Nonsurgical Rejuvenation of the Neck.

Nonsurgical skin tightening in the neck is an area of significant growth with seemingly countless devices. Optimal treatment choice depends on the patient's concerns, anatomy, and lifestyle. Patients with minimal skin laxity, but dynamic platysmal bands may benefit from botulinum toxin injections. Mild to moderately lax skin can be addressed with microfocused ultrasound or radiofrequency with microneedling. Significant sun damage and laxity can both be addressed with fractional ablative lasers. Options for submental preplatysmal fat include percutaneous radiofrequency, radiofrequency-helium plasma, deoxycholic acid injections, and cryolipolysis. Of these, percutaneous radiofrequency has the highest patient satisfaction and lowest complication rate.

A Surgeon's Armamentarium for Ocular Management in Facial Paralysis: A Comprehensive Review.

OBJECTIVE: To review the current management paradigm of the eye in patients with facial paralysis. METHODS: A PubMed and Cochrane search was done with no date restrictions for English-language literature on facial synkinesis. The search terms used were "ocular," "facial," "synkinesis," "palsy," "neurotization," and various combinations of the terms. A total of 65 articles were included. RESULTS: Facial paralysis may result in devastating ocular sequelae. Therefore, assessment of the eye in facial paralysis is a critical component of patient management. Although the management should be individualized to the patient, the primary objective should include an ophthalmologic evaluation to implement measures to protect the ocular surface and preserve visual acuity. The degree of facial paralysis, lacrimal secretion, corneal sensation, and position of the eyelids should be assessed thoroughly. Patients with the anticipated recovery of facial nerve function may respond to more conservative temporizing measures to protect the ocular surface. Conversely, patients with expected prolonged paralysis should be appropriately identified as they will benefit from surgical reconstruction and rehabilitation of the periorbital complex. The majority of reconstructive measures within a facial surgeon's armamentarium augment coverage of the eye but are unable to restore blink. Eyelid reanimation restores the esthetic proportionality of the eye with blinking and reestablishes protective functions necessary for ocular preservation and function. CONCLUSIONS: Ocular preservation is the primary priority in the initial management of the patient with facial paralysis. An accurate assessment is a critical component in identifying the type of paralysis and developing an individualized treatment plan.

Does Bulky Adenopathy in Human Papilloma Virus-Positive Oropharyngeal Squamous Cell Carcinoma Require a Planned Post-Treatment Neck Dissection for Occult Residual Disease?

PURPOSE: A planned neck dissection was traditionally considered for a large nodal disease after definitive chemoradiation, yet controversy exists for the human papilloma virus-positive oropharyngeal squamous cell carcinoma (HPV OPSCC). We aimed to measure the frequency of persistent occult neck disease in planned neck dissection for HPV OPSCC presenting with a large (≥3.0 cm) nodal burden. METHODS: We designed a retrospective cohort study at a single tertiary referral institution. The study population was sampled from 2006 to 2018 and subjects with HPV OPSCC and adenopathy ≥3.0 cm. Inclusion criteria encompassed subjects who completed primary chemoradiation therapy (CRT) or primary radiation therapy (RT), and subsequently underwent a planned neck dissection. We excluded subjects who did not complete therapy or had less than 1-year follow-up. Our primary predictor variable was the size of cervical adenopathy on presentation (3.0-3.9 cm, 4.0-4.9 cm, 5.0-5.9 cm, and ≥6.0 cm). Our primary outcome of interest was the presence of disease based on the histopathology review. Other variables included the demographics, primary treatment with CRT or RT, and post-treatment clinical or radiographic evidence of disease. Chi-square testing was used to compare rates of persistent disease, with varying sizes of cervical adenopathy on presentation. The alpha level for statistical significance was set at 0.05. RESULTS: A total of 86 subjects were analyzed, with forty-one females and forty-five males, ranging from 36 to 77 years (mean 54.6 years). From the total study sample, 35% showed persistent disease, and 67% of those subjects had occult disease at the time of planned neck dissection. Greater than 20% of subjects had persistent disease when the nodal burden was ≥3.0 cm at presentation. Furthermore, there was a statistically significant difference in the rates of persistent microscopic disease among subjects with nodal burden of different sizes based on chi-square testing (P = .01, χ2 = 10.66). CONCLUSIONS: Our data suggest that subjects with HPV OPSCC presenting with a nodal burden ≥3.0 cm are likely to have 23% chance of persistent occult neck disease after primary CRT or RT. These findings may support the routine treatment of these subjects with a planned neck dissection after initial therapy to confirm or surgically complete disease eradication.

Controversies and Contemporary Management of Orbital Floor Fractures.

Substantial controversy exists regarding the timing of intervention and management of patients with orbital floor fractures. Recent advances in computer-aided technology, including the use of 3-dimensional printing, intraoperative navigational imaging, and the use of novel implants, have allowed for improvement in prospective management modalities. As such, this article aims to review the indications and timing of repair, surgical approaches, materials used for repair, and contemporary adjuncts to repair. Indications for orbital floor fracture repair remain controversial as many of these fractures heal without intervention or adverse sequelae. Intraoperative navigation and imaging, as well as endoscopic guidance, can improve visualization of defects mitigating implant positioning errors, thereby reducing the need for secondary corrective procedures. Patient-specific implants may be constructed to fit the individual patient's anatomy using the preoperative CT dataset and mirroring the contralateral unaffected side and have been shown to improve pre-operative efficiency and minimize postoperative complications. With increased data, we can hope to form evidence-based indications for using particular biomaterials and the criteria for orbital defect characteristics, which may be best addressed by a specific surgical approach.

Nonsurgical Rejuvenation of the Neck.

Nonsurgical skin tightening in the neck is an area of significant growth with seemingly countless devices. Optimal treatment choice depends on the patient's concerns, anatomy, and lifestyle. Patients with minimal skin laxity, but dynamic platysmal bands may benefit from botulinum toxin injections. Mild to moderately lax skin can be addressed with microfocused ultrasound or radiofrequency with microneedling. Significant sun damage and laxity can both be addressed with fractional ablative lasers. Options for submental preplatysmal fat include percutaneous radiofrequency, radiofrequency-helium plasma, deoxycholic acid injections, and cryolipolysis. Of these, percutaneous radiofrequency has the highest patient satisfaction and lowest complication rate.

Surgical Management of Necrotizing Fasciitis of the Head and Neck.

OBJECTIVE: The purpose of this study was to highlight risk factors and surgeries for necrotizing fasciitis (NF) of the head and neck in the literature. NF is rare but can rapidly progress. MATERIALS AND METHODS: A literature search was done using PubMed and SCOPUS. Articles that discussed NF of the head and neck and a specific surgical technique were included. A bivariate Pearson correlation was conducted using an α level of 0.05. RESULTS: The study included 31 articles encompassing 77 patients who presented with head and neck NF. Diabetes mellitus (23.4%) was the most common comorbidity observed. Surgical techniques, such as debridement (96.10%) and incision/exploration (97.40%), were common. CONCLUSION: Immediate surgical intervention should be performed when treating patients presenting with NF of the head and neck.

Trends in Facial Paralysis Management: A National Survey Study.

INTRODUCTION: Advances in operative management, minimally invasive procedures, and physical therapy have allowed for dramatic improvements in functional and cosmetic outcomes in patients with facial paralysis. Our goal was to evaluate the current trends and practice patterns in the diagnosis and management of facial paralysis by provider demographics. MATERIALS AND METHODS: An electronic questionnaire was distributed to members of the American Academy of Facial Plastic and Reconstructive Surgery (AAFPRS). Practice patterns in the diagnosis and treatment were compared by level of training (fellowship-trained facial plastic and reconstructive surgeon versus non-fellowship trained), practice type (academic and private), practice length, patient volume, and presence of a dedicated facial nerve clinic. The bivariate associations of the outcome variables and the stratification factors were analyzed using 2-way contingency tables and Fisher's exact tests. RESULTS: The survey was sent to 1129 members of the AAFPRS. The response rate was 11.7% (n=132). Most respondents were fellowship-trained surgeons (79%) in the academic setting (55%), and most have been in practice for more than 10 years (53%). Practice setting and patient volume were the factors most associated with significant variations in management, including the use of facial paralysis grading scales, photography/videography, patient-reported outcome metrics, as well as differences in both noninvasive and surgical management. CONCLUSION: Based on the present study, several physician demographic factors may play a role in choosing which diagnostic and treatment options are employed for facial paralysis, with practice setting and patient volume appearing to be the 2 variables associated with the most significant differences.

Facial synkinesis: A distressing sequela of facial palsy.

INTRODUCTION: Synkinesis refers to abnormal involuntary facial movements that accompany volitional facial movements. Despite a 55% incidence of synkinesis reported in patients with enduring facial paralysis, there is still a lack of complete understanding of this debilitating condition, leading to functional limitations and decreased quality of life.1 This article reviews the diagnostic assessment, etiology, pathophysiology, rehabilitation, and nonsurgical and surgical treatments for facial synkinesis. METHODS: A PubMed and Cochrane search was done with no date restrictions for English-language literature on facial synkinesis. The search terms used were "facial," "synkinesis," "palsy," and various combinations of the terms. RESULTS: The resultant inability to control the full extent of one's facial movements has functional and psychosocial consequences and may result in social withdrawal with a significant decrease in quality of life. An understanding of facial mimetic musculature is imperative in guiding appropriate intervention. While chemodenervation with botulinum toxin and neurorehabilitation have continued to be the primary treatment strategy for facial synkinesis, novel techniques such as selective myectomy, selective neurolysis, free-functioning muscle transfer, and nerve grafting techniques are becoming increasingly utilized in treatment regimens. Facial rehabilitation, including neuromuscular retraining, soft tissue massage, and relaxation therapy in addition to chemodenervation with botulinum toxin, remains the cornerstone of treatment. In cases of severe, intractable synkinesis and non-flaccid facial paralysis, surgical interventions, including selective neurectomy, selective myectomy, nerve grafting, or free muscle transfer, may play a more significant role in alleviating symptoms. DISCUSSION: A multidisciplinary approach involving therapists, clinicians, and surgeons is necessary to develop a comprehensive treatment regimen that will result in optimal outcomes. Ultimately, therapy should be tailored to the severity and pattern of synkinesis, and each patient approached on a case-by-case basis. A multidisciplinary approach involving therapists, clinicians, and surgeons is necessary to develop a comprehensive treatment regimen that will result in optimal outcomes.

Genioplasty and Mandibular Implants.

Genioplasty is a useful technique employed for both aesthetic and, in the case of obstructive sleep apnea, functional purposes. Mandibular implants similarly represent a powerful tool in the facial surgeons armamentarium. Herein, we review relevant anatomy, patient evaluation, and various techniques employing both alloplastic augmentation and osseous modification of the mandible.

Jaw in a Day: Immediate Dental Rehabilitation during Fibula Reconstruction of the Mandible.

Reconstructing mandibular defects presents challenges to dental rehabilitation related to altered bone and soft tissue anatomy. Dental implants are the most reliable method to restore the lost dentition. Immediate dental implants have been placed for many years but with unacceptably low rates of dental/prosthetic success. Current virtual technology allows placement of both fibulas and guided implants in restoratively driven positions that also allow immediate dental rehabilitation. Inexpensive three-dimensional printing platforms can create provisional dental prostheses placed at the time of surgery. This article reviews our digital and surgical workflow to create an immediate dental prosthesis to predictably restore the dentition during major jaw reconstruction with fibula free flaps.

Postoperative outcomes of autologous rib graft for microtia repair in children: A NSQIP study.

OBJECTIVE: To compare the effect of surgical specialty and patient factors on 30-day postoperative outcomes and complications for children undergoing autologous costochondral grafting for microtia reconstruction. METHODS: The American College of Surgeons National Surgical Quality Improvement Program Pediatric (NSQIP-P) database was searched from 2012 through 2017 for patients who underwent autologous rib grafting (CPT 21230). The group was further filtered for coexisting ICD 9 or 10 code for microtia (744.23, Q17.2) as an indication for surgery. Outcomes analyzed included patient demographics, medical comorbidities, admission type (inpatient vs. outpatient), operative time, surgeon specialty, length of hospital stay (LOS), complications, and readmission. RESULTS: A total of 375 pediatric patients were identified of which 157 were female and 218 were male. Mean age at time of surgery was 9.6 years. Postoperative complications and readmission occurred in 5.6% and 3.5% of patients, respectively. Surgical site infection was the most common complication. Average operative time was 246.9 min. When comparing Otolaryngology to Plastic Surgery with multivariate analysis, there was no difference in admission type (OR 1.00, p = 0.993), complication rate (OR 0.91, p = 0.744), readmission (OR 0.68, p = 0.576), operative time (p = 0.471) or total LOS (p = 0.266). CONCLUSION: The present study demonstrated postoperative complications and readmission rates following microtia repair as reported by the NSQIP-P database. Overall complication and readmission rates were low. No significant risk factors were identified on multivariate analysis. There were no differences between surgical specialty for complication rate, operative time, hospital stay or readmission when accounting for demographic data and comorbidities.

Facial Protection to Prevent Facial Trauma and Allow for Optimal Protection after Facial Fracture Repair.

Facial skeletal fractures continue to affect humankind, and many methods to alleviate and prevent the injuries outright have been sought after. Prevention is desired, but the implementation and general compliance may contribute to missed opportunities to decrease the burden of facial skeletal trauma. In this article, we explore the preventative as well as postoperative options for the protection of the facial skeleton.

Perfusion dynamics in pedicled and free tissue reconstruction: Infrared thermography and laser fluorescence video angiography.

OBJECTIVE: Preoperative planning, design, and perioperative monitoring of microsurgical free flaps is of paramount importance to successful reconstruction. Infrared Thermography provides an indirect method by which vascular perfusion may be monitored and has previously shown efficacy in detection of cutaneous perforators. In a proof-of-concept study, we assessed the utility of infrared thermography in delineating angiosomes and monitoring for adequate tissue perfusion in the preoperative, intraoperative, and postoperative setting. This technology was compared to conventional indocyanine green fluorescence angiography (ICG-FA). METHOD: Four patients undergoing locoregional pedicled or free flap reconstruction were assessed using ICG-FA and Forward-looking infrared (FLIR) thermography in standardized conditions. Monitoring of flap angiosomes and tissue perfusion using both fluorescent pixel intensity and thermography was then performed implementing proprietary software. CONCLUSION: Our study is unique in that tissue perfusion intraoperatively was assessed with both thermography and indocyanine green fluorescence angiography (ICG-FA), which represents a previously established system. We demonstrate that smartphone compatible thermal cameras may be used as an adjunct to clinical exam, as well as other monitoring technologies, providing further information in not only selection of perforators, in the operative setting, but also in the early detection of poor flap viability secondary to microvascular compromise allowing for timely salvage.

Rugby-related adult maxillofacial trauma injuries: a NEISS database study.

PURPOSE: The primary objective of this study is to delineate the data on maxillofacial trauma in rugby utilizing the National Electronic Injury Surveillance System (NEISS) database. Specifically, we want to establish the prevalence of facial rugby injuries in terms of age, mechanism of injury, and degree of injury in order to develop ways to limit facial trauma in the future. METHODS: The NEISS database was accessed in February 2020 in order to identify adult patients (> 19 years of age) presenting to the emergence department (ED) for rugby-related head and facial injuries from the previous 10 years (2009-2018). Descriptive statistics were organized and presented. Chi-squared testing (χ2) was performed to compare categorical variables, and ANOVA was performed to compare continuous variables. RESULTS: A total of 507 patients (national estimate = 18,952) from 2009 to 2018 were identified as appropriate for study inclusion. The most common injuries were those to the facial region including the eyelid, eye area, and nose (59.4%). The most frequently encountered facial fracture while playing rugby was the nasal bone (58.6%). Overall, 98.4% of patients who presented to the ED with rugby injuries were treated and released, 1.2% were admitted or observed, and 0.4% left against medical advice. CONCLUSIONS: When evaluating a patient with a rugby-related injury, one should expect injuries to the eyelid, eye area, or nose. The most common fracture pattern will most likely be nasal bone. Despite these injuries, the vast majority of patients will be treated and released.

Hearing Rehabilitation Implementing a Transcutaneous Bone Conduction Device: Single-Center Experience.

Bone conduction implants based on percutaneous abutment acoustic transmission have been implemented in patients with satisfactory outcomes. However, adverse soft tissue outcomes present a limitation. Transcutaneous bone conduction devices (t-BCDs) are an alternative that may mitigate these complications. A retrospective review was performed of patients who underwent implantation of a t-BCD from 2013 to 2017. Surgical outcomes were reviewed including wound complications, frequency of device use, patient concerns regarding the device, and reported patient satisfaction. A total of 37 patients were implanted with the bone-anchored hearing aids, BAHA Attract (Cochlear™ Baha® Implant System). Average follow-up time was 271.8 days. Postoperatively, 7 (18.9%) patients complained of soft tissue changes or issues with wound healing. Twelve (32.4%) patients requested adjustment of their devices. The t-BCD is an excellent option for hearing rehabilitation. Overall, the complication rate is low, patient satisfaction is high, and successful conversion from a percutaneous device is possible with minimal risk.

Treatment of Oligometastatic Disease in Squamous Cell Carcinoma of the Head and Neck.

OBJECTIVE: No surgical or radiotherapeutic treatment guidelines exist for oligometastatic head and neck squamous cell carcinoma (oHNSCC), and only recently have interventions with curative intent been studied. Herein, we sought to elucidate survival rates among patients with oHNSCC to determine if treatment with curative intent is warranted in this population. STUDY DESIGN: Retrospective chart review. METHODS: We retrospectively reviewed cases of oHNSCC treated between March 1998 and March 2018. Fisher's exact test was used to compare patients treated with radiotherapy (RT) to those who underwent surgical excision and to compare outcomes of patients with oligometastases at the time of initial presentation to those that developed oligometastatic disease after primary treatment. RESULTS: Eighty one patients with metastases to the lungs, ribs, pelvis, vertebral column, liver, clavicle, and sternum were included. Overall, 32 patients (40%) were alive 5 years post-treatment. The site of metastasis, the modality of treatment, and the time of development of oligometastatic disease did not significantly affect 5-year survival. CONCLUSION: Herein, we demonstrate that multi-modality treatment of oHNSCC is warranted for some patients with an estimated 40% 5-year survival. Aggressive treatment of the primary and regional sites is necessary in addition to treatment of the metastatic site and incurs a survival benefit compared to patients with metastatic HNSCC treated with systemic therapy alone. oHNSCC should be approached separately from polymetastatic disease. Patients should be counseled about the possibility for long-term survival, and aggressive initial treatment with the intention for cure should be considered in this population. LEVEL OF EVIDENCE: 4 Laryngoscope, 131:E1476-E1480, 2021.

Reconstructive Options During Nonfunctional Laryngectomy.

OBJECTIVE: A paucity of data exists regarding surgical outcomes for patients undergoing total laryngectomy for a dysfunctional larynx. Herein, we present the largest study evaluating the method of closure on postoperative fistula rate and swallowing ability. METHOD: We performed a retrospective review of patients undergoing total laryngectomy for a dysfunctional larynx after primary radiation or chemoradiation therapy for laryngeal carcinoma from 1998 to 2020. Demographic information, operative details, length of hospitalization, fistula formation, method of fistula treatment, and need for enteral feeding 6 months after surgery were analyzed. RESULTS: A total of 268 patients were included. Flaps were performed in 140 (52.2%) patients, including radial forearm free flaps (RFFF), pectoralis flaps, and supraclavicular flaps. Sixty-four (23.9%) patients developed postoperative fistulas. There was no significant difference in the fistula rate between flap and primary closure methods (P = .06). However, among patients who had a flap, RFFF had a significantly lower fistula rate (P = .02). Significantly more patients who had initial closure with a pectoralis flap required an additional flap for fistula repair than those who underwent RFFF or primary closure (P < .05). Last, whereas 87 patients (32.5%) required an enteral feeding tube 6 months after surgery, significantly fewer patients who underwent RFFF were feeding tube-dependent (P = < .0001). CONCLUSION: Herein, we present the largest study of outcomes after total laryngectomy for dysfunctional larynx. Postoperative fistula rates are high, 23%; however, the majority of patients, 67%, will not require long-term enteral support. The RFFF is an excellent option demonstrating the lowest rates of postoperative fistula and enteral feeding tube dependence. LEVEL OF EVIDENCE: 4 Laryngoscope, 131:E1510-E1513, 2021.

The Influence of Photo Editing Applications on Patients Seeking Facial Plastic Surgery Services.

BACKGROUND: The utilization of the smartphone and social media have introduced paradigm shifts to cosmetic surgery. Much has been studied regarding social media and its influences in plastic surgery; however, little is known about facial editing applications and how these relate to plastic surgery practices. OBJECTIVES: The authors sought to discover if face-editing applications influence patients' pursuit of plastic surgery, who utilizes these applications, and why. METHODS: An anonymous survey was administered between September and December 2019, including questions about demographics, familiarity, and utilization of face-editing applications, motivations in utilization and influences towards pursuing cosmetic procedures, and attitudes towards applications. RESULTS: Seventy patients completed the survey and 32.9% admitted to utilizing face-editing applications. Patients utilizing applications were significantly younger (36.9 years) than those who did not (54 years [P < 0.001]). Among those familiar with applications, women were significantly more likely than men to utilize them (100% vs 78.6%, respectively [P = 0.047]). Social media was the most common influence for utilizing apps (87%). The majority confirmed that these applications played a role in pursuing cosmetic procedures (56.5%). Most patients did not regret their utilization of these applications (87%). CONCLUSIONS: Face-editing applications serve a role regarding patient decision-making to pursue cosmetic surgery. Several motivators exist for application utilization, the largest of which is social media. Younger females are the most likely demographic to utilize applications and generally do not express regret in doing so. Plastic surgeons would benefit by understanding patient motivations and expectations created by utilizing these applications.

Volleyball-related Adult Maxillofacial Trauma Injuries: A NEISS Database Study.

INTRODUCTION: Craniofacial trauma among athletes of various sports has been well detailed and described. Despite this research, there is a dearth of literature describing the nature of facial trauma secondary to volleyball, despite its global popularity. METHODS: A cross-sectional analysis of volleyball-related facial trauma was conducted using the National Electronic Injury Surveillance System (NEISS) database from 2009 to 2018. Patient demographics (age, sex, and race), medical injury information (injury type and location), and disposition (observed and discharged, admitted, deceased) were collected and analyzed. χ2 testing was performed to compare categorical variables. RESULTS: A total of 235 volleyball-related facial traumas were recorded with an estimated 10,424 visits occurring nationally. The majority of injuries were among young adults aged 20 to 29 years (52.3%) and was evenly distributed for men and women. Lacerations were the most frequent injury type (37.9%), whereas the face was the most common site of injury (41.7%). The majority of fractures involved the nose (71.4%) and among individuals aged 20 through 49 (90.5%). Males had significantly more lacerations than females (75.3% vs 24.7%), whereas females had significantly more contusions/abrasions (64.5% vs 35.5%) and concussions (72.9% vs 27.1%). CONCLUSIONS: Volleyball-related craniofacial injuries can vary depending on patient demographics. This information can help with the development of safety and preventative measures for individuals participating in the sport.