Alloplastic Facial Implants.

As the face ages, there is thinning of the epidermis, volume loss and rearrangement of the soft tissues, and malabsorption of the skeletal framework. It is essential to have a thorough understanding of the aging process for successful facial augmentation and rejuvenation. Alloplastic implants can be used to provide a long-lasting solution for augmentation of skeletal deficiencies, restoration of facial irregularities, and rejuvenation of the face. In this study, we describe the ideal implant characteristics along with the advantages and disadvantages of various implant materials. We also present techniques in nasal and premaxillary augmentation, midface augmentation, mandibular augmentation, and lip augmentation. Additionally, computer-aided design and manufacturing as well as bioprinting are emerging technologies with growing applications in facial plastic and reconstructive surgery. We discuss their role in the creation of patient-specific custom implants. The overall goal of facial rejuvenation is to address multiple aspects of the facial aging process including deficiencies in the skin, soft tissues, and skeletal framework. The use of alloplastic implants alone or synergistically with additional surgical procedures can restore a wide range of anatomical deficits that occur with age.

Septal Perforation Repair Using Bilateral Rotational Flaps With Interposed Mastoid Periosteal Graft.

OBJECTIVES/HYPOTHESIS: To evaluate the outcomes of endonasal repair of septal perforations utilizing opposing bilateral rotational flaps and a periosteum interposition graft. METHODS: Retrospective review of a single surgeon, tertiary referral center experience of patients who underwent septal perforation repair. Patient demographics, etiology of perforation, closure rate, and complication data were obtained. Patients screening positively for cocaine use or anti-neutrophil cytoplasmic antibodies (ANCA) were not offered repair. RESULTS: A total of 104 patients were included, 65 male and 39 female with mean age of 45.4 years. Etiology of perforations included prior surgery in 45, trauma in 15, and unknown in 44, and the average perforation size in each etiologic group were 1.35 cm, 1.25 cm, and 1.30 cm, respectively. The greatest dimension of perforations repaired ranged from 0.5 cm to 1.5 cm. The overall success rate was 87.5% at 6 month follow-up. Successful closure was achieved in 95.6%, 86.7%, and 79.5%, respectively (χ2  = 5.264, P = .0218). CONCLUSION: Our described technique is a reliable endonasal approach with predictable outcomes in septal perforations up to 1.5 cm in size. Having an unknown etiology of septal perforation may be a risk factor for failure. LEVEL OF EVIDENCE: 4 Laryngoscope, 131:1497-1500, 2021.

Modified Skoog Method for Hump Reduction.

Dorsal hump reduction is a key component of rhinoplasty. Spreader grafts are the most frequently used technique; however, dorsal irregularities may result. The modified Skoog method involves removal of the osseocartilaginous dorsal hump, its modification, further reduction of the nasal dorsum, replacement of the modified dorsal segment, and suspension of the upper lateral cartilages. The dorsal segment acts as an onlay spreader graft, preserves the middle vault, closes the open roof deformity, and creates a smooth dorsal contour from radix to anterior septal angle. The modified Skoog method produces optimal functional and aesthetic outcomes in appropriately selected patients.

A Guide to Facial Trauma Triage and Precautions in the COVID-19 Pandemic.

COVID-19 is an emerging viral illness that has rapidly transmitted throughout the world. Its impact on society and the health care system has compelled hospitals to quickly adapt and innovate as new information about the disease is uncovered. During this pandemic, essential medical and surgical services must be carried out while minimizing the risk of disease transmission to health care workers. There is an elevated risk of COVID-19 viral transmission to health care workers during surgical procedures of the head and neck due to potential aerosolization of viral particles from the oral cavity/naso-oropharynx mucosa. Thus, patients with facial fractures pose unique challenges to the variety of injuries and special considerations, including triaging injuries and protective measures against infection. The proximity to the oral cavity/naso-oropharyngeal mucosa, and potential for aerosolization of secretions containing viral particles during surgical procedures make most patients undergoing operative interventions for facial fractures high risk for COVID-19 transmission. Our proposed algorithm aims to balance patient care with patient/medical personnel protection as well as judicious health care utilization. It stratifies facial trauma procedures by urgency and assigns a recommended level of personal protective equipment, extreme or enhanced, incorporating current best practices and existing data on viral transmission. As this pandemic continues to evolve and more information is obtained, the protocol can be further refined and individualized to each institution.

Intranasal Bolsters: A Novel Technique for Nasal Bone Stabilization.

Nasal bone stabilization, in the setting of comminuted nasal fracture or surgical osteotomy, represents a challenging surgical experience. Postoperative shifting of osseous fragments may result in compromised outcomes in an otherwise well-performed procedure. Although prior studies have reported nasal bone fixation with implementation of wires, plates, or halos, these techniques are often difficult to employ routinely. Herein, the authors describe a novel and facile technique for the maintenance of unstable nasal bones using customized intranasal bolsters.

Utility of a Systematic Approach to Teaching Photographic Nasal Analysis to Otolaryngology Residents.

IMPORTANCE: Photographic nasal analysis constitutes a critical step along the path toward accurate diagnosis and precise surgical planning in rhinoplasty. The learned process by which one assesses photographs, analyzes relevant anatomical landmarks, and generates a global view of the nasal aesthetic is less widely described. OBJECTIVES: To discern the common pitfalls in performing photographic nasal analysis and to quantify the utility of a systematic approach model in teaching photographic nasal analysis to otolaryngology residents. DESIGN, SETTING, AND PARTICIPANTS: This prospective observational study included 20 participants from a university-based otolaryngology residency program. The control and intervention groups underwent baseline graded assessment of 3 patients. The intervention group received instruction on a systematic approach model for nasal analysis, and both groups underwent postintervention testing at 10 weeks. Data were collected from October 1, 2015, through June 1, 2016. INTERVENTION: A 10-minute, 11-slide presentation provided instruction on a systematic approach to nasal analysis to the intervention group. MAIN OUTCOMES AND MEASURES: Graded photographic nasal analysis using a binary 18-point system. RESULTS: The 20 otolaryngology residents (15 men and 5 women; age range, 24-34 years) were adept at mentioning dorsal deviation and dorsal profile with focused descriptions of tip angle and contour. Areas commonly omitted by residents included verification of the Frankfort plane, position of the lower lateral crura, radix position, and ratio of the ala to tip lobule. The intervention group demonstrated immediate improvement after instruction on the teaching model, with the mean (SD) postintervention test score doubling compared with their baseline performance (7.5 [2.7] vs 10.3 [2.5]; P < .001). At 10 weeks after the intervention, the mean comparative improvement in overall graded nasal analysis was 17% (95% CI, 10%-23%; P < .001). CONCLUSIONS AND RELEVANCE: Otolaryngology residents demonstrated proficiency at incorporating nasal deviation, tip angle, and dorsal profile contour into their nasal analysis. They often omitted verification of the Frankfort plane, position of lower lateral crura, radix depth, and ala-to-tip lobule ratio. Findings with this novel 10-minute teaching model should be validated at other teaching institutions, and the instruction model should be further enhanced to teach more sophisticated analysis to residents as they proceed through training. LEVEL OF EVIDENCE: NA.

The Saddle Deformity: Camouflage and Reconstruction.

This article presents a comprehensive review of past and present modalities in the surgical management of saddle nose deformities. Various surgical techniques, including allograft materials, are systematically reviewed. The senior author's surgical experience and current management approach are highlighted.

Comparison of Neurovascular Characteristics of Facial Skin in Patients After Primary and Revision Rhytidectomies.

IMPORTANCE: Wound healing influences both the cosmetic and functional outcomes of facial surgery. Study of cutaneous innervation may afford insight into patients' preoperative wound healing potential and aid in their selection of appropriate surgical procedures. OBJECTIVE: To present the quantitative and qualitative differences of epidermal nerve fibers (ENFs), neurotransmitters, vasculature, and mast cells in facial skin among patients after primary and revision rhytidectomies. DESIGN, SETTING, AND PARTICIPANTS: This pilot study collected cutaneous specimens from 8 female patients aged 42 to 66 years who underwent primary rhytidectomy (n = 5) and revision rhytidectomy (n = 3) at Centennial Lakes Surgery Center, Edina, Minnesota, from July 2010 to March 2014. Tissue was processed for confocal/epifluorescence microscopy and indirect immunofluorescent localization of several neural and tissue antigens as well as basement membrane and mast cell markers. INTERVENTION: Primary rhytidectomy vs revision rhytidectomy with selection of a small area of redundant, otherwise disposed of tissue anterior to the tragus for ENF study. MAIN OUTCOMES AND MEASURES: Demographic characteristics included smoking status; 10-point rating scales for facial sensation, pain, and paresthesias; and confocal/epifluorescence microscopy to quantify ENFs, neurotransmitters, vasculature, and mast cells. RESULTS: Patients in the primary rhytidectomy group had a mean (SD) of 54.4 (31.6) ENFs/mm (range, 14.2-99.2 ENFs/mm), and those in the revision rhytidectomy group had a mean (SD) of 18.6 (5.8) ENFs/mm (range, 13.8-25.0 ENFs/mm). A patient in the primary rhytidectomy group was a 25-pack-year smoker and had 14.2 ENFs/mm, the lowest in both groups. In addition to these structural neural changes, functional neural changes in revision rhytidectomy samples included qualitative changes in normal neural antigen prevalence (substance P, calcitonin gene-related peptide, and vasoactive intestinal peptide). Capillary loops appeared less robust and were less common in dermal papilla among samples from both the primary and revision groups, and mast cells were more degranulated. No differences were found in subjective, self-reported postoperative facial sensation. CONCLUSIONS AND RELEVANCE: Previous skin elevation was associated with decreased epidermal nerve fiber density and qualitative changes in dermal nerves, capillaries, and mast cells in a clinical sample of patients undergoing rhytidectomy. Future research is needed to determine whether histological findings predict wound healing and to better understand the effects of surgery on regenerative capacity of epidermal nerve fibers. LEVEL OF EVIDENCE: NA.

Computed tomography scan does not correlate with patient experience of nasal obstruction.

OBJECTIVES/HYPOTHESIS: Third-party payors have begun to demand imaging studies to document septal deviation prior to authorizing septoplasties. This study aims to determine whether septal deviation findings on computed tomography (CT) correlate with symptoms of nasal obstruction as determined by the Nasal Obstruction Symptom Evaluation (NOSE) scale. STUDY DESIGN: Prospective and retrospective chart review. METHODS: Patients 18 years or older undergoing CT scans, which included the nasal septum, were asked to complete a NOSE scale survey and report the laterality of any possible obstruction. Coronal CT images of subjects were graded by two blinded otolaryngologists and two blinded neuroradiologists using a grading system devised by the authors. RESULTS: Seventy-three subjects met inclusion/exclusion criteria. Interobserver reliability about the degree of septal deviation on CT scans was moderately good to substantial (κ values, 0.43 to 0.72). There was poor correlation between NOSE scores and degree of deviation on CT scans (Kendall's τ, 0.031 to 0.045; P values all >.05). There was poor concordance between the side of symptoms that patients reported and the side that observers thought was most deviated on CT. CONCLUSIONS: There is little correlation between septal deviation findings on CT scans and symptoms of nasal obstruction. The results do not support a role for CT scans as either a clinically meaningful or necessary test to investigate uncomplicated nasal obstruction. LEVEL OF EVIDENCE: 4.

Cysticercosis with an Orbital Tropism in Twins.

Two fraternal twin sisters developed cysticercosis localizing to the right lateral orbit over the same period after a presumed common-source exposure in China. This case demonstrates that cysticercosis can be related to travel. Similar temporal and spatial occurrences of these infections suggest a genetic tropism of the infecting organism in these twins.

Improving posttraumatic facial scars.

Posttraumatic soft-tissue injuries of the face are often the most lasting sequelae of facial trauma. The disfigurement of posttraumatic scarring lies in both their physical deformity and psychosocial ramifications. This review outlines a variety of techniques to improve facial scars and limit their lasting effects.

Assessment of pulsed-dye laser therapy for pediatric cutaneous vascular anomalies.

IMPORTANCE: Although facial vascular malformations are often treated by facial plastic surgeons, no reliable validated assessment tool exists for surgeons to assess results. OBJECTIVES: To use our assessment tool to analyze results from pulsed-dye laser therapy used for pediatric facial vascular malformations, and to determine interrater reliability of our assessment tool in a standard clinical environment without the use of professional photography. DESIGN: A blinded retrospective review of pediatric patients who underwent pulsed-dye laser therapy for treatment of hemangiomas of infancy (HOIs) and port-wine stains. Three pediatric otolaryngologists and facial plastic surgeons independently rated all of the pictures using our assessment tool. SETTING: Tertiary care pediatric hospital. RESULTS: Pulsed-dye laser therapy was performed in 22 patients, 17 with HOIs and 5 with port-wine stains. Patients with HOIs treated only by pulsed-dye laser showed, on average, a 50% to 75% improvement in color, 1% to 24%, improvement in thickness, and 1% to 24% improvement in size of the lesion. Eight patients with HOIs underwent surgery after laser therapy, and of these, 100% saw improvement in color, thickness, and size. Port-wine stains showed a 1% to 24% improvement in color and no improvement in thickness or size. Interrater reliability for questions 1 to 6 was 0.92, 0.92, 0.93, 0.91, 0.70, and 0.10, respectively. CONCLUSIONS AND RELEVANCE: Currently, no standardized or validated methods exist to evaluate results from intervention of pediatric facial HOIs and port-wine stains. Our assessment tool is reliable to assess patients with HOIs and port-wine stains who undergo pulsed-dye laser therapy and surgical reconstruction. LEVEL OF EVIDENCE: 3.

A randomized controlled trial of fractional laser therapy and dermabrasion for scar resurfacing.

BACKGROUND: Dermabrasion has been the standard resurfacing procedure for postsurgical scars, but recovery can be long. Fractionated carbon dioxide (CO2 ) laser is a safe, effective tissue resurfacing modality, but no prospective trial has compared its safety or efficacy with that of dermabrasion for postsurgical scar resurfacing. OBJECTIVE: To compare the safety and efficacy of single-treatment fractional photothermolysis with that of single-treatment dermabrasion for postsurgical scar resurfacing on the face. METHODS AND MATERIALS: A split-scar method was used to compare fractionated CO2 laser and diamond fraise dermabrasion on postsurgical scars of the face. Primary endpoint was safety at day 0, 1 week, and 1 month. Secondary endpoint was efficacy at 3 months as measured by blinded evaluation of standardized photographs. RESULTS: Safety data revealed that there was less erythema (p = .001) and bleeding (p = .001) at day 0, less erythema (p = .01) and edema (p = .046) at 1 week, and a trend toward less erythema at 1 month (p = .06) with fractionated CO2 . Efficacy data at 3 months revealed equivalent scar improvements (p = .77). CONCLUSION: Fractionated CO2 laser therapy should be considered a safe alternative for surgical scar resurfacing on the face. The safety profile exceeds that of dermabrasion, and it has a quicker clinical recovery and equivalent cosmetic efficacy.

3D analysis of tissue expanders.

This article reviews some of the phenomena associated with tissue expansion that are amenable to study with 3D imaging and presents selected cases from the literature where the technology has been used to answer clinical questions and plan procedures. The authors discuss implant selection, remodeling, contraction, and 3D analysis. Future directions and limitations of the use of this technology in the head and neck are also described.

A comparison of anterior vs posterior isolated mandible fractures treated with intermaxillary fixation screws.

OBJECTIVE: To compare complication rates after use of intermaxillary fixation (IMF) bone screws for anterior (ie, symphyseal/parasymphyseal) and posterior (ie, body and angle) mandible fractures. METHODS: A retrospective analysis of isolated mandible fractures treated with intraoperative IMF bone screws at 2 major level 1 trauma centers within the Department of Otolaryngology-Head and Neck Surgery at the University of Minnesota. From January 1, 2003, through January 31, 2006, we accrued 53 patients with 67 isolated mandible fractures treated with intraoperative IMF bone screws. These patients had at least 6 weeks of follow-up. RESULTS: Twenty-one patients had anterior mandible fractures and 32 had posterior mandible fractures. In the anterior group, there was 1 incident of wound dehiscence, resulting in a total complication rate of 5%. In the posterior fracture group, there was 1 infection (3%), 4 malunions/malocclusions (12%), and 1 nonunion (3%), for an overall complication rate of 19%. The difference between groups for malocclusion rates (12% vs 0%) was significant (P < .001). CONCLUSIONS: The IMF bone screw system has a superior speed and safety profile. It produces better occlusion results in anterior mandible fractures and might have a lower overall complication rate compared with arch bars. Given this, IMF bone screws are the preferred modality of intermaxillary fixation in properly selected mandible fractures.

Assessing fundamental 2-dimensional understanding of basic soft tissue techniques.

OBJECTIVE: To develop a written practical examination and scoring system for assessing trainee skills in basic soft-tissue techniques. DESIGN: A brief written practical examination was developed to assess the ability of trainees to sketch preoperative plans and postoperative results for common soft-tissue techniques: simple-excision, M-plasty, geometric broken line closure, Z-plasty, V-to-Y flap, and rhombic flap. A scoring system was developed to assign 0 to 5 points to each of 10 items on the examination for a total score of 0-50. The 15-minute examination was administered as a pretest, posttest, and 3-month posttest assessment as part of a soft-tissue course at our institution. SETTING: University of Minnesota, Otolaryngology Department. RESULTS: Three raters reviewed all examination answer sheets independently. The pretest scores of examinees correlated strongly with their level of training; the average pretest for junior residents (PGY 1-2) compared with senior residents (PGY 4-5) was 17.3 (of 50) versus 26.0 (p < 0.01). The scoring system showed a high intrarater reliability and high interrater reliability with correlation coefficients of r = 0.99 and r = 0.95, respectively and agreement coefficients of κ = 0.82 and κ = 0.77, respectively. CONCLUSION: This written practical examination and scoring system may be used to assess the skills of trainees accurately in basic soft tissue techniques and to expose areas of deficiency that can be addressed in future training sessions.

Osseocartilaginous rib graft rhinoplasty: a stable, predictable technique for major dorsal reconstruction.

OBJECTIVE: To assess the long-term stability of osseocartilaginous dorsal onlay rib grafts used for augmentation rhinoplasty. METHODS: Patients who had rib grafts used for augmentation rhinoplasty from 2000 through 2009 were assessed for graft viability, graft mobility, graft warping, maintenance of dorsal projection, functional airway status, need for revision surgery, and donor site morbidity. A retrospective cohort study using telephone follow-up was conducted. RESULTS: A total of 58 rib graft rhinoplasties were performed in the 10-year review period, 39 of which used dorsal onlay grafts. The mean duration of clinical follow-up was 24 months, and the median duration of clinical follow-up was 16 months. Thirty-three of 33 osseocartilaginous onlay grafts (100%) and 5 of 6 cartilaginous onlay grafts (83%) were viable, rigid, and had maintained dorsal projection at last follow-up. None of the grafts warped. Twenty-nine of 33 patients receiving osseocartilaginous onlay grafts (88%) and 5 of 6 patients receiving cartilaginous onlay grafts (83%) had persisting relief of their nasal obstruction. Twelve of the 39 patients (30%) had revision surgery, mostly performed for minor cosmetic revision. CONCLUSIONS: Osseocartilaginous onlay rib grafts provide an ideal scaffold for dorsal nasal augmentation and restoration of nasal airway in patients with collapse of the nasal framework due to a saddle deformity, history of trauma, or history of multiple septorhinoplasties. The graft has excellent viability, lacks potential for long-term warping, achieves bony fusion to the nasal bones, and allows surgical molding of the cartilaginous tip.

Clinical consensus statement: Diagnosis and management of nasal valve compromise.

OBJECTIVE: To create a clinical consensus statement to address ambiguities and disparities in the diagnosis and management of nasal valve compromise (NVC). SUBJECTS AND METHODS: An updated systematic review of the literature was conducted. In addition, a Modified Delphi Method was used to refine expert opinion and facilitate a consensus position. RESULTS: After two rounds of surveys and conference calls, 36 items reached consensus, six items reached near consensus, and 10 items reached no consensus. The categories that had the greatest percentage of consensus or near consensus items were as follows: definition, history and physical examination, outcome measures, and management. Conversely, the categories with greater percentage of no consensus items were adjunctive tests and coding. CONCLUSION: The consensus panel agreed that NVC is a distinct clinical entity that is best evaluated with history and physical examination findings. Endoscopy and photography are useful but not routinely indicated, whereas radiographic studies are not useful in evaluating NVC. Other objective nasal outcome measures may not be useful or accepted for NVC. Nasal steroid medication is not useful for treatment of NVC in the absence of rhinitis, and mechanical treatments may be useful in selected patients. Surgical treatment is the primary mode of treatment of NVC, but bill coding remains ambiguous and confusing.