Facial Rejuvenation in a Patient With Granulomatosis With Polyangiitis-Treatment Protocol for Compromised Skin Flap.

Facial rejuvenation outcomes have not been well studied in patients with granulomatosis with polyangiitis (GP)-formerly Wegener granulomatosis. This report highlights a case of a 49-year-old female with a history of GP, presenting with facial aging and functional nasal concerns. The patient underwent facial rejuvenation and nasal reconstruction procedures, including primary open functional rhinoplasty, septal perforation repair with Alloderm, deep-plane rhytidectomy, platysmaplasty, nanofat grafting, and fractionated erbium laser to the face (sparing the nose and peri-incisional areas). Despite a routine operation, postoperative course was complicated by wound healing and vascular congestion issues related to her underlying autoimmune disease. This case highlights the risks associated with postsurgical healing in patients with GP undergoing esthetic surgery. To the best of our knowledge, this report is the first to discuss management considerations in a patient with GP undergoing facial rejuvenation surgery.

Rhinoplasty for Thick-Skinned Noses: A Systematic Review.

OBJECTIVE: The purpose of this systematic review is to critically examine the literature published on rhinoplasties in thick-skinned patients to determine how to maximize outcomes in these patients. METHODS: The PubMEd and Google Scholar databases were searched for clinical studies related to nasal skin thickness as it relates to rhinoplasty surgery and surgical outcomes. RESULTS: We performed a review of the current body of literature and identified twenty-eight articles that met our inclusion criteria for final analysis. Three articles were level of evidence 1 by CEBM guidelines, while the majority were level 4 (39%) and 5 (32%). Most papers were published in the USA (35%), followed by Saudi Arabia (14%). Here, we outline the current body of literature regarding thick-skinned noses in rhinoplasty surgery and identify optimization strategies. CONCLUSION: We highlight a management scheme subdivided into preoperative, intraoperative and postoperative timepoints for the comprehensive management of this patient population. Optimal results rely on an individualized medical and surgical treatment plan and regimen to achieve desired and realistic results. LEVEL OF EVIDENCE III: 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 .

Correction of the Overly Shortened Nose.

The overly shortened nose can often be the result of previous rhinoplasty. The causes can include weakening or missing cartilage for nasal tip support as well as contraction and scarring of the skin. The purpose of this article was to provide the authors' approach to this deformity.

Platelet-Rich Plasma for Skin Rejuvenation: Facts, Fiction, and Pearls for Practice.

Platelet-rich plasma (PRP) has gained popularity in facial plastic surgery because of its role in wound healing. PRP, having a higher concentration of platelets, allows for greater release of growth factors and biologically active proteins, which in turn activates the wound-healing cascade stimulating neoangiogenesis and collagen production. One of the most popular uses for PRP is for facial skin rejuvenation in the form of dermal injections and topical application during microneedling. The promising nature of PRP makes using it for injection and/or in conjunction with microneedling a good addition to any practice that deals with skin rejuvenation.

Single-incision sural nerve harvest: Technical considerations for cross-facial nerve grafting.

b.a. is the senior author and performed all of the procedures described, and conceptualized and edited the article. l.e.i. was responsible for data collection and analysis, editing the manuscript, and compiling the figures. d.b.y. performed the first single-incision nerve harvest with b.a. and is responsible for b.a. adopting the practice. b.l. is b.a.'s partner and assisted with the majority of surgeries and proofread the manuscript. g.g.m. was cosurgeon on many of the described cases and is partly responsible for conceptualizing the article. g.l.p. was responsible for data collection and writing of the original manuscript and compiling the illustrations. Laryngoscope, 129:2464-2466, 2019.

Modified Selective Neurectomy for the Treatment of Post-Facial Paralysis Synkinesis.

BACKGROUND: To address functional and smile dysfunction associated with post-facial paralysis synkinesis, the senior author (B.A.) has offered "modified selective neurectomy" of the lower division of the facial nerve as a long-term solution. This article examines technical considerations and outcomes of this procedure. METHODS: A retrospective review was conducted of patients who underwent modified selective neurectomy of buccal and cervical branches of the facial nerve performed by a single surgeon over a 4½-year period. House-Brackmann facial grading scores, electronic clinician-graded facial function scale, and onabotulinumtoxinA (botulinum toxin type A) dosages were examined before and after the procedure. RESULTS: Sixty-three patients underwent modified selective neurectomy between June 20, 2013, and August 12, 2017. There were no serious complications. The revision rate was 17 percent. Temporary oral incompetence was reported in seven patients (11 percent) postoperatively. A statistically significant improvement was achieved in electronic clinician-graded facial function scale analysis of nasolabial fold depth at rest, oral commissure movement with smile, nasolabial fold orientation with smile, nasolabial depth with smile, depressor labii inferioris lower lip movement, midfacial synkinesis, mentalis synkinesis, platysmal synkinesis, static score, dynamic score, synkinesis score, periocular score, lower face and neck score, and midface and smile score. There was a significant decrease in botulinum toxin type A dosage and House-Brackmann score after surgery. CONCLUSION: Modified selective neurectomy of the buccal and cervical divisions of the facial nerve is an effective long-term treatment for smile dysfunction in patients with post-facial paralysis synkinesis. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Rhinoplasty in the African American Patient: Anatomic Considerations and Technical Pearls.

There are several anatomic considerations as well as variations in patients of African heritage. The goal of improvement in aesthetics and functionality must be in balance with racial preservation. Preoperative counseling must discuss patient expectations and surgical limitations based on patients' skin and cartilage. Dorsal augmentation, increased tip projection, and rotation are often needed. Understanding the thick, sebaceous skin often seen in African Americans assists in postoperative management of swelling.

Cross-facial nerve grafting for facial reanimation.

Dynamic facial reanimation is the gold standard treatment for a paralyzed face. Over the last century, multiple nerves have been utilized for grafting to the facial nerve in an attempt to produce improved movement. However, in recent years, the use of cross facial nerve grafting with a second stage gracilis free flap has gained popularity due to the ability to generate a spontaneous smile and facial movement. Preoperative history taking and careful examination, as well as pre-surgical planning, are imperative to whether cross facial nerve grafting with a second stage gracilis free flap is appropriate for the patient. A sural nerve graft is ideal given the accessibility of the nerve, the length, as well as the reliability and ease of the nerve harvest. The nerve can be harvested using a small incision, which leaves the patient with minimal post operative morbidity. In this chapter, we highlight the pearls and pitfalls of cross facial nerve grafting.

Microbiology and antibiotic prophylaxis in rhinoplasty: a review of 363 consecutive cases.

IMPORTANCE: A practical technique for reducing infectious complications from rhinoplasty would represent an important surgical advance. OBJECTIVES: To describe the microbial flora of patients undergoing septorhinoplasty and to evaluate the role of preoperative and postoperative antibiotic prophylaxis. DESIGN, SETTING, AND PARTICIPANTS: We performed a retrospective medical record review of 363 consecutive adult patients who underwent preoperative nasal swab testing and rhinoplasty or septorhinoplasty in a single private practice: 279 women (76.9%) and 84 men (23.1%). The average patient age was 35.9 years (age range, 17-70 years). MAIN OUTCOMES AND MEASURES: Identification of endogenous nasal flora and pathogenic bacteria treated with culture-directed antibiotics; evaluation of comorbidities, perioperative infections, and antibiotic treatments. RESULTS: A total of 174 patients (47.9%) underwent primary rhinoplasty, and 189 (52%) underwent revision rhinoplasty. On preoperative nasal culture, 78.2% of patients had normal flora; 10.7% had Staphylococcus aureus; and 0.28% had methicillin-resistant S aureus (MRSA). In 7.4% of patients, fecal coliforms including Escherichia coli, Enterobacter species, and Citrobacter species were found. Age, sex, smoking, the use of oral contraceptives, or the presence of seasonal allergies did not significantly change the nasal flora or the postoperative infection rate. Patients with adult acne were found to have an increased incidence of colonization with fecal coliforms (43.8%; P < .001). Patients with diabetes were found to have an increased incidence of colonization with S aureus (66.7%; P = .002). The overall infection rate was 3.0% (11 of 363 patients), with 4.0% (7 of 174 patients) seen in primary septorhinoplasties and 2.1% (4 of 189 patients) seen in revision cases. Coliforms accounted for 5 cases (45.5%) of postoperative infections, while S aureus was responsible for 4 cases (36.4%), including 1 case of MRSA. CONCLUSIONS AND RELEVANCE: The results of this study suggest that risk factors alone may not reliably predict the subset of patients in whom antibiotic prophylaxis is indicated. Knowledge of the endogenous nasal flora and the microbiology of common pathogens in patients undergoing septorhinoplasty will help to further reduce the incidence of infectious complications. LEVEL OF EVIDENCE: 3.

The supraclavicular artery island flap in head and neck reconstruction: applications and limitations.

IMPORTANCE: The supraclavicular artery island (SAI) rotational flap may have advantages compared with free-tissue transfer in head and neck reconstruction. Because this flap has not been extensively described for head and neck reconstruction of oncologic defects, guidelines for its indications would benefit the reconstructive surgeon. OBJECTIVE: To describe the applications and limitations of the SAI flap as an alternative to free-tissue transfer in reconstruction of head and neck defects. DESIGN, SETTING, AND PARTICIPANTS: Retrospective case series of 45 patients with defects related to malignant and nonmalignant disease undergoing reconstructive surgery from August 18, 2010, through September 28, 2012, at an academic, tertiary referral center. Each defect was deemed unsuitable for primary or local flap closure and would require regional tissue or free-tissue transfer. Mean follow-up was 10.3 (range, 1-31) months. INTERVENTION: Use of the SAI flap for reconstruction of soft-tissue defects of the head and neck. MAIN OUTCOMES AND MEASURES: Defect site, flap dimensions, time to raise the flap, and complications. RESULTS: Defects of the oral cavity, oropharynx, laryngopharynx, esophagus, trachea, temporal bone, and cervicofacial skin underwent reconstruction. Mean flap dimensions were 6.1 cm wide and 21.4 cm long, with a mean skin paddle length of 7.9 cm. Harvest time was less than 1 hour. Donor-site complications included minor dehiscence in 6 patients and prolonged wound care in 2. Partial skin flap necrosis occurred in 8 patients, whereas 2 had complete loss of the skin paddle. Seven patients developed a salivary fistula, 4 of which healed spontaneously. Flap length greater than 22 cm correlated with flap necrosis (P = .02). A history positive for smoking correlated with an increased risk of flap dehiscence (P = .02). CONCLUSIONS AND RELEVANCE: The SAI flap provides an alternative to free-tissue transfer for soft-tissue reconstruction after head and neck oncologic surgery. This flap is easy to harvest and versatile. However, the SAI flap has limitations in length and, because it is a rotational flap, is less capable of reconstructing some complex head and neck defects.

Transconjunctival lower blepharoplasty with fat repositioning: a retrospective comparison of transposing fat to the subperiosteal vs supraperiosteal planes.

IMPORTANCE: Differences in technique and outcome between fat transposed to the subperiosteal and supraperiosteal planes during transconjunctival lower blepharoplasty remain to be elucidated. OBJECTIVE: To provide a single-surgeon comparison of transconjunctival lower blepharoplasty with fat repositioning (TCBFR) to the subperiosteal vs the supraperiosteal plane. DESIGN: A retrospective medical record review of patients who underwent TCBFR to the subperiosteal or the supraperiosteal plane by a single surgeon from January 1, 2009, through December 31, 2011. Differences in surgical technique, postoperative course, complications, patient satisfaction, and aesthetic results (by blinded assessment of preoperative and postoperative photographs) are reviewed using a 4-point scale. SETTING: An ophthalmic plastic surgical practice. PARTICIPANTS: The first 20 consecutive patients who underwent TCBFR to the supraperiosteal plane and the previous 20 who underwent TCBFR to the subperiosteal plane. INTERVENTION: Transconjunctival lower blepharoplasty with fat repositioning. MAIN OUTCOME MEASURES: Intraoperative findings, postoperative course, complications, and aesthetic results. RESULTS: We included 40 patients (27 women and 13 men) with a mean age of 57 years and mean follow-up of 10 months. Subperiosteal TCBFR was more meticulous and less disruptive of normal anatomy and resulted in less bleeding. Supraperiosteal surgery was faster yet more traumatic, leading to more bruising, swelling, and with more clinically evident temporary postoperative contour irregularities. All patients expressed a high level of satisfaction (100%). Blinded assessment of results demonstrated no statistically significant difference (P = .45) between the 2 surgical approaches with regard to the final aesthetic result. CONCLUSIONS AND RELEVANCE: Transconjunctival lower blepharoplasty with fat repositioning can be performed safely and effectively, whether fat is translocated to the subperiosteal or the supraperiosteal plane. Aesthetic results are comparable between the 2 approaches. LEVEL OF EVIDENCE: 4.

Effacing the orbitoglabellar groove with transposed upper eyelid fat.

PURPOSE: An age-related depression can develop over the superonasal orbital rim, which the authors have called the "orbitoglabellar groove (OGG)." It is, in part, related to volume loss over the rim as is seen at the lower eyelid/cheek interface (nasojugal groove). An upper eyelid fat pedicle can be transposed over the OGG during standard upper blepharoplasty surgery to reduce this depression. METHODS: The charts of patients who underwent fat transposition to the OGG during upper blepharoplasty over a 20-month period (2010-2012) are retrospectively reviewed. Only primary eyelid surgery patients are included in the study. The procedure, its results, and complications are presented. RESULTS: Seventeen patients are included in this study. Eleven patients (65%) are women and 6 (35%) patients are men. The average patient age is 56 years (range 47-80 years), and the average follow up is 10 months (6-14 months). Two patients (12%) developed a transient induration over the transposed fat pedicle in the postoperative period which resolved with a combination 5-fluorouracil/kenalog injection. There were no cases of postoperative infection, prolonged swelling, motility disturbance, diplopia, or eyelid malposition. Clinical effacement of the OGG was noted in all cases, and physician and patient assessment of surgical results are equally good. CONCLUSIONS: The OGG is an involutional periorbital hollow present over the superonasal orbital rim. The depression can be reduced with native eyelid fat transposition during upper blepharoplasty in a similar way that lower blepharoplasty with fat repositioning effaces the nasojugal groove. The learning curve for the procedure is quick, especially for those who have experience with its lower eyelid counterpart.