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Nasal reconstruction has been refined to the point that its goals should include full restoration of form and function in addition to providing an aesthetically-pleasing result. Contemporary facial plastic surgeons have all the tools available in their armamentarium to repair the complex composite structure of nasal lining, structure, and skin cover. Nasal defects most often result from oncologic surgery or, less commonly, nasal trauma. While defects of nasal cover are more prominent, the impact of unrepaired nasal lining defects should not be underestimated. Meticulous repair of lining, structure and cover are all required for functional, stable and aesthetic nasal reconstruction.

The needs of patients with a cleft lip and/or palate (CL/P) extend beyond surgical repair. A multidisciplinary approach to the care of patients with CL/P is the widely accepted standard in most regions of the developed world. Patients with CL/P in developing countries have needs similar to those of patients in industrialized nations. However, the existing shortages of healthcare resources have precluded provision of the most basic care to those with a CL/P. Innovative applications of technology can facilitate the delivery of speech therapy, evaluation of audiometric data, and limited dental evaluation for these patients with a modest financial investment. One method by which this care might be provided is with the use of Internet-based modalities. This represents a near universally available method to fill a conspicuous gap in the preoperative evaluation and postoperative care of patients with CL/P in the developing world. With rapidly expanding access to the Internet, particularly with wireless-3G connectivity worldwide, it is time to expand our delivery of humanitarian care beyond surgery alone in treating patients with CL/P in medically underserved areas.

Nasal reconstruction has reached a point in its evolution such that its goals no longer include simply filling the defect. The contemporary facial reconstructive surgeon aims for an aesthetic and functional result in the vast majority of cases. Cutaneous nasal defects most often result from oncologic surgery, such as either Mohs excision or square technique, or, less commonly, traumatic or iatrogenic injury. This article discusses the current practices in the repair of nasal defects. Although this article focuses on reconstruction of oncologic defects, the principles discussed can be effectively applied to traumatic defects, as well.

Background. Atelectasis is commonly encoun- tered in patients undergoing rectus abdominus tissue transfer. Primary closure of the anterior rectus sheath may contribute to this process. Augmentation of the closure with mesh may decrease the incidence of Atelectasis. Methods. In this retrospective review 32 patients with preop- erative and postoperative augmentation were compared to 23 who had primary closure of the anterior rectus sheath. Results. Augmentation consisted of acellular dermis (25) or mesh (7). Postoperative atelectasis was radiographically detected in: 91% (n 5 29) of augmented patients versus 83% (n 5 19) of primary closure patients. Major atelectasis in 41% (n 5 13) of augmented patients versus 61% (n 5 14) of primary closure patients p

Context: Although commonly performed, data are lacking regarding efficacy and safety of lymph node dissection (LND) for recurrent/persistent papillary thyroid cancer (PTC). Objective: Evaluate the efficacy and morbidity of LND in recurrent/persistent PTC. Design: Retrospective review of central or lateral LND performed for persistent/recurrent PTC between January 2004 and March 2006. Setting: Multidisciplinary thyroid cancer clinic with a single surgeon at an academic medical center. Participants: Seventy-five patients who underwent 79 LND for persistent/residual PTC. Safety analysis included all 79 resections. Exclusion criteria for the efficacy analysis were factors prohibiting evaluation of thyroglobulin (Tg) response. Forty-one resections were included in the efficacy analysis. Intervention: Selective LND per standard of care. Main Outcome Measure: Primary outcome was the Tg response to LND. Secondary outcomes were surgical complications. Results: Thirty-nine of the 41 evaluable resections also had Tg data allowing classification of Tg response. Of 39 classifiable resections, 16 (41%) resulted in undetectable postoperative stimulated Tg levels. An additional 12 resections resulted in significant (≥50%) reductions in suppressed or stimulated Tg levels for an overall improvement rate of 72%. Of all 79 resections, 25 (32%) resulted in minor and 7 (9%) resulted in major complications. Conclusions: LND for persistent/recurrent PTC is a relatively safe procedure in experienced hands. It can lead to an undetectable Tg in 41% of cases and produce a major Tg reduction in an additional 31%. Its efficacy in short-term follow-up is comparable with that reported for I-131, and it should be considered in the management of persistent/recurrent PTC.

Numerous materials are available for use in augmentation rhinoplasty. For the moderate-to-severe saddle nose deformity, we prefer use of irradiated homologous costal cartilage. This method has been effective in augmentation of the nasal dorsum as well as nasal tip modification, when septal or auricular cartilage is lacking. During the past 25 years, we have used irradiated costal cartilage at our institution via the external rhinoplasty approach for robust and versatile reconstruction of the nasal framework and esthetic nasal tip modification. This article contains a detailed discussion of the technique as well as selected illustrative cases.

Objective Free tissue transfer to the skull base provides a watertight seal to prevent CSF leakage and donor tissue tailored to the individual defect. Study Design and Setting Retrospective chart review of 38 patients who underwent free tissue transfer to the skull base between November 1995 and October 2005 at an academic, tertiary referral center. Results There were 23 male and 15 female patients (average age, 58.1 years) with skull base defects resulting from oncologic resection or head trauma most frequently. Donor sites included the radial forearm (25), rectus abdominis (12), latissimus dorsi (4), anterolateral thigh, scapula, serratus anterior, and ulna (1 each). Seven patients required a second free tissue transfer indicated for flap death (3), partial flap necrosis (2), pneumocephalus (1), or tumor recurrence (1). Two patients died in the immediate postoperative period. Conclusions Free tissue transfer is a robust option in the repair of post-surgical and post-traumatic skull base defects.

Objectives Laryngotracheal stenosis is a complex problem resulting most often from intubation, trauma,or autoimmune disease. Management options include dilation or airway reconstruction including laryngotracheoplasty (LTP), cricotracheal resection (CTR), and tracheal resection (TR). We describe our experience with management of this difficult problem. Study design Retrospective chart review of patients treated for laryngotracheal stenosis between January 1995 and July 2005 at an academic, tertiary referral center. Methods A total of 127 patients were treated during the study period. Patients were followed, and hospital records were reviewed. Results There were 38 male and 89 female patients with an average age of 55.5 years treated for laryngotracheal stenosis resulting from intubation (64), idiopathic (25) or autoimmune disease (18), radiation (9), trauma (5), prior surgery (4), and relapsing polychondritis (2). Thirty-three percent were treated for grade I stenosis, 44% grade II, 19% grade III, and 4% grade IV. Seventy percent of patients undergoing initial dilation required a subsequent procedure. LTP, CTR, or TR was performed in 43%, 48%, 71%, and 100% of patients with grade I through IV stenosis, respectively. Among 76 patients undergoing LTP, CTR, or TR, 24 (32%) required a subsequent intervention. Among 36 patients treated with primary LTP, CTR, or TR, only 10 (28%) required further therapy. Twenty-two of 35 (63%) tracheostomy-dependent patients were ultimately decannulated. Three patients died in the immediate postoperative period. Conclusions Patients undergoing dilation for laryngotracheal stenosis require multiple procedures. However, major reconstructive procedures are well tolerated and currently represent a viable primary treatment for laryngotracheal stenosis.

Although recent clinical trials suggest that conjugate vaccination will be less effective for the prevention of AOM than for IPD, these trials have demonstrated impressive reductions in the incidence of AOM due to invasive and antibiotic-resistant pneumococcal serotypes. These data suggest that if serotype replacement does occur in immunized children, the causative agents are likely to be less virulent than vaccine strains. Furthermore, a recent cost-effectiveness analysis projected that immunization of healthy infants with the heptavalent conjugate vaccine could prevent over one million episodes of AOM and 12,000 cases of invasive pneumococcal disease. Because significant reductions have been demonstrated in the incidence of frequently recurrent AOM, children with the worst disease stand to benefit most from vaccination. Based on data currently available, however, the conjugate vaccine is not going to eradicate AOM. Consequently, there will continue to be a need to scrutinize the threshold for prescribing antibiotics. In addition, there will be an ongoing need for surgery in some cases of recurrent AOM and persistent OME.

Previously, we demonstrated that the anti-inflammatory drug chloroquine (CQ) inhibited LPS-induced TNF-α transcription. To define further the mechanism of CQ, we studied the effect of this drug on mitogen-activated protein kinase signaling pathways involved in regulation of TNF production. CQ interfered with phosphorylation of extracellular signal-regulated kinases (ERK)1/2 and the ERK-activating kinases mitogen-activating protein/ERK kinase (MEK)1/2. Both CQ and PD98059, a MEK1 inhibitor, reduced luciferase reporter activity driven by human TNF promoter sequences. However, CQ appeared to mediate these effects by deactivating Raf, the upstream activator of MEK. These findings were supported by functional data demonstrating that CQ and PD98059 interfered with TNF expression in several human and murine cell types while neither inhibitor blocked TNF production in murine RAW264.7 macrophages, a cell line that does not require MEK-ERK signaling for TNF production. Finally, we evaluated whether CQ could sensitize HeLa cells to undergo anti-Fas-mediated apoptosis, an effect observed when ERK activation is interrupted in this cell line. CQ rendered HeLa cells sensitive to anti-Fas treatment in a manner similar to PD98059. Taken together, these data argue that therapeutic concentrations of CQ interfere with ERK activation by a novel mechanism, an effect that could be responsible, at least in part, for the potent anti-inflammatory effects of this drug.

Chloroquine (CQ) is a lysosomotropic weak base with over 60 years of clinical use for the treatment of malaria and rheumatologic disorders. Consistent with its anti-inflammatory properties, CQ has been shown to interfere with TNF-α release from mononuclear phagocytes. Because it is unclear how CQ mediates these immunomodulatory effects, we set out to elucidate its mechanism of action. CQ exhibited dose-dependent inhibition of LPS-induced TNF-α release from human PBMC at therapeutically attainable concentrations. Additional studies to determine the specificity of this effect showed that although CQ reduced IL-1β and IL-6 release, secretion of RANTES was unaffected. CQ acted by reducing TNF-α mRNA accumulation without destabilizing its mRNA or interfering with NF-κB nuclear translocation or p50/p65 isoform composition of DNA-binding complexes. Intracellular cytokine staining indicated that CQ reduced TNF-α production pretranslationally without interfering with TNF-α processing or release. We utilized bafilomycin A1 pretreatment to block the pH-dependent trapping of CQ in endosomes and lysosomes. Although bafilomycin A1 alone did not interfere with TNF-α expression, preincubation augmented the ability of CQ to reduce TNF-α mRNA levels, suggesting that CQ did not act by a lysosomotropic mechanism. Using confocal microscopy, we showed that bafilomycin A1 pretreatment resulted in a dramatic redistribution of quinacrine, a fluorescent congener of CQ, from cytoplasmic vacuoles to the nucleus. These data indicate that CQ inhibits TNF-α gene expression without altering translocation of NF-κB p50/p65 heterodimers. This dose-dependent effect occurs over a pharmacologically relevant concentration range and does not require pH-dependent lysosomotropic accumulation of CQ.

The antimalarial drug chloroquine accumulates inside the macrophage phagolysosome by ion trapping where it exerts potent antifungal activity against Histoplasma capsulatum and Cryptococcus neoformans by distinct mechanisms. Chloroquine inhibits growth of H. capsulatum by pH-dependent iron deprivation, whereas it is directly toxic to C. neoformans. Clearly, clinical studies are required to document the potential therapeutic efficacy of chloroquine or related congeners as adjuvant therapy in fungal disease. Moreover, the diversity of pathogenic microorganisms inhibited and/or killed by chloroquine makes this drug an attractive candidate for prophylactic therapy.

We describe two cases of airway foreign bodies (FB) consisting of a dental crown. The shape and composition of dental crowns complicate their extraction from the tracheobronchial tree, sometimes necessitating thoracotomy. We describe the use of a multidisciplinary approach involving rigid and flexible bronchoscopy in concert with the use of wire snares under fluoroscopic guidance for extraction of these challenging FB. These cases illustrate that this multidisciplinary approach can allow successful extraction of the difficult FB from much of the tracheobronchial tree and the avoidance of thoracotomy.

Exposure to tobacco carcinogens is causally associated with head and neck squamous cell carcinoma (HNSCC), but the underlying molecular mechanisms remain unclear. Here, we reported that AKT is activated at a higher frequency in both HNSCC tumors and the adjacent mucosa from HNSCC patients who are smokers than those from HNSCC patients who are non-smokers. Adding physiologically relevant concentrations of 4-(methylnitrosamino)-1-(3-pyridyl)-1-1butanone (NNK), a major tobacco carcinogen, to normal head and neck epithelial cells and HNSCC cell lines, rapidly and constitutively activated AKT through phosphorylation in a dose- and time-dependent manner. AKT phosphorylation was associated with activation of downstream signaling mediators BAD, MDM2, GSK-3β, mTOR. These alterations correlated with increased proliferation and decreased etoposide-induced apoptosis in NNK-exposed cells. Finally, NNK exposure to mouse head and neck epithelia resulted in epithelial hyperproliferation and reduced apoptosis, which is correlated with AKT activation. Our results suggest that AKT activation is an early event and plays a pivotal role in mediating tobacco-induced HNSCC carcinogenesis.

In the setting of known facial nerve sacrifice or injury, patients require precautions to prevent exposure keratitis and the morbidity that follows. One recommended treatment is surgical placement of a gold weight with or without lateral tarsal strip. In patients in whom the facial nerve has been sacrificed, it is unknown whether rehabilitation should be simultaneous or in the perioperative period.Case series with chart review of patients who underwent immediate rehabilitation of the eye (gold weight and lateral tarsal strip) following facial nerve resection.From 1998 to 2009, 52 patients were studied. Postoperative ophthalmologic complications and the need for revision surgeries were measured.A gold weight was placed in all patients, and 48 of 52 (92%) simultaneous lateral tarsal strips were performed. The facial nerve was sacrificed in 51 of 52 (88%) patients, and the remaining patient had a known preoperative facial nerve paralysis. Thirty-six of 52 (69%) required free tissue transfer for reconstruction, underscoring the extensive resections performed. A 1.2-g gold weight was placed in 50 of 52 (96%) patients. Three (6%) patients required gold weight revision with a larger weight and 3 (6%) for extrusion. Eight (16.7%) patients underwent revision of the lateral tarsal strip for ectropion.No patients developed ophthalmologic complications. Patients undergoing radical surgical resections with known or suspected injury of the facial nerve should be considered for simultaneous rehabilitation of the upper and lower eye.

The rib is a generous source of donor cartilage. Thus, costal cartilage harvest is a frequently performed adjunctive procedure in facial plastic and reconstructive surgery. Pneumothorax is an uncommon complication of rib graft harvest but is potentially highly morbid. Although chest radiography is the current diagnostic study of choice to rule out air in the chest, there is growing evidence that ultrasonography is less expensive and more sensitive. Furthermore, the portability of the ultrasonographic unit allows for immediate evaluation and more rapid diagnosis. The use of ultrasonography also precludes exposing the patient to ionizing radiation. We present a case in which ultrasonography was used to rapidly confirm the absence of pneumothorax after costal cartilage harvest and review the literature associated with use of ultrasonography for detection of this uncommon but serious complication.

Laryngeal adenoid cystic carcinoma (ACC) is a rare clinical entity that poses a number of diagnostic and therapeutic challenges. We present a case of ACC of the subglottic larynx, and we review its diagnosis and management. We also discuss the workup of submucosal masses of the subglottic larynx, with an emphasis on clinical and radiologic diagnosis, surgical treatment, radiotherapy, and emerging therapies. The presence of a submucosal mass in the subglottic larynx should raise suspicion for the presence of ACC.

The alar cartilages provide the contour and structural support of the nasal tip. Current rhinoplasty concepts support preservation of alar structure with suture techniques or judicious cephalic trim indicated for tip deformities. In many primary cases and some revisions, adequate alar structure exists to achieve the desired aesthetic and functional results with conservative surgical methods. In some primary and most revision cases, however, the existing tip structure is inadequate to create a structurally sound and aesthetically pleasing nasal tip without adding structure. In these cases, alar cartilage grafting techniques are indicated to recapitulate nasal tip contour and structure.

To describe our experience with coblation technology for facial resurfacingRetrospective chart review of all patients treated with coblation at our institutionTwenty-four patients (22 female) underwent a total of 29 coblation procedures for aging face (n = 21) or acne scarring (n = 3). The perioral region was the most frequently treated aesthetic subunit (n = 14), followed by the lower eyelid (n = 7). Five patients underwent full-face coblation. Three patients underwent a second coblation procedure for aging face while a single patient with severe acne scarring underwent 3 procedures. Repeat coblation was delayed at least 5 months (mean, 9 months). Seventeen coblation procedures (59%) were performed concurrently with procedures including, but not limited to, injection treatment, rhinoplasty, blepharoplasty, or combined face/necklift; no adverse events occurred. Seven procedures, including a full-face coblation, were performed in the office under local anesthesia and oral sedation without any adverse events. Mean follow-up was 6 months (range, 1 week to 24 months). No complications were observed. All patients were satisfied with the results after their final coblation treatment.Facial coblation is a safe and effective treatment modality for facial resurfacing.

Male skin care has undergone significant development over the past decade, with many companies now marketing skin care products directly to the male consumer. Despite the claims of many of these companies, few over-the-counter products have data to support their efficacy at a clinical level. A basic, effective regimen for preventive male skin care should include twice-daily facial cleansing and twice-daily moisturizer application, which should include sunscreen during the day. This article focuses on topical therapies directed at the maintenance and repair of photoaged male skin. The future holds promise for new developments in skin care. However, in the absence of significant scientific breakthroughs, the most cost-effective intervention will continue to be prevention.

The transforming growth factor-β (TGF-β) pathway is a critical regulator of cell growth and proliferation (1). The key players in this pathway include the heteromeric TGF-β transmembrane receptor complex that, following binding to TGF-β, phosphorylates and activates a family of intracellular signaling molecules known as the Smads. Several molecules, including c-Ski and SnoN, negatively regulate TGF-β signaling.

Objective We sought to evaluate the functional and aesthetic outcomes of immediate facial reconstruction with a Gore-Tex (expanded polytetrofluoroethylene) sling in irradiated patients undergoing large head and neck tumor extirpation with facial nerve resection. Study Design and Setting We conducted a retrospective study of 17 patients at two academic institutions who underwent extirpative surgery with immediate Gore-Tex sling reconstruction and completed radiotherapy. Functional and aesthetic results were evaluated at three intervals. Results All patients had excellent immediate results and good or excellent intermediate-term results. At long-term follow-up, results were good to excellent in 47% and unacceptable in 35% of patients. Conclusion In irradiated patients undergoing total parotidectomy with immediate facial reconstruction using Gore-Tex slings, early results are excellent, but there is a high incidence of major wound complications and unacceptable results in long-term follow-up. Significance There is a high rate of late complications associated with immediate facial reconstruction with Gore-Tex slings in irradiated patients.

The prognosis of head-and-neck squamous cell carcinoma (HNSCC) has not been improved in the past 20 years. Validation of HNSCC biomarkers for targeted therapy has been hindered by a lack of animal models mimicking human HNSCC at both the pathological and molecular levels. Here we report that overexpression of K-ras or H-ras and loss of transforming growth factor-β type II receptor (TGFβRII) are common events in human HNSCC. Activation of either K-ras or H-ras in combination with TGFβRII deletion from mouse head-and-neck epithelia caused HNSCC with complete penetrance, some of which progressed to metastases. These tumors displayed pathology indistinguishable from human HNSCCs and exhibited multiple molecular alterations commonly found in human HNSCCs. Additionally, elevated endogenous TGFβ1 in these lesions contributed to inflammation and angiogenesis. Our data suggest that targeting common oncogenic pathways in tumor epithelia together with blocking the effect of TGFβ1 on tumor stroma may provide a novel therapeutic strategy for HNSCC.

Background. DuraPrep is a widely used, alcohol-based surgical prep solution. The risk of surgical fire associated with incomplete drying of this agent in the context of electrosurgical procedures has been described previously. To date, there have been no reports of fire during tracheostomy associated with a flammable prep agent before entering the airway. We describe an operating room fire occurring during awake tracheostomy associated with the use of DuraPrep. Methods. A 62-year-old man with copious body hair underwent tracheostomy in the operating room. The neck was prepared with DuraPrep surgical solution, and after at least 3 minutes, the operative field was draped. Activation of electrocautery ignited a fire, and the patient was burned on his neck and shoulders. Results. The fire was extinguished, and the patient recovered from both the tracheostomy and the burns. Conclusion. This case illustrates that DuraPrep should be avoided in the hirsute patient, because body hair interferes with drying of this solution and increases the risk of fire. © 2006 Wiley Periodicals, Inc. Head Neck, 2006

In vitro studies indicate that deregulation of the PI3K/AKT pathway is important in head and neck squamous cell carcinoma (HNSCC) tumorigenesis, as has been observed in several other cancers. However, the in vivo role of PI3K/AKT pathway deregulation in HNSCC remains unknown. The objective of this study was to investigate the in vivo roles of PIK3CA, PTEN and AKT alterations in head and neck tumorigenesis. To this end, we developed inducible head and neck specific transgenic PIK3CA and AKT mice, and inducible head and neck specific knockout PTEN mice under the control of an RU486-responsive Keratin 5 promoter. Both PIK3CA or AKT transgene expression was induced in mouse head and neck epithelia, i.e. buccal mucosa, tongue, and esophagus, upon RU486 application in a dose- and time- dependent manner. PTEN deletion was also achieved in mouse head and neck epithelia after five consecutive RU486 applications. The PIK3CA and AKT inducible transgenic mice exhibited severe head and neck epithelial hyperplasia, dysplasia, and carcinoma in situ, but no visible tumor formation after one year of observation. Further, the inducible head and neck specific PTEN knockout mice developed oral, but not esophageal SCCs. To investigate whether the inducible PIK3CA or AKT mice harbored higher cancer susceptibility upon tobacco carcinogen exposure, we applied a subcarcinogenic dose of 4NQO, a surrogate of a tobacco carcinogen, to the PIK3CA and AKT mice. Both PIK3CA and AKT mice developed oral and/or esophageal SCCs as early as one month after 4NQO exposure, and by 4 months, all PIK3CA and AKT transgenic mice developed oral and/or esophageal SCCs. Interestingly, a higher incidence of esophageal in comparison with oral SCC (93% versus. 19% of mice) was observed in the AKT transgenic mice, while a higher incidence of oral versus esophageal SCC (74% vs. 44% of mice) was found in the PIK3CA mice, suggesting a tissue specificity of AKT and PIK3CA in head and neck tumorigenesis. Studies investigating the underlying molecular mechanism of each molecule in head and neck tumorigenesis are currently underway. In conclusion, our data demonstrate an oncogenic role of PIK3CA and AKT, and a tumor suppressive role of PTEN in head and neck tumorigenesis in vivo. Our inducible head and neck specific mouse models are powerful tools to evaluate the roles of PIK3CA, PTEN, and AKT during each stage and site involved in head and neck tumorigenesis, and to test novel therapeutics targeting this important signaling pathway. Citation Information: Cancer Res 2009;69(23 Suppl):B19.