM AUTHOR]

The authors present their views on the merits of external rhinoplasty in the context of a renewed awareness of the endonasal approach. Why do we continue to perform rhinoplasty via an open approach? The benefits of this technique such as its unparalleled exposure, the opportunity for technical precision, and the ability to better preserve nasal function are thoroughly explored. The criticisms of this technique are presented and discussed. The authors thoughts on rhinoplasty as a whole are examined. [ABSTRACT FROM AUTHOR]

Objectives/Hypothesis: Despite considerable effort being dedicated to contouring reconstruction plates, there remains limited evidence demonstrating an association between contour and reconstructive outcomes. We sought to evaluate whether optimizing mandibular reconstruction plate contouring is associated with reduced postoperative hardware complications. Study Design Retrospective cohort study. Methods: A cohort study was performed with adult patients (age ≥18 years) who underwent mandibulectomy and osseous free flap reconstruction following oncologic ablation at the University Health Network in Toronto, Canada, between January 1, 2003 and December 31, 2014. Patients with computed tomography scans performed within 1 year of reconstruction were included. Computer‐based three‐dimensional models were generated and used to calculate the mean plate‐to‐bone gap (mm). The primary outcome was plate exposure. Secondary outcome included a composite of plate exposure or intraoral dehiscence. Logistic regression models were fitted for each outcome accounting for other patient and surgical characteristics associated with the primary outcome. Results: Ninety‐four patients met inclusion criteria, with a mean age of 60.4 (standard deviation [SD] 14.9). The mean follow‐up time was 31.4 months (range 3–94). Reconstruction was performed with fibular (57%) and scapular free flaps (43%). In the multivariable model, small mean plate‐to‐bone gap (<1 mm) was independently associated with 86% reduced odds of plate exposure (odds ratio [OR] 0.12; 95% confidence interval [CI] 0.02–0.55). Mean plate‐to‐bone gap less than 1 mm was also independently associated with reduced odds of developing a composite of plate exposure or intraoral dehiscence (OR, 0.29; 95%CI, 0.11–0.75). Conclusion: Optimizing plate contouring during mandibular reconstruction may decrease the development of postoperative hardware complications. Level of Evidence: 4 Laryngoscope, 132:61–66, 2022 [ABSTRACT FROM AUTHOR]

Objective  The aim of this study is to determine if Hyams grade may help predict which patients with esthesioneuroblastoma (ENB) tumors are likely to develop regional recurrences, and to determine the impact of tumor extent on regional failure in ENB patients without evidence of nodal disease at presentation. Design  The study was designed as a retrospective review for ENB patients. Settings  The study was prepared at tertiary care academic center for ENB patients. Participants  Patients with ENB were included in the study. Main Outcome Measures   Oncologic outcomes (5-year regional and locoregional control (LRC) and overall survival) in patients with Hyams low grade versus high grade. Oncologic outcomes based on radiographic disease extent. Results  A total of 43 patients were included. Total 25 patients (58%) had Hyams low-grade tumor, and 18 (42%) had high-grade tumor. Of the 34 patients without regional disease at presentation, 8 (24%) were treated with elective nodal radiation. There were no statistically significant differences in 5-year regional control in the Hyams low-grade versus high-grade groups (78 vs. 89%; p  = 0.4). The 5-year LRC rates in patients with low grade versus high grade were 73 versus 89% (p  = 0.6). The 5-year overall survival rates in patients with low-grade versus high-grade tumors were 86 versus 63% (p  = 0.1). Radiographic extension of disease into the olfactory groove, olfactory nerve, dura, and periorbita were statistically associated with decreased 5-year overall survival (5-year OS 49 vs. 91% [ p  = 0.04], 49 vs. 91% [ p  = 0.04], 44 vs. 92% [ p  = 0.02], and 44 vs. 80% [ p  = 0.04], respectively). Conclusion  ENBs are associated with a risk of regional failure. The current analysis suggests that Hyams low-grade and high-grade malignancies have comparable rates of early and delayed regional recurrences, although small sample size may limit our conclusions. [ABSTRACT FROM AUTHOR]

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Background: Endoscopic endonasal approaches (EEAs) have been adopted as an alternative to standard transcranial approaches for olfactory groove meningiomas (OGMs). However, the relative cost‐effectiveness remains controversial. Methods: Cost‐utility analysis from a societal perspective comparing EEA vs transcranial approaches for OGM was used in this study. Surgical treatment was modeled using decision analysis, and a Markov model was adopted over a 20‐year horizon. Parameters were obtained from literature review. Costs were expressed in 2017 Canadian dollars. Results: In the base case, EEA was cost‐effective compared with transcranial surgery with an incremental cost‐effectiveness ratio of $33 523 ($30 475 USD)/QALY. There was a 55% likelihood that EEA was cost‐effective at a willingness‐to‐pay of $50 000/QALY. EEA remained cost‐effective at a cerebrospinal fluid leak rate below 60%, gross total resection rate above 25%, and base cost less than $66 174 ($60 158 USD). Conclusion: EEA may be a cost‐effective alternative to transcranial approaches for selected OGM. [ABSTRACT FROM AUTHOR]