Facial Fat Fitness: A New Paradigm to Understand Facial Aging and Aesthetics.

Traditionally, facial adipose tissue has been perceived and treated as a homogenous volume-occupying subcutaneous depot. However, recent research from across disciplines is converging to reveal a far more anatomically organized and functionally dynamic role of facial adipose tissue. In this narrative review, we will discuss new insights into adipocyte function and facial adipose anatomy that have far-reaching implications for the practice of aesthetic facial plastic surgery. These concepts are synthesized into a "facial fat fitness" model which can be used to explain clinical observations in facial aging and aesthetic surgery. Fat fitness relates to the quality of facial adipose tissue, as opposed to quantity, and describes whether adipose tissue is in a predominantly healthy hyperplastic or unhealthy hypertrophic state. Fat fitness is modulated by lifestyle factors, and may be impacted positively or negatively by facial aesthetic treatments. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

The Submandibular Gland and The Aging Neck: A Longitudinal Volumetric Study.

INTRODUCTION: The true effect of aging and other patient factors on submandibular gland (SMG) volume is unclear. We sought to evaluate the effects of age, body mass index (BMI), sex and race on SMG volume using computed tomography (CT) imaging. METHODS: We conducted a retrospective longitudinal study of adult subjects with multiple CT images of the neck at least 7 years apart. Subjects with history of salivary gland pathology, neck dissection, head and neck radiation, active infection or dental artifact were excluded. Three-dimensional volumes were measured. Age, BMI, sex and race data were analyzed to track their longitudinal effect on SMG volume. RESULTS: The study comprised 64 patients (Females n=36; Males n=28) with mean age of 47.1 and 58.5 at each respective time point (mean difference 11.4). Mean SMG volume increased from 10.1 ml to 10.5 ml (P < 0.05). Males had significantly greater SMG volume compared to females. Majority of growth occurred in the < 40 year age bracket (0.1 ml/year), more significantly in the male cohort. When controlling for aging and sex, a change in BMI was the only patient factor that predicted a change in SMG volume. An increase of 1.0 kg/m2 predicted a 0.17 ml increase in gland volume. Race had no significant effect. CONCLUSION: Our findings suggest that the majority of SMG volume change occurs in early adulthood ( < 40 years), especially in males. Among the factors we studied, a change in BMI was the only significant predictor of SMG volume change. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to Table of Contents or the online Instructions to Authors www.springer.com/00266 . Genital Surgery.

The Aging Parotid Gland: A Longitudinal Volumetric Study and Implications for Treatment.

BACKGROUND: The parotid gland accounts for significant soft tissue volume in the face and is therefore of central relevance to facial and neck rejuvenation. OBJECTIVES: The aim of this study was to determine how parotid gland volume is predicted by age and other factors. METHODS: We conducted a retrospective longitudinal study of patients with multiple computed tomography (CT) scans of the neck performed at least 7 years apart. Parotid gland volumes were measured and multiple linear regression analysis was performed to model the relations between age, body mass index (BMI), and parotid volume. RESULTS: The study cohort comprised 70 patients. The mean [standard deviation] ages at initial and final imaging time points were 47.5 [12.6] and 58.8 [12.2] years, respectively, with an average of 11.3 years elapsed between CT scans. The mean parotid gland volume increased from 28.7 [10.0] to 32.2 [10.7] mL over the average 11.3-year period (P = 0.03). However, the results of the multiple linear regression analysis show that when controlling for BMI and sex, age alone does not predict parotid volume (P = 0.29). BMI was directly correlated with gland volume (P < 0.01). An increase of 1.0 kg/m2 in BMI predicted an increase in parotid volume by 1.1 mL. Male sex was also associated with significantly greater parotid volume. CONCLUSIONS: Mean parotid volume increased over time but these gains were driven by increases in BMI and not age alone. These findings are highly relevant to the treatment of the aging face and neck.

Variations in the management of acute Bell's palsy.

OBJECTIVE: To identify presiding practices among neurotologists (ORL) in the care of acute Bell's palsy, and to compare them to neurologists' treatment patterns. STUDY DESIGN AND METHODS: Cross-sectional survey study. SUBJECTS: Neurotologists and neurologists. RESULTS: Ninety-one responses to the survey were obtained. The majority of participants (87.9%) always prescribe steroids. ORL were more likely to prescribe higher doses (≥60 mg) than neurologists (89.7% vs. 58.0%) (p = 0.001). Anti-viral medication was initially prescribed by 46.2% of respondents (56.1% ORL vs. 38.0% neurologists; p = 0.085). An MRI was always ordered by 17 participants (18.7%), while an MRI was sometimes ordered by 45 participants (49.5%). ORL were not only more likely to always order an MRI (24.4% vs. 14.0%), but also more likely to never order an MRI (43.9% vs. 22.0%) (p = 0.009). Laboratory blood work was never ordered by 45.1% of respondents, with 70.7% of OTO and 24.0% of neurologists indicating that they would never order labs (p < 0.001). CONCLUSIONS: ORL almost always prescribe steroids, prescribe antivirals around 50% of the time, and only sometimes obtain imaging for acute Bell's palsy. Compared to neurologists, ORL are more likely to order high dose steroids (≥60 mg), more commonly prescribe antivirals, and are less likely to order laboratory blood work. Regarding the treatment of acute Bell's palsy, there are discrepancies both within otolaryngology, and between otolaryngology and neurology, despite recently published guidelines from both specialties.

Deep Cheek Fat Volumes and Midfacial Aging.

BACKGROUND: Midfacial volumizing procedures are increasingly common in facial rejuvenation. However, the changes that occur in midfacial fat with aging are poorly understood. OBJECTIVES: The aim of this study was to determine how deep cheek fat volume is predicted by age. METHODS: We conducted retrospective cross-sectional and longitudinal studies of patients based on facial computed tomography (CT) scans. In the cross-sectional cohort, multiple linear regression analysis was performed to model the relations between age and deep cheek fat volumes. In the longitudinal analysis, changes to deep cheek fat volumes were tracked among subjects who underwent multiple facial CT scans. RESULTS: The cross-sectional cohort comprised 109 patients. The mean (SD) age of the subjects was 59.7 (15.0) years (range, 21.7-91.1 years). A linear regression analysis showed that increasing age was associated with increasing deep cheek fat volume (ß = 0.015, P < 0.001). Additional regression analyses showed that the gain of fat with aging was more pronounced in the caudal aspect of the cheek (ß = 0.007, P < 0.001) than in the cephalad (ß = 0.005, P < 0.001). Twenty-three subjects were identified for longitudinal analysis. The mean (SD) ages at initial and final imaging time points were 50.0 (5.8) and 60.3 (5.2) years. In the deep fat compartment, there was an average gain of 0.23 mL over 10.3 years (P = 0.03). CONCLUSIONS: Age is an important predictor of midfacial deep cheek fat volume. In this study, there is no evidence of adipose volume loss in the deep cheek compartment. Rather, aging was associated with an increase in deep cheek fat, possibly reflecting pseudoherniation of buccal fat.

Patterns of Superficial Midfacial Fat Volume Distribution Differ by Age and Body Mass Index.

BACKGROUND: The changes that occur to midfacial fat with increasing age and BMI are poorly understood. The aim of this study was to determine how superficial cheek fat volume and distribution are differentially predicted by changes in BMI versus age. METHODS: We conducted a retrospective observational study of patients with facial computed tomography scans. Superficial cheek fat volumes were measured, and multiple linear regression analysis was performed to model the relationships between cheek fat and corresponding sex, age, and BMI data. RESULTS: A total of 109 patients were included in our analysis (51 male, 58 female). The subjects' ages ranged from 21.7 to 91.1 years with a mean (SD) age of 59.7 (15.0) years. The mean (SD) superficial cheek volume of the subjects was 10.46 (2.57) cc. Female subjects had a significantly greater mean total superficial cheek fat volume compared to male subjects (11.18 cc vs. 9.64 cc; P < 0.001). The results of multiple linear regression analysis indicated that together, age, sex, and BMI explained 50.8% of the variance in cheek fat volumes (R2 = 0.51, P < 0.001). BMI significantly predicted total cheek fat volume (ß = 0.239, P < 0.001), in addition to age (ß = 0.029, P < 0.017) and sex (ß = - 1.183, P = 0.001; female = 0, male = 1). Age predicted the greatest gain of fat in the caudal subdivision of cheek (ß = 0.015, P < 0.001), whereas BMI predicted the greatest gain in the cephalad subdivision (ß = 0.106, P < 0.001). CONCLUSIONS: Age, sex, and BMI are important predictors of midfacial fat volume. This study shows that increases in age and BMI differentially predict the distribution of superficial cheek fat. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Superior Semicircular Canal Dehiscence: A Case Report and Literature Review of an Otologic Condition Associated With Severe Psychiatric Disturbance and Suicide Attempt.

We report the case of a man suffering from superior semicircular canal dehiscence with severe audiovestibular symptoms. The patient had a history of posttraumatic stress disorder and traumatic brain injury, and he had a presumed diagnosis of schizophrenia, with suicidal ideation. The patient was treated surgically with complete resolution of his symptoms and a retraction of his schizophrenia diagnosis. This case highlights the overlap between tinnitus and auditory hallucinations, as both result in auditory perception without an external stimulus. Ascertaining the appropriate cause of a patient's auditory symptoms is integral to providing appropriate medical and possibly surgical care.

From the Deep-Plane Rhytidectomy to the Vertical Platysma Advancement.

This article provides the facial plastic surgeon with anatomic and embryologic evidence supporting use of the deep-plane technique and understanding the evolution of the technique over decades to the vertical platysma advancement for optimal treatment of facial aging. The original description of the deep-plane rhytidectomy described a basic subsuperficial musculoaponeurotic system dissection in the midface. This plane of dissection provides access to deeper anatomic structures. A detailed description of the procedure is provided to allow safe and consistent performance. Insights into anatomic landmarks, technical nuances, and alternative approaches for facial variations are presented.

Sequencing of Sclerosing Microcystic Adenocarcinoma Identifies Mutational Burden and Somatic Variants Associated With Tumorigenesis.

BACKGROUND/AIM: Sclerosing microcystic adenocarcinoma (SMA) is a rare oral cavity neoplasia, histologically resembling microcystic adnexal carcinoma (MAC) of the skin. Only nine SMA cases have been reported in the literature, frequently in the context of immunosuppression; SMA has not been recognized in the most recent WHO tumor classification. We sought to identify potential molecular mechanisms of tumorigenesis in a case of SMA relative to those known for MAC. CASE REPORT: A 41-year-old female with psoriatic arthritis undergoing immunosuppression therapy presented with a tongue mass. Biopsy revealed a diagnosis of SMA. Partial glossectomy and neck dissection showed no residual tumor or nodal disease. RESULTS: whole exome sequencing revealed moderate mutational burden and putative loss of function mutations in CDK11B but no overlap with known MAC mutations. CONCLUSION: We characterized the genomic profile of SMA for the first time, identifying both mutational burden and unique somatic variants associated with tumorigenesis.

Cochlear Implant Mapping Through Telemedicine-A Feasibility Study.

OBJECTIVE: Access to postoperative aural rehabilitation limits cochlear implant (CI) penetration to the candidate population. The purpose of this study was to evaluate the effectiveness of remote CI programming and aural rehabilitation via telehealth. STUDY DESIGN AND SETTING: Retrospective study of one cochlear implant center. PATIENTS AND INTERVENTION: Patients undergoing cochlear implantation from 2015 to 2018 undergoing remote programming as part of routine audiologic follow up. MAIN OUTCOME MEASURES: AzBio scores, impedances, comfort and threshold levels, and responses to the International Outcome Inventory for Hearing Aids questionnaire modified for CIs (IOI-CI). RESULTS: A total of 22 CIs in 20 patients were included during the study period. Threshold, comfort, and impedance levels were readily obtained via telehealth and were not significantly different between telehealth and live sessions. AzBio scores and warble tone pure tone averages were also similar and acceptable in both session modalities. Based on IOI-CI scores, patients were very satisfied with their hearing outcomes. CONCLUSIONS: Using telemedicine, reliable measurements were readily obtained and hearing outcomes after remote programming were comparable to those expected after in-person programming sessions. Patients were overall satisfied with their remote programming sessions. Telehealth is a cost-effective and safe way to deliver post-CI audiologic care, particularly to patients with limited mobility or those in remote locations.

Neck Deformities in Plastic Surgery.

This article provides facial plastic surgeons with the insight to avoid and address common pitfalls in neck procedures. Many aesthetic issues are created from overtreatment or undertreatment of components of the neck. Using the platysma muscle as the divide, ease of access to superficial anatomy leads to overtreatment problems, whereas difficulty of access to deeper structures leads to undertreatment problems and to overall imbalances. Strategies to accurately assess and treat all structures of the neck proportionally can be used to both avoid and treat any neck aesthetic issues. The advent of minimally invasive techniques has resulted in new complications.

Long-term Patterns of Age-Related Facial Bone Loss in Black Individuals.

IMPORTANCE: Facial skeletal changes that occur with aging have critical importance to the aesthetics of the aging face and the field of facial rejuvenation. Patterns of bony change may differ based on race, but existing research is limited primarily to white or unspecified racial populations. OBJECTIVE: To longitudinally document patterns of facial skeletal change among black individuals. DESIGN, SETTING, AND PARTICIPANTS: This retrospective case series study evaluated the medical records of patients treated at an urban tertiary medical center and with at least 2 facial computed tomographic (CT) images obtained at least 6 years apart between 1973 and 2017. All patients were self-identified black adults initially aged 40 to 55 years with no history of facial surgery who required repeated facial CT imaging that included the entire midface and cranium. All data analysis took place between August 1, 2018, and October 31, 2018. MAIN OUTCOMES AND MEASURES: Facial CT scans were analyzed for 2-dimensional measurements to document changes in glabellar angle, bilateral maxillary angles, frontozygomatic junction width, orbital width, and piriform width. RESULTS: A total of 20 patients were included in our analysis (6 men, 14 women). The patients' mean (SD) initial age was 46.8 (5.8) years, with a mean (SD) follow-up of 10.7 (2.9) years. There was a significant increase in mean (SD) piriform aperture width from 3.24 (0.37) cm to 3.31 (0.32) cm (P = .002) and mean (SD) female orbital width from 3.77 (0.25) cm to 3.84 (0.19) cm (P = .04). There was a significant decrease in mean (SD) frontozygomatic junction width from 5.46 (1.38) mm to 5.24 (1.42) mm (P < .001). No significant differences were found in glabellar angles, maxillary angles, or male orbital width between initial and final imaging time points. CONCLUSIONS AND RELEVANCE: This study is the first to our knowledge to document longitudinal bony changes of the face among a population of black individuals. Although significant facial skeletal changes can be observed over an average 10-year period, they are minor in comparison to previously published data among whites. This study suggests that there may be significant differences in facial bony aging between races which may have an impact on the aesthetics of aging and hold implications for facial rejuvenation. LEVEL OF EVIDENCE: NA.

Effects of Vocal Training on Students' Voices in a Professional Drama School.

OBJECTIVE: The purpose of this study was to investigate the effect of vocal training on acoustic and aerodynamic characteristics of student actors' voices. STUDY DESIGN: Prospective cohort study. SETTING: Tertiary medical facility speech and swallow center. SUBJECTS AND METHODS: Acoustic, aerodynamic, and Voice Handicap Index-10 measures were collected from 14 first-year graduate-level drama students before and after a standard vocal training program and analyzed for changes over time. RESULTS: Among the aerodynamic measures that were collected, mean expiratory airflow was significantly reduced after vocal training. Among the acoustic measures that were collected, mean fundamental frequency was significantly increased after vocal training. On average, Voice Handicap Index-10 scores were unchanged after vocal training. CONCLUSION: The cohort of drama students undergoing vocal training demonstrated improvements in voice aerodynamics, which indicate enhanced glottal efficiency after training. The present study also found an increased average fundamental frequency among the actors during sustained voicing and no changes in jitter and shimmer despite frequent performance.

Biliary tumorigenic effect on hypopharyngeal cells is significantly enhanced by pH reduction.

Biliary reflux has been considered a potential risk factor in upper aerodigestive tract malignancies. It is not yet clearly known how pH affects the bile-induced activation of NF-κB and its related oncogenic pathway previously linked to hypopharyngeal carcinogenesis. In this study, repetitive applications of conjugated primary bile acids with unconjugated secondary bile acid, deoxycholic acid (DCA), on human hypopharyngeal primary cells reveal that strongly acidic pH (4.0) optimally enhances the tumorigenic effect of bile, by inducing activation of NF-κB, STAT3 nuclear translocation, bcl-2 overexpression and significant overexpression of the oncogenic mRNA phenotype, compared to weakly acidic pH (5.5) or neutral pH (7.0). As the pH becomes less acidic the partially activated primary bile acids and activated DCA begin to exert their influence; however, with significantly less intensity compared to bile acids at strongly acidic pH. Our findings suggest that biliary tumorigenic effect is strongly pH dependent. Controlling pH during reflux events may be therapeutically effective in reducing the potential risk of bile-induced hypopharyngeal cancer.

Impact of warm ischemia on phosphorylated biomarkers in head and neck squamous cell carcinoma.

OBJECTIVES: To quantitatively and visually characterize changes in phosphorylated biomarker expression in head and neck squamous cell carcinoma specimens from excision through 90 minutes of warm ischemia. MATERIALS AND METHODS: Tissue biospecimens were procured prospectively. Head and neck squamous cell carcinoma specimens from 5 patients were subdivided into three parts upon excision, exposed to warm ischemia of 15, 30, or 90 minutes, and routinely biobanked. Relative change in biomarker expression of p-Akt, p-ERK, and p-Stat3 was measured by immunoblot densitometry. Immunofluorescent stains were performed to visually supplement the quantitative analysis. RESULTS: From 15 to 30 minutes of ex vivo ischemia, there was a significant decrease in p-Akt (p = 0.045) as the mean intensity fell by 44.9%. This decrease in p-Akt remained significant at the 90 minute time point (p = 0.015). From 15 to 30 minutes of ischemia, there was a trend toward a decline in p-ERK, which became significant by 90 minutes of ex vivo warm ischemia (p = 0.008). These changes were supported by qualitative differences in p-ERK fluorescence at 0 and 90 minutes warm ischemia. CONCLUSION: Some phosphorylated biomarkers of HNSCC remain highly dynamic during the period of ex vivo warm ischemia after surgical excision but before biobanking. These findings have critical implications for studies that attempt to correlate protein phosphorylation with clinical outcome. We conclude that ex vivo warm ischemia time is a major determinant of tissue quality that may explain inconsistent results from biomarker research in head and neck squamous cell carcinoma.