Optimal Facelift Vector and its Relation to Zygomaticus Major Orientation.

BACKGROUND: The vector of superficial musculoaponeurotic system (SMAS) redraping in rhytidectomy is often described in relation to the zygomaticus major muscle (ZMM), so that suspension prevents distortion of the mimetic musculature and a "facelifted appearance." There are no data describing the true orientation of this muscle in the midface. OBJECTIVES: The aim of this study was to define the vector of the ZMM relative to the Frankfort horizontal plane. METHODS: One hundred patients underwent deep plane rhytidectomy. As part of this procedure the tissues overlying the ZMM are elevated, allowing muscle orientation to be measured as an angle relative to the Frankfort horizontal plane. RESULTS: Data for 200 hemifaces were aggregated. The average ZMM angle was 59° (standard deviation, 6°; range, 41-72°) relative to the Frankfort horizontal plane, and showed a statistically significant pattern of change with advancing age, becoming more acute with increasing age below the age of 60 years and more obtuse with age over 60 years. CONCLUSIONS: The native vector of the ZMM varies significantly between rhytidectomy patients as demonstrated by the high variance in this cohort. Assumptions about its orientation should not be made in rhytidectomy techniques that do not identify its course. Standard vectors of SMAS redraping, such as superior-lateral, vertically oblique, and purely vertical, should be reconsidered and a customized vector implemented in each case. Aging affects the orientation of the muscle, which can potentially be explained by soft tissue and bony changes at its attachments. This furthers the variability of the SMAS vector in each individual case.

A Novel Extended Deep Plane Facelift Technique for Jawline Rejuvenation and Volumization.

BACKGROUND: Jawline aging is a complex process. We believe loss of posterior jawline definition and volume depletion is an underappreciated factor in the aging face. OBJECTIVES: The aim of this study was to describe a novel composite, rotational flap modification of an extended deep-plane rhytidectomy. We evaluated long-term efficacy on improving jawline contour and volumization of the posterior mandibular region overlying the gonial angle. METHODS: We performed a prospective study on patients who underwent our modification of extended deep-plane rhytidectomy. We define and introduce the mandibular defining line, a new anatomic metric in evaluating the mandibular contour. We define the area of the posterior lower face overlying the gonion and mandibular angle as the gonial area. Using 3-dimensional photography, we quantify contour changes along the mandibular border and volume change along the gonial area. RESULTS: Eighty-nine patients (178 hemifaces) were analyzed. The mean gonial area volume gained was 3.5 cc. Average follow-up was 19 months. There was a statistically significant change in the mean mandibular defining line from 7.1 cm preoperatively to 9.8 cm postoperatively. This represents a lengthening of the visual perspective of the mandibular contour of 2.7 cm. CONCLUSIONS: Composite, rotational flap modification of extended deep-plane rhytidectomy provides significant long-term augmentation of volume to the posterior mandibular region and lengthens the visual perspective of the inferior mandibular contour, creating a more youthful jawline. In selected cases, this may obviate the need for other volumization procedures used to improve jawline contour, such as autologous fat grafting.

Extended Deep Plane Facelift: Incorporating Facial Retaining Ligament Release and Composite Flap Shifts to Maximize Midface, Jawline and Neck Rejuvenation.

This article describes our extended, deep plane facelift technique. This procedure releases 4 key retaining ligaments in the face and neck, the zygomatic cutaneous, masseteric cutaneous, mandibular cutaneous, and cervical retaining ligaments. Once released, the composite deep plane flap is repositioned to volumize the midface and gonial angle. Important anatomic considerations during deep plane dissection are discussed. In the neck, focus is on extending the deep plane dissection of the platysma, releasing the cervical retaining ligaments, creating a platysmal hammock to support the submandibular gland, defining the inferior mandibular contour, and minimizing the need to open the neck.

Therapeutic Cannabis and Endocannabinoid Signaling System Modulator Use in Otolaryngology Patients.

OBJECTIVES: 1) review benefits and risks of cannabis use, with emphasis on otolaryngic disease processes; 2) define and review the endocannabinoid signaling system (ESS); and 3) review state and federal regulations for the use and research of cannabis and ESS modulators. METHODS: This manuscript is a review of the current literature relevant to the stated objectives. RESULTS: Cannabis (marijuana) use is increasing. It is the most widely used illicit substance in the world. There is increasing interest in its therapeutic potential due to changing perceptions, new research, and legislation changes controlling its use. The legal classification of cannabis is complicated due to varied and conflicting state and federal laws. There are currently two synthetic cannabinoid drugs that are FDA approved. Current indications for use include chemotherapy-related nausea and vomiting, cachexia, and appetite loss. Research has demonstrated potential benefit for use in many other pathologies including pain, inflammatory states, and malignancy. Data exists demonstrating potential antineoplastic benefit in oral, thyroid, and skin cancers. CONCLUSIONS: ESS modulators may play both a causal and therapeutic role in several disorders seen in otolaryngology patients. The use of cannabis and cannabinoids is not without risk. There is a need for further research to better understand both the adverse and therapeutic effects of cannabis use. With increasing rates of consumption, elevated public awareness, and rapidly changing legislation, it is helpful for the otolaryngologist to be aware of both the adverse manifestations of use and the potential therapeutic benefits when talking with patients.

Buccal space malignancy in the setting of chronic sialadenitis: A report of 2 cases.

We report the cases of an 89-year-old woman and a 77-year-old woman with long-standing chronic sialadenitis (60 and 10 years, respectively) who were referred to our large academic medical center for sialendoscopy. Both patients presented with symptoms of acute parotid duct obstruction in the background of long-standing parotid duct disease. Imaging demonstrated ductal dilation and periductal inflammation and, along with the clinical findings, was supportive of a diagnosis of acute parotitis in the setting of chronic obstructive parotid disease. Both patients underwent sialendoscopy. Intraoperative findings suggested the presence of a mass lesion in both cases, and biopsy confirmed a buccal space malignancy in each. Although benign processes such as ductal strictures and sialolithiasis are frequent causes of parotid duct system complaints, the possibility of a malignancy should be entertained and ruled out. Even in patients who have long-standing obstructive parotid symptoms, malignancy can be encountered as a new diagnosis. We discuss the unique presentation, workup, and management of our 2 patients, and we briefly review the current literature.

Management of Forehead Scars.

This article provides an overview of scar management within the forehead region. It addresses the unique challenges specific to the treatment of forehead wounds. A logical, stepwise approach is used. A subsite based treatment algorithm is provided along with a review of current best practices. Pertinent case examples are included for demonstration purposes.

Esthetic and functional reconstruction after parotidectomy in pediatric patients - A case series.

Parotidectomy is a mainstay of treatment for benign and malignant parotid lesions in children and adults. Depending on surgical methods used and tumor size, parotidectomy may result in significant facial disfigurement as well as functional challenges. We describe a series of four pediatric patients, ages 13-16 who presented to our clinic with a parotid mass. All patients underwent parotidectomy with immediate reconstruction by local tissue rearrangement or free fat graft. Esthetic and functional reconstruction after parotidectomy is not well described in pediatric otolaryngology literature. A review of current literature and description of reconstructive methods is included.