Journal Articles

Nasal Valve Reconstruction Using a Titanium Implant: An Outcomes Study. 

Neal D. Goldman, MD, Richard Alexander, MD, Laura F. Sandoval, DO and Steven R. Feldman, MD

Craniomaxillofacial Trauma and Reconstruction. 2017.


Septoplasty alone is not always sufficient to correct nasal obstruction. Various techniques have been employed to repair nasal valve collapse and improve airflow.

This article aimed to evaluate outcomes and quality of life following nasal valve reconstruction using a titanium implant in patients with nasal valve collapse.

This is a single-center retrospective study that consisted of a telephone questionnaire of 37 quality-of-life measures and questions related to the surgical procedure and recovery process to evaluate postsurgical outcomes.

Fifteen patients completed the survey. There was a significant improvement in nasal blockage/obstruction, breathing through the nose, sleeping, breathing through nose during exercise, the need to blow nose, sneezing, facial pain/pressure, fatigue, productivity, and restlessness/irritability after surgery. Overall, 100% of patients were satisfied with the results and would recommend this procedure. The most common postoperative complaints were pain (33%) and difficulty breathing (33%). Patients noticed no increase (20%) or a slight increase (73%) in the size of their nose. Sixty percent of patients cannot see the implant and 13% report the implant is barely noticeable.

Nasal valve repair with a titanium implant was successful at improving symptoms of nasal obstruction and other quality-of-life issues. Satisfaction was high among all patients. The implants are palpable, thought to be visible by some patients, yet accepted by the majority of patients. This approach may be especially important in patients with prior nasal surgery but continue to experience refractory symptoms.


Comparison of Photographic Methods. 

Kristin K. Marcum, MD, Neal D. Goldman, MD, and Laura F. Sandoval, DO

Journal of Drugs in Dermatology. February 2015. Volume 14. Issue 2. 


BACKGROUND: Photo documentation has become increasing important in medicine, especially given the demand for cosmetic procedures. Standard photography is not always adequate; newer techniques exploring the use of polarized, cross and ultraviolet photography can give detailed information on subtle skin lesions including skin pigmentation and skin surface characteristics.

OBJECTIVE: To use various methods of photography including standard photography, cross polarized light, parallel polarized light and ultraviolet passing photography to assess which method most effectively captures skin features such as texture, pigment, and/ or vascularity.

METHODS: A prospective analysis comparing advanced photographic techniques including standard photography, polarized light photography, cross-polarized light photography and ultraviolet light passing photography. The photos were then evaluated and scored by two experts and a blinded observer to characterize the differences visualized in each type of photography compared to standard photography in terms of subsurface skin features, hypopigmentation, hyperpigmentation, and rhytids.

RESULTS: 9 subjects completed the study. Overall, of the 3 photographic methods compared to standard photography, UV passing most enhanced the visualization of subsurface features and hypopigmentation, with increased hyperpigmentation as well. Enhancement of these features made UV passing best for capturing photodamage. Cross-polarized photography was best for visualizing hyperpigmentation, but also heightened visualization of hypopigmentation and subsurface features such as vascularity. Parallel-polarized photography enhanced visualization of skin texture.

CONCLUSIONS: These methods of photography show a quantifiable and reproducible selective ability to evaluate and document elements such as skin texture, vascularity, and pigmentation. Each of these techniques has unique properties that can add to the precision of the clinical evaluation and can be of particular value to providers of cosmetic procedures where photo documentation has become increasingly important in providing an objective means of evaluating outcomes.


Evaluation of Headache Relief with Cosmetic OnabotulinumtoxinA Injections.

Goldman ND, Dorton LH, Marcum KK, Gilbert RM, Sandoval LF.

Journal of Cosmetic Dermatology.  September 2014.  Volume 13, Issue 3, Pages 224-231. 


Chronic headaches are common and can have a significant effect on quality of life. Approved treatment options are vast and include the use botulinum toxin injections. The objective of this study is to evaluate the effects of purely cosmetic onabotulinumtoxinA (BOTOX(®) ) injections on the frequency and severity of chronic headaches. Patients seeking treatment of hyperfunctional facial lines were enrolled to complete pre- and posttreatment questionnaires assessing headache symptoms. Quantitative data was compared using paired two-tailed student t-tests between groups of patients who received onabotulinumtoxinA injections, both onabotulinumtoxinA and hyaluronic acid (Restylane(®) ) injections, and hyaluronic acid injections. One hundred and ten patients were enrolled; 73 completed the study. Of the 45 patients with pretreatment headaches, 76% (22/29) that received cosmetic onabotulinumtoxinA injections alone and 69% (27/39) that received onabotulinumtoxinA with or without hyaluronic acid injections reported overall improvement in headaches. Patients who received only onabotulinumtoxinA reported a significant decrease in the frequency (P = 0.0016) and severity (P = 0.0002) of headaches, and the number of days over-the-counter medications were taken (P = 0.0238). It took an average 9.5 days for headache improvement vs. 4.4 days for an appearance change. In patients who received only hyaluronic acid injections (n = 6), no significant improvement in headaches was reported. Overall satisfaction was high and unaffected by whether patients experienced headache relief. The majority of patients (93%) reported that they would "definitely" or "likely" receive onabotulinumtoxinA injections again in the future. Purely cosmetic onabotulinumtoxinA injections of doses between 15-50 units can significantly decrease the severity and frequency of headaches.


Patient Outcomes, Satisfaction, and Improvement in Headaches after Endoscopic Brow-Lift.

Panella NJ, Wallin JL, Goldman ND.

JAMA Facial Plastic Surgery 2013. July 2013, Volume 15, No. 4, Pages 263-267. 


IMPORTANCE: To improve preoperative counseling for patients considering endoscopic brow-lift (EBL).

OBJECTIVES: To understand patient-reported outcomes, satisfaction, and recovery after EBL surgery to improve preoperative counseling.

DESIGN, SETTING, AND PARTICIPANTS: A retrospective telephone survey of 57 patients who had EBL or EBL with concurrent rhytidectomy to assess cosmetic and functional outcomes using 47 questions.

 MAIN OUTCOME AND MEASURE: Questions evaluated outcomes, satisfaction, and recovery.

RESULTS: Fifty-three patients (93%) reported the procedure was successful, and 55 patients (96%) would recommend undergoing this procedure. Forty-two (74%) were incidentally told they looked younger; 37 patients (65%) were told they looked less tired. Forty-two patients (74%) reported increased confidence. Fifty-one patients (89%) required analgesics for less than 1 week, 44 patients (77%) reported scars as unnoticeable, 54 patients (95%) reported postoperative edema lasting less than 2 weeks, 16 patients (28%) reported alopecia at an incision site, and 36 patients (63%) had some numbness. In the 16 patients who reported headaches before surgery, 8 patients (50%) reported an improvement in either frequency or intensity. Patients who underwent rhytidectomy were significantly more likely to take 2 weeks or longer to return to normal activities. No differences were noted between rhytidectomy with EBL compared with EBL alone in analgesic use, edema, numbness, alopecia, and satisfaction.

CONCLUSIONS AND RELEVANCE: Endoscopic brow-lift is well tolerated and most patients are happy with the outcome. Relying on patient-reported information helps us to better understand the surgical experience and to improve preoperative counseling.


Recognition and Treatment of Non-Infectious Hyaluronic Acid Reactions.

Hatcher JL, Goldman ND.

Journal of Dermatological Treatment. December 2014, Volume 25, No. 6, Pages 513-515. 


OBJECTIVE: To differentiate a non-infectious inflammatory reaction following hyaluronic acid injection for facial rejuvenation from other reported complications, and describe appropriate treatment.

METHODS: Using a review of the literature and information available from the manufacturer, recommendations for management of non-infectious hyaluronic acid reactions are made.

 RESULTS: Patients who are afebrile with a normal white blood cell count and negative cultures, who appear to have an infectious process following hyaluronic acid injection are in fact having an inflammatory response. The inflammation may worsen with antibiotic therapy. Treatment should be systemic and/or local steroids, which may need to be for up to 6 months.

CONCLUSION: After reviewing the literature, non-infectious inflammatory reaction following hyaluronic acid injection is exceedingly rare with only one other reported case. Erythematous skin in the week following injection without other infectious markers, such as fever or elevated serum white blood cell count, is an inflammatory reaction and should be treated with steroid therapy.


Nonmelanoma Skin Cancer Treatment Training Varies Across Different Medical Specialists.

Romero PC, Kinney MA, Taylor SL, Levender MM, David LR, Goldman ND, Khanna VC, Williford PM, Feldman SR.

Journal of Dermatological Treatment.  June 2013, Volume 24, No. 3, Pages 215-220.  



Physicians from various specialties treat patients with nonmelanoma skin cancer (NMSC). The isolation of specialties from each other may result in different approaches to skin cancer training.

 PURPOSE: Our purpose was to determine the type and amount of NMSC surgical training that is received during dermatology, general surgery, internal medicine, otolaryngology, and plastic surgery residencies.

METHODS: E-mail contact information for residency program directors of all accredited programs in each specialty was compiled through the American Medical Association's online residency database. A total of 920 residency program directors were emailed surveys concerning the training of residents in the treatment of NMSC.

RESULTS: Forty-two of 920 surveys were returned. All surveyed specialty groups, except internal medicine, had training in NMSC treatment including simple excision, split thickness skin grafts, and tissue rearrangement. A majority of the dermatology and plastic surgery programs instruct their residents in Mohs micrographic surgery and full thickness skin grafts. Electrodessication and curettage was most often instructed in dermatology, general surgery, and plastic surgery programs.

CONCLUSION: Greater consistency in NMSC treatment training may be beneficial. Because different approaches may be best suited to particular clinical situations, NMSC treatment training should include adequate exposure to all NMSC treatment techniques.


Microtia Reconstruction.

Quatela VC, Thompson SK, Goldman ND.

Facial Plastic Surgery Clinics of North America.  Volume 14, Issue 2, Pages 117-127. 


Success in microtia surgery requires meticulous patient education, planning, technique, and follow-through. When these principles are followed, excellent results as well as tremendous satisfaction are achievable for both the patient and surgeon.


Nonmelanoma Skin Cancer: An Episode of Care Management Approach.

Housman TS, Williford PM, Feldman SR, Teuschler HV, Fleischer AB Jr, Goldman ND, Balkrishnan R, Chen GJ.

Dermatologic Surgery.  July 2003, Volume 29, Issue 7, Pages 700-711. 


BACKGROUND: The incidence of nonmelanoma skin cancers (NMSCs) was estimated at 1.3-million cases for the year 2000 and is on the rise. It is the most common form of cancer in the United States, more common than all other cancers combined. To determine the contributors to the cost of NMSC care, an episode of care of NMSC needed to be defined.

OBJECTIVE: To define and validate an episode of NMSC care.

DESIGN: Using survey and Medicare part A and part B claims data of the Medicare Current Beneficiary Survey (MCBS), 1992 to 1995, an algorithm was created to define an episode of care for the diagnosis and treatment of an NMSC. MCBS estimates of the number of episodes occurring in three service settings (physician's office, outpatient/ambulatory surgical center, or hospital) and demographics were compared to data from independent datasets, including the National Ambulatory Medical Care Survey (NAMCS, 1995), the National Survey of Ambulatory Surgery (NSAS, 1994 to 1996), and the National Hospital Discharge Survey (NHDS, 1992 to 1997).

RESULTS: Pathology claims for NMSC diagnosis served as the indicator of NMSC episodes. The procedures, office visits, and tests that resulted in and from the pathology specimen were identified. The sum of the associated charges to Medicare or Medicare payments for all identified claims equaled the total cost of the episode of NMSC care. For example, these preliminary results demonstrated significant differences between medical and surgical subspecialties.

CONCLUSION: This study defined and validated a model of an episode of NMSC care. This model's initial results serve as preliminary data for the design of further studies addressing the differences between specialties and settings. The use of this model will allow identification of factors that determine the cost of NMSC treatment and that are associated with higher cost of care.


Skin Cancer is Among the Most Costly of All Cancers to Treat for the Medicare Population.

Housman TS, Feldman SR, Williford PM, Fleischer AB Jr, Goldman ND, Acostamadiedo JM, Chen GJ.

Journal of American Academy of Dermatology.  March 2003, Volume 48, Issue3, Pages 425-429. 


BACKGROUND: Compared with other malignancies, nonmelanoma skin cancer (NMSC) is associated with much less morbidity and mortality. NMSC is, however, far more common than other malignancies. The cost of managing NMSC has not been assessed.

OBJECTIVE: The purpose of our study was to determine where the cost of NMSC management ranks among other cancers in the Medicare population.

DESIGN: Representative Medicare part A and B claims data were obtained from the Medicare current beneficiary survey, 1992 to 1995. Claims associated with cancer costs were identified using the International Classification of Diseases, Ninth Revision, Clinical Modification codes. Weights were applied to obtain nationally representative estimates.

RESULTS: Average Medicare expenditure on cancer management was $13 billion per year. The 5 most costly cancers to Medicare were lung and bronchus, prostate, colon and rectum, breast, and NMSC. The mean annual cost per patient using Medicare for all cancers was $17,094. Malignancies of lung and bronchus, colon and rectum, breast, and prostate were 11 to 19 times more costly per affected patient than NMSC.

CONCLUSION: In addition to classifying cancers by number of cases and number of deaths, the financial impact of treatment can also be used to prioritize different malignancies. Such a scheme ranks NMSC far higher than would death statistics. In light of its already high and rising incidence, the cost of NMSC care to Medicare is likely to increase. However, to maintain the cost-effective management of NMSC, it is essential to preserve the current low per-patient cost of its management.


Cost of Nonmelanoma Skin Cancer Treatment in the United States.

Chen JG, Fleischer AB Jr, Smith ED, Kancler C, Goldman ND, Williford PM, Feldman SR.

Dermatologic Surgery.  December 2001, Volume 27, Issue 12, Pages 1035-1038. 


BACKGROUND: Despite being the most prevalent form of cancer, the economic impact of nonmelanoma skin cancer (NMSC) in the United States has not been assessed.

OBJECTIVE: To determine the overall cost and to estimate the cost per episode of NMSC care in the United States in physicians' offices, outpatient surgery centers, and inpatient settings.

METHODS: Data from the Medicare Current Beneficiary Study 1992-1995 were analyzed to obtain the total cost of NMSC and the cost in different settings. To normalize these data on a per episode basis, the cost in each setting was divided by the number of procedures performed in each setting obtained from the National Hospital Discharge Survey (NHDS, 1992-1997), the National Survey of Ambulatory Surgery (NSAS, 1994-1996), and the National Ambulatory Medical Care Survey (NAMCS, 1995).

RESULTS: The total cost of NMSC care in the United States in the Medicare population is $426 million/year. Physician office-based procedures for NMSC accounted for the greatest percentage of money spent to treat NMSC and the greatest percentage of procedures. The average cost per episode of NMSC when performed in a physician's office setting was found to be $492. The cost per episode of care in inpatient and outpatient settings were $5537 and $1043, respectively.

CONCLUSION: Compared to other cancers, the relative magnitude of NMSC treatment costs is currently small because NMSC is managed efficiently and effectively, primarily in office-based settings. Legislative or regulatory measures that discourage office treatment of NMSC will lead to increased cost.


Combined Tongue and Pharyngeal Flaps for Reconstruction of Large Recurrent Palatal Fistulas.

Bagatin M, Goldman ND, Nishioka GJ.

Archives of Facial Plastic Surgery. April 2000, Volume 2, No. 2, Pages 146-147. 


Recurrent palatal fistulas following primary cleft palate repair are uncommon, with an incidence ranging between 9% and 34%.1-3 Factors that contribute to the development of a recurrent fistula include the size of the initial cleft, the method of repair, and the surgeon.3 When fistulas recur they are usually located in the anterior palate and are small to moderate in size. When large defects are seen they typically follow repeated surgical attempts at closure.


Malar Augmentation with Self-Drilling Single-Screw Fixation.

Goldman ND, Alsarraf R, Nishioka G, Larrabee WF Jr.

Archives of Facial Plastic Surgery. July 2000, Volume 2, No. 3, Pages 222-225. 


Augmentation with malar implants has traditionally relied on fixation techniques such as creation of a precise pocket, external taping, and transcutaneous fixation techniques with bolsters. We present an alternate technique that fixates the implants to the rigid facial skeleton rather than to the dynamic active facial soft tissues. To avoid the use of expensive drills, we describe use of self-drilling screws for fixation of malar implants. The technique avoids transconjunctival incisions, allows wide exposure, and is presented as an alternative to traditional fixation techniques.


Meta-Analysis in Otolaryngology.

Alsarraf R, Alsarraf NW, Kato BM, Goldman ND.

Archives of Otolaryngology Head & Neck Surgery.  June 2000, Volume 126, No. 6, Pages 711-716. 


OBJECTIVE: To examine the results of meta-analyses in otolaryngology and compare these results with the individual component studies that constitute each meta-analysis.

DESIGN: A retrospective review of the literature.

MAIN OUTCOME MEASURES: Studies that conducted pooled statistical systematic analyses indexed on MEDLINE for the 10-year period from January 1989 to January 1999 were selected for keyword or subject headings of meta-analysis and otolaryngology  (N = 22). Analysis consisted of a modified funnel graph depiction of the individual studies that made up each meta-analysis. Each meta-analysis was evaluated for consistency among these individual studies and comparison of the median result with the weighted mean meta-analysis result. In addition, the methodologic quality of each meta-analysis was assessed in terms of the rigor with which component studies were evaluated.

RESULTS: Ten (46%) of the 22 meta-analyses did not provide the individual study results that made up their meta-analyses. The results of 10 studies (46%) were similar to the median result of their individual component studies. The results of 2 studies (9%) differed from this median result, with widely heterogeneous component study results.

CONCLUSIONS: A large proportion of meta-analyses in otolaryngology  (46%) fail to provide the individual study results necessary to analyze the meta-analysis result critically. Most remaining studies do provide results that accurately compare with the median of their component study results. Only a small proportion of meta-analyses were found to have disparate results, and each appropriately discusses the heterogeneity of the individual studies that comprise their meta-analysis.


Isolated Intracranial Mucocele.

Alsarraf R, Goldman ND, Kuntz C, Stanley RB Jr.

Archives of Otolaryngology Head & Neck Surgery.  September 1999, Volume 125, No. 9, Pages 1023-1024. 


Intracranial mucoceles have been previously reported as direct extradural extensions of mucoceles of the paranasal sinuses. We describe a patient with 2 silent mucoceles isolated within the parenchyma of the frontal lobe of the brain. The patient had undergone multiple previous intranasal polypectomy and ethmoidectomy procedures, and the unsuspected mucoceles were discovered on a computed tomographic scan obtained to evaluate recurrent rhinosinusitis symptoms. Craniotomy was required for removal of the mucoceles.


Thyroid Cancers. I. Papillary, Follicular, and Hürthle Cell.

Goldman ND, Coniglio JU, Falk SA.

Otolaryngology Clinics of North America.  August 1996, Volume 29, No. 4, Pages 593-609. 


The well differentiated thyroid carcinomas, papillary, follicular, and Hürthle cell, comprise the majority of malignant thyroid diseases. This article presents guidelines for the evaluation and treatment of these malignancies. Prognostic factors, surgical treatment of the thyroid and regional lymph nodes, postoperative detection of recurrence, and treatment of distant metastases are discussed.


Microtia Repair.

Quatela VC, Goldman ND.

Facial Plastic Surgery.  October 1995, Volume 11, No. 4, Pages 257-273.  


Management of microtia can be one of the most rewarding yet humbling challenges faced by the reconstructive surgeon. The preferred method of total auricular reconstruction is with autologous cartilage and skin, based on modifications of the methods of Tanzer and Brent. Our goals in auricular reconstruction of microtia are: (1) a satisfied patient; (2) proper positioning; and (3) a pleasing size and contour. The reconstructive process in classic microtia reconstruction can be divided into four stages. The first stage is the creation and placement of the underlying framework derived from the autologous rib cartilage of the sixth to eighth ribs. The second stage is rotation of the lobule from the microtia remnant into position inferiorly on the helical rim. The third stage is elevation by creation of an auriculocephalic angle with a skin graft. The final stage is formation of the tragus from a composite graft from the opposite ear. Atypical microtia presents distinct challenges to the reconstructive surgeon. Complete framework insertion may not be necessary with the presence of some recognizable structure. Other circumstances arise that make each reconstruction unique, such as low-lying hairline or skin shortage. The extreme situations of skin shortage will benefit from the use of a temporoparietal fascia flap. However, adherence to the well-established principles of total auricular reconstruction will lead to satisfaction of the patient, the patient's family, and the surgeon.


Book Chapters


Becker D, Goldman ND, Brissett AE, Carniol PJ, Kellman RM, Khosh M, Rhee JS, Spiegel JH, Wayne I.  American Academy of Otolaryngology Head & Neck Surgery Foundation Home Study Symposium Section 4/ June 2010 Plastic and Reconstructive Problems


Becker D, Goldman ND, Brissett AE, Carniol PJ, Kellman RM, Khosh M, Rhee JS, Spiegel JH, Wayne I.  American Academy of Otolaryngology Head & Neck Surgery Foundation Home Study Course Self-Assessment Examination Section 4/ April 2010 Plastic and Reconstructive Problems


Fedok FG, Miller PJ, Porter JP, Becker D, Goldman ND, Khosh M, Rhee J, Wayne I.  American Academy of Otolaryngology Head & Neck Surgery Foundation Home Study Course Symposium Section 4/ May 2008 Plastic and Reconstructive Problems


Fedok FG, Miller PJ, Porter JP, Becker D, Goldman ND, Khosh M, Rhee J, Wayne I.  American Academy of Otolaryngology Head & Neck Surgery Foundation Home Study Course Self-Assessment Examination Section 4/ May 2008 Plastic and Reconstructive Problems


Alford El, Paniello RC, Pellitteri PK, Becker D, Fedok FG, Goldman ND, Miller PJ, Porter JP. American Academy of Otolaryngology Head & Neck Surgery Foundation Home Study Course Symposium Section 4/July 2006 Plastic and Reconstructive Problems


Alford El, Paniello RC, Pellitteri PK, Becker D, Fedok FG, Goldman ND, Miller PJ, Porter JP. American Academy of Otolaryngology Head & Neck Surgery Foundation Home Study Course Self-Assessment Examination Section 4/May 2006 Plastic and Reconstructive Problems


Kern RC, Marple BF, Goldman ND, Senior BA, Sherris DA, Smith TL, Thaler ER.  American Academy of Otolaryngology Head & Neck Surgery Foundation Home Study Course Self-Assessment Examination Section 5/ November 2005 Rhinology and Allergic Disorders

Kern RC, Marple BF, Goldman ND, Senior BA, Sherris DA, Smith TL, Thaler ER.  American Academy of Otolaryngology Head & Neck Surgery Foundation Home Study Course Symposium Section 5/September 2005 Rhinology and Allergic Disorders


Quatela VC, Goldman ND.  Nasal Augmentation.  In Practical Aspects of Facial Plastic Surgery.  Willet MJ, ed., Appleton and Lange, Inc., 1997


Goldman ND, Kaufman D.  Airway and Ventilator Management, In Principles of Medicine for the Medical Student.  Illig C, ed., Laennec Press, May 1996


Hengerer AS, Goldman ND.  Management of Aspiration, In Otolaryngology. English GM, ed., Lippincott Company, Philadelphia, February 1996