No abstract

The management of facial paralysis continues to evolve. Understanding the facial nerve anatomy and the different methods of evaluating the degree of facial nerve injury are crucial for successful management. When the facial nerve is transected, direct coaptation leads to the best outcome, followed by interpositional nerve grafting. In cases where motor end plates are still intact but a primary repair or graft is not feasible, a nerve transfer should be employed. When complete muscle atrophy has occurred, regional muscle transfer or free flap reconstruction is an option. When dynamic reanimation cannot be undertaken, static procedures offer some benefit. Adjunctive tools such as botulinum toxin injection and biofeedback can be helpful. Several new treatment modalities lie on the horizon which hold potential to alter the current treatment algorithm.

OverviewHead and neck trauma is commonly encountered and managed by general plastic surgeons, oral maxillofacial surgeons, and otolaryngologists. It is important to be aware of the relative prevalence of carotid artery injury found in asymptomatic blunt facial trauma patients, as they can develop devastating ischemic stroke or even death. With improved screening criteria, studies have demonstrated increased detection of blunt carotid injury (BCI) occurring in of 1-2.6% of blunt trauma cases. Skull base fractures, facial fractures, cervical spine fractures, and thoracic injuries, along with a host of other risk factors, have been identified as risk factors for BCI. The importance of early diagnosis and initiation of immediate treatment of BCI is highlighted by high rates of ischemic stroke (60%) and mortality (19-43%) associated with untreated extracranial carotid artery injuries (ECAI) that could be reduced significantly with timely treatment. [1][2][3][4][5][6] Similarly, intracranial carotid artery injuries (ICAIs) carry poor prognosis and require prompt management. With increased awareness of screening criteria and improved detection, there is a growing consensus for aggressive, early antithrombotic therapy. The majority of surgical interventions consist predominantly of endovascular techniques. Although long-term data are lacking, endovascular techniques have shown efficacy in reducing neurologic complications and demonstrated safety measures in both select extracranial and ICAIs. AnatomyThe carotid artery is located adjacent to vital neurovascular structures and is responsible for supplying adequate blood flow to the brain. It is divided by a segmental classification popularized by Bouthillier et al (►Fig. 1). AbstractWith increased awareness and liberal screening of trauma patients with identified risk factors, recent case series demonstrate improved early diagnosis of carotid artery trauma before they become problematio. There remains a need for unified screening criteria for both intracranial and extracranial carotid trauma. In the absence of contraindications, antithrombotic agents should be considered in blunt carotid artery injuries, as there is a significant risk of progression of vessel injury with observation alone. Despite CTA being used as a common screening modality, it appears to lack sufficient sensitivity. DSA remains to be the gold standard in screening. Endovascular techniques are becoming more widely accepted as the primary surgical modality in the treatment of blunt extracranial carotid injuries and penetrating/blunt intracranial carotid lessions. Nonetheless, open surgical approaches are still needed for the treatment of penetrating extracranial carotid injuries and in patients with unfavorable lesions for endovascular intervention.

Objective To provide aggregate data regarding the ability of functional rhinoplasty to improve nasal obstruction as measured by the Nasal Obstruction Symptom Evaluation (NOSE) score. Data Sources PubMed, EMBASE, Cochrane databases. Review Methods A search was performed with the terms "nasal obstruction" and "rhinoplasty." Studies were included if they evaluated the effect of functional rhinoplasty on nasal obstruction with the NOSE score. Case reports, narratives, and articles that did not use the NOSE score were excluded. Functional rhinoplasty was defined as surgery on the nasal valve. This search resulted in 665 articles. After dual-investigator independent screening, 16 articles remained. Study results were pooled with a random effects model of meta-analysis. Change in NOSE score after surgery was assessed via the mean difference between baseline and postoperative results and the standardized mean difference. Heterogeneity was assessed and reported through the I statistic. Results Patients in the included studies had moderate to severe nasal obstructive symptoms at baseline. The NOSE scores were substantially improved at 3-6, 6-12, and ≥12 months, with absolute reductions of 50 points (95% CI, 45-54), 43 points (95% CI, 36-51), and 49 points (95% CI, 39-58), respectively. All of these analyses showed high heterogeneity. Conclusions Nasal obstruction as measured by the NOSE survey is reduced by 43 to 50 points (out of 100 points) for 12 months after rhinoplasty. Our confidence in these results is limited by heterogeneity among studies, large variability in outcomes beyond 12 months, and the inherent potential for bias in observational studies.

Autologous skin grafting to the donor site in patients who undergo radial forearm free flap reconstruction (RFFF) is associated with cosmetic and functional morbidity. Integra artificial dermis (Integra Lifesciences, Plainsboro, NJ) is a bovine collagen based dermal substitute that can be used as an alternative to primary autologous skin transplantation of the donor site. We describe a staged reconstruction using Integra followed by ultrathin skin grafting that results in highly aesthetic and functional outcomes for these defects. A retrospective review of 29 patients undergoing extirpative head and neck oncologic resection were examined. Integra graft placement was performed at the time of RFFF harvest followed by autologous split thickness skin grafting at 1 to 5 weeks postoperatively. Healing fully occurred within 4-6 weeks with negligible donor site complications, excellent cosmesis, and minimal scar contracture. Composite reconstruction with Integra artificial dermis offers advantages over traditional methods of coverage for select cases of radial forearm free flap donor site closures.