HOW I DO IT
From the 4th Annual Cleveland Clinic Florida, Otolaryngology Symposium 2005
| BOTULINUM TOXIN TYPE A (BOTOX) FOR FACIAL REJUVENATION—David Greene, MD, Head, Department of
Otolaryngology, Cleveland Clinic Florida, Naples
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| Botulinum toxin type A (Botox): safe and approved by Food and Drug Administration (FDA) for cosmesis; weakens muscles
that pull downward on brow and produce aging patterns of brow and eyelids; relaxes, refreshes, and rejuvenates periorbital
area by relaxing glabella, and eliminating crow’s-feet and forehead furrows
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| Botox browlift: caveat—brow ptosis develops when entire frontalis muscle “ironed out”; key muscle groups—glabellar;
frontalis; lateral orbicularis oculi; goals—weaken brow depressors; relax glabellar frown lines; break up frontal furrows;
preserve ability of lateral frontalis to elevate lateral brow; recommendations—locate involved muscle with respect
to surface of skin; use careful palpation to place injection directly into belly of underlying muscle; injections into
wrinkles of forehead ineffective; tips on locating injection sites—corrugator muscles (common source of complaint
among young women; large, readily palpable, and felt above eyebrow); orbicularis oculi (thin; to assess situation, patient
must “squint, or crunch and grin”; located directly under skin); frontalis muscles (less bulky and lie deeper than corrugators;
place needle at intermediate depth); procerus muscle (pulls downward; located by going down to bone and backing
out “a little bit”); point—treatment efficacy improves along with increased injection accuracy
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| Frown lines: central problem; corrugator muscles—have soft tissue insertions located above brow; injections placed too
low in brow head can affect levator muscle and produce iatrogenic ptosis; to improve injection accuracy, palpate muscle
while patient performs 3 grimaces; pointers—move fingers over forehead furrows to locate frontalis muscle; have patient
squint and grin to bring out crow’s-feet produced by lateral orbicularis oculi
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| Glabellar frown lines: involve corrugator, procerus, and depressor supercilii muscles; approach—have patient frown;
palpate muscle; inject Botox directly into muscle belly; use thumb to avoid orbit; caveat—in some cases, frown brings
eyebrow below orbital rim, causing surgeon to inject too low and infiltrate Botox near levator muscle; spread out Botox
injections—grasp musculature and place 2 or 3 injections of 2.5 U above head of brow (injections should be placed on
both sides symmetrically); 2 injections of 1.25 U can be placed into procerus muscle
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| Crow’s-feet: when injecting orbicularis oculi muscle, going too far—medially can impair eye closure; inferiorly can
impair lip function; medially and superiorly can affect levator muscle and induce ptosis; points—to stay outside orbit,
palpate lateral orbital wall and rim; to accentuate crow’s-feet and feel muscle moving subcutaneously, have patient close
eyes, squint, and grin; browlift—start slowly (ie, place 2 Botox injections of 1.25 U beyond orbital rim); assess patient
response and degree of brow elevation; if patient likes result and further elevation helpful, administer additional Botox;
when significant brow elevation required—once response determined, gradually increase amount of Botox administered;
once surgeon gains appropriate skill, Botox can be placed below tail of brow
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| Forehead furrows: goal to break up straight line furrows, not flatten forehead; administer “V-shaped” series of injections;
preserve elevation over brow; focus on deepest furrows
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| Botox preparation: potency must be consistent at every use; do not use preparation techniques that will disturb or destroy
Botox; care and handling—gently rotate bottle of Botox while mixing in 4 mL of saline (never shake solution); to
maintain freshness, keep solution on ice; response to injection varies inversely with age of solution; use tuberculin syringe
with removable siliconized needles (syringe can contain 25 U of solution); take up solution with 22-gauge needle
and inject with short 30-gauge needle; coordinate patient scheduling so entire bottle of solution used in 1 day; can treat
≤4 patients with 1 bottle
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| Botox administration in younger patients: corrugator frown lines, crow’s-feet, and frontalis furrows constitute basic problems
requiring management; strategy—inject highest dose of Botox into glabella; remaining injections divided between orbicularis
oculi and frontalis muscles; when used to manage frown, Botox injections—eliminate vertical rhytids, procerus
wrinkles, crow’s-feet, and resting furrows caused by chronic tonicity of frontalis muscles; provide high, arched brows; restore
youthful appearance by cleaning up extra skin in superior sulcus of upper eyelid; preserve muscle function laterally
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| Additional aspects: dosing—corrugator muscle requires largest single dose given in 1 site, ie, 2.5 U; typically, 1 site at orbicularis
oculi muscle receives 1.25-U dose; 35-U dosing protocol—uses 1 syringe containing 25 U and 1 syringe containing 10
U; recommendation—using drawing to document each injection site helps perfect dosing within 1 or 2 treatment sessions
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| Tips: improvements in injection accuracy may reduce amount of Botox needed; to facilitate treatment—obtain before
and after photos; document location of rhytids, doses, and injections
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| ENDOSCOPIC MANAGEMENT OF ZENKER’S DIVERTICULUM—Gregory N. Postma, MD, Professor, Department
of Otolaryngology and Director, Center for Voice and Swallowing Disorders, Medical College of Georgia, Augusta
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| Zenker’s diverticulum: most common symptomatic diverticulum of esophagus or pharynx; believed caused by abnormality
in cricopharyngeus muscle and inherent weakness between inferior constrictor and cricopharyngeus; detected—
when patients fed during examination with swan-type laryngoscope, (people with good-sized pouches often develop regurgitation
in posterior cricoid or left piriform sinus); by referring primary care physician or gastroenterologist who
found pouch on barium swallow
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| Advantages of endoscopic surgery: speed; success rate equals that achieved with open surgery, but complication rate
markedly lower with stapling technique; excellent technique for revision surgery; elimination of external scarring; ability
to perform simultaneous laryngeal procedures, eg, injection augmentation procedures
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| Diverticulostomy using gastrointestinal (GI) stapling device: administer—perioperative antibiotics; ≈10 mg of dexamethasone
(Decadron); placement of nasogastric tube (NGT)—abandoned if first attempt fails; passage can facilitate
management of patient with difficult exposure, history of anterior cervical discectomy, or marked osteophytes; avoid
standard laryngoscopy position—place patient’s head and neck in neutral position; do not place rolls under shoulders;
to avoid incisors when operating on patient with marked osteophytes, head lowered and turned to right or left;
pointers—perform suture retraction on small pouches; use 0° and 30° telescopes for visualization and Weerda laryngoscope
to achieve exposure; when exposure tight, use 0° telescope to achieve visualization; several staplers can be used to
manage large pouches; patients generally go home 4 hr after stapling (patients living far from home should be hospitalized
overnight); metal plates or osteophytes in neck—can frustrate efforts to place laryngoscope into pouch; to facilitate
scope placement, insert alligator forceps through scope and pull cricopharyngeus muscle anteriorly; when stapling
small pouches, surgeon should—place stitches on either side of pouch, attach hemostats, and pull cricopharyngeus toward
self; approach provides more room to place staple gun and avoids perforating base of pouch; use 30° telescope to
facilitate visualization of stapling process
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| Other options: Dohlman procedure—indicated when stapler cannot be used; requires high magnification; open
procedure—indicated when endoscopic procedures cannot be performed
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| Disadvantages of endoscopic approach: exposure can be difficult, but with experience and proper patient positioning, surgeon
should achieve proper exposure; small pouches can be troublesome; injecting percutaneous Botox into muscle can
eliminate symptoms in patient who has thin neck, small Zenker’s diverticulum, and minimal symptomatology; postoperative
scarring can develop between rows of staples
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| Observations: complications from endoscopic surgery—dental damage; perforations (easily repaired); patient
questionnaire—75% of patients felt normal after surgery; with stratification, stapling achieved markedly better results
than Dohlman procedure; data suggest—endoscopic procedure should be considered standard treatment for Zenker’s
diverticulum
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| UVULOPALATOPHARYNGOPLASTY (UPPP) WITH PALATAL FLAP AND RELEASING INCISIONS FOR OBSTRUCTIVE
SLEEP APNEA SYNDROME (OSAS)—Dr. Greene
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| Uvulopalatopharyngoplasty: standard of care for oropharyngeal obstruction, ie, most common site of obstruction in sleep-
disordered breathing; goals—widen, heighten, and deepen oropharyngeal airway; stabilize lateral pharyngeal wall; improve
aerodynamics of palate; prevent airway collapse; success rate of UPPP alone—40% overall; 5% with retroglossal
obstruction; remains key concern during patient selection and when deciding whether to add tongue-base procedure to
management approach; response to poor success rates—more radical surgery; multilevel surgery; complications—
nasopharyngeal stenosis; velopharyngeal insufficiency; dysphagia; scar contracture; narrowing of palate into pointed arch
after healing; pain; speech disturbance; secretion collection; globus
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| Integrative approach to sleep apnea: success depends on—maximizing medical therapy initially; patient selection; maximizing
efficacy and minimizing morbidity of UPPP; patients presenting with good airways may—have tongue that
drops into pharynx; belong to older age group; have profound relaxation of muscles during sleep that causes airway collapse;
not benefit from UPPP; when selecting surgical candidates, look for—obstructive anatomy that can be repaired,
eg, large tonsils, long webbed palates, palate retroposition caused by posttonsillectomy scarring of posterior pillars, deviated
septum, and enlarged tongue base; large base of tongue that appears collapsible and palpable; poor prognostic factors
include age, obesity, retrognathia, short neck, and severe macroglossia
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| Tips for successful UPPP: preserve maximum amount of mucosa (denuding too much underlying musculature causes scarring);
achieving tension-free closure key; placing sutures deep at key points helps avoid tension; putting releasing incisions
through mucosal webs to widen airway and release palate anteriorly also helpful; keep incisions on oral surface of
palate (palatal flap); reorient rather than resect, ie, excessive resection can cause disastrous effects long term
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| UPPP with releasing incisions and palatal flap: Fairbanks incisions—placement angles vary; serve as releasing incisions;
palatal flap—breaks up incision to avoid scar contracture; prevents scarring against posterior pharyngeal wall; improves
precision; approach—if tonsils present, perform mucosa-sparing tonsillectomy; determine point of reflex where palate
touches posterior pharyngeal wall; fold palate forward; pull uvula forward to identify webs; create Fairbanks incisions obliquely;
make horizontal incision at dimple, with triangular notch at midline; elevate palatal flap; place palate against posterior
pharyngeal wall (assess overlap and assure velopharyngeal competence); excise excess tissue; preserve lateral flaps;
flaps—preserve majority of mucosa (ie, anterior and posterior mid-palate flaps; anterior and posterior tonsillar pillar flaps
bilaterally); should be closed from posterior to anterior without tension (keep closure on oral side of palate); normal
mucosa—located along edge of incision can be preserved by placing incisions on interior surface; preserved during tonsillectomy
can be used to reline tonsillar fossa and minimize closure tension; key point—tissue preservation avoids delayed
complications and scarring; bleeding complications minimized by—careful dissection; low energy cautery; probe with
small cutting tip; procedure—avoids complications; provides excellent airway; uses releasing incisions to avoid palatal
contracture or narrowing of palatal arch; reduces pain
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| Combination of palatal flap and Fairbanks incision: improves technique; spares mucosa; reorients redundant tissue; reduces
morbidity; provides airway similar in appearance to that achieved with traditional UPPP; permits closure without
tension; reduces risk for nasopharyngeal stenosis; surgical management of obstructive sleep apnea (OSA)—efficacy
limited by multilevel, multifactorial, and progressive disease; does not provide definitive cure, so be conservative up
front because patient may need “tune up”
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| RADIOFREQUENCY ABLATION OF THE TONGUE BASE (RFBOT) FOR OSAS—Dr. Greene
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| Retroglossal obstruction: must be identified and treated to increase success rate of OSAS surgery; twofold strategy for
managing obstruction—maxillofacial expansion; soft tissue reduction, ie, reduce, stiffen, and suspend
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| Integrative management approach: maximize medical therapy; surgical options—RFBOT; tongue suspension with Repose
bone screw system; genioglossus advancement; hyoid suspension; partial glossectomy vs lingual tonsillectomy;
points—large lingual tonsils should be removed; traditional glossectomies morbid and should be avoided
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| RFBOT methodology: available systems—coblation (used most often; fast and effective); somnoplasty (possesses most
clinical data; only technique approved by FDA); Ellman tongue probe (potentially impressive option); goal—treat 12 sites
over ≥2 sessions, 15 to 20 sec per site
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| Coblation: not approved by FDA; should be centered on or posterior to circumvallate papillae; going anterior or lateral to circumvallate
papillae causes problems; work posteriorly to avoid edema and swelling of floor of mouth; preoperative
pointers—think small initially; draw diagram to avoid hitting same collagen bundle twice; inject treatment site with
lidocaine with epinephrine immediately before surgery; avoid fasciculation of tongue (exit site if tongue begins to quiver);
points of procedure—perform coblation in conjunction with UPPP; expose base of tongue; use suction cautery should
blood vessel be cut; when operating laterally, go deep and parallel to mucosa
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| Somnoplasty of tongue base: good technique; unpleasant; should be coordinated with other treatment
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Educational Objectives
| The goal of this program is to educate the listener about techniques currently used in otolaryngologic surgery. After hearing
and assimilating this program, the clinician will be better able to:
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 | 1. Achieve successful facial rejuvenation using Botox injections.
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| 2. Perform successful endoscopic repair of Zenker’s diverticula.
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| 3. Determine the advantages of using a combination of uvulopalatopharyngoplasty, releasing incisions, and palatal flap
to manage obstructive sleep apnea syndrome (OSAS).
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| 4. Discuss the multilevel nature of obstruction associated with OSAS.
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| 5. Use radiofrequency ablation of the tongue base to manage retroglossal obstruction in patients with OSAS.
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Discussed on This Program
Botulinum toxin type A [Botox, Botox Cosmetic]
Dexamethasone [Decadron, others]
Lidocaine HCl with epinephrine (several trade names and preparations)
Suggested Reading
Fairbanks DN: Operative techniques of uvulopalatopharyngoplasty. Ear Nose Throat J 78:846, 1999; Han D et al: Revised
uvulopalatopharyngoplasty with uvula preservation and its clinical study. ORL J Otorhinolaryngol Relat Spec
67:213, 2005; Hatton MP, Rubin PA: A review of facial anatomy as it relates to the use of botulinum toxin. Int Ophthalmol
Clin 45:39, 2005; Postma GN et al: Endoscopic Zenker’s diverticulotomy. Ear Nose Throat J 81:380, 2002; Li KK et
al: Overview of phase I surgery for obstructive sleep apnea syndrome. Ear Nose Throat J 78:836, 1999; Sher AE et al:
The efficacy of surgical modifications of the upper airway in adults with obstructive sleep apnea syndrome. Sleep 19:156,
2996; Stuck BA et al: Tongue base reduction with temperature-controlled radiofrequency volumetric tissue reduction for
treatment of obstructive sleep apnea syndrome. Acta Otolaryngol 122:531, 2002; Stupak HD, Maas CS: New procedures
in facial plastic surgery using botulinum toxin A. Facial Plast Surg Clin North Am 11:515, 2003; Vartanian AJ, Dayan
SH: Facial rejuvenation using botulinum toxin A: review and updates. Facial Plast Surg 20:11, 2004.
Faculty Disclosure
In adherence to ACCME guidelines, the Audio-Digest Foundation requests all lecturers to disclose any significant financial
relationship with the manufacturer or provider of any commercial product or service discussed. The following has been disclosed:
Dr. Greene is affiliated with ArthroCare Corp., GlaxoSmithKline, Aventis, and Schering; Dr. Postma is affiliated
with Pentax, AstraZeneca, and the Speaker’s Bureau of Sanofi-Aventis (SAA).
Drs. Greene and Postma gave their scientific presentations at the 4th Annual Cleveland Clinic Otolaryngology Symposium
2005, presented March 17 to 19, 2005 in Naples, Florida, by the Cleveland Clinic Florida. The Audio-Digest Foundation
thanks the speakers and the sponsors for their cooperation in the production of this program.
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