Septal Reconstruction: Simple to Complex.

Nasal septal deviation is a frequent problem treated by otolaryngologists and facial plastic surgeons. Complete correction of the septal deformity is often essential both for straightening a crooked nose and for restoration of the nasal airway. While standard septoplasty techniques provide excellent outcomes in most patients, severe septal deformities may require treatment with more advanced maneuvers including adjacent grafting, caudal septal replacement, and even extracorporeal septoplasty. This article reviews a range of septoplasty techniques, with an emphasis on complex septal reconstruction and approaches that can be utilized to maintain keystone stability and establish a robust midline L-strut even in cases with challenging anatomy.

Implications of Ozempic and Other Semaglutide Medications for Facial Plastic Surgeons.

Obesity is a growing global health concern, leading to various health issues, including diabetes. Semaglutide-based medications, such as Ozempic, Wegovy, and Rybelsus, have emerged as potential treatments. These medications, belonging to the glucagon-like peptide-1 (GLP-1) receptor agonist class, mimic the action of GLP-1, regulating appetite and promoting weight loss. Clinical trials have shown their effectiveness in reducing body weight and improving metabolic parameters. Ozempic, though Food and Drug Administration-approved for diabetes, is also used off-label for weight loss alone. Rapid weight and fat loss with Ozempic can lead to the characteristic "Ozempic face," where facial volume and fat are depleted, resulting in wrinkles and sagging skin. Providers prescribing Ozempic seldom counsel patients about the potential impact on the face. As a result, the plastic surgery community faces a challenge in managing facial changes associated with rapid weight loss. Dermal fillers, skin tightening techniques, and surgical interventions are useful for both restoration of facial volume and to manage excess skin. Discontinuation of Ozempic should be considered prior to general anesthesia due to gastrointestinal side effects including delayed gastric emptying. As the popularity of Ozempic grows, facial plastic surgeons must be aware of both the impact on facial appearance and perioperative considerations.

Functional Browlifting.

Brow ptosis is an abnormal descent of the eyebrow resulting in a displeased appearance and/or functional deficit. While most cases of brow ptosis do not result in a functional impairment, functional brow surgery is generally reserved for individuals with severe brow asymmetry or visual field deficit related to excess soft tissue pushing downward on the eyelid. A combination of both intrinsic and extrinsic anatomic factors contributes to an unfavorable brow shape, contour, and position. Proper management of brow ptosis requires an understanding of both surgical and nonsurgical modalities. Traditionally, individuals with functional brow ptosis are treated by browpexy via blepharoplasty approach, direct browlift, mid-forehead browlift, or less commonly endoscopic browlift.

Local Cutaneous Flaps in Nasal Reconstruction.

Facial plastic surgeons use a variety of reconstruction techniques to overcome challenges in restoring the function, structural integrity, and intricate nasal contour in nasal reconstruction. Local cutaneous flaps provide excellent skin texture, thickness, and color match in nasal reconstruction. They offer an excellent cosmetic appearance for small- to medium-sized defects and are preferentially utilized when feasible. This article aims to provide an updated review of local cutaneous flaps for nasal defect repair and describe the major principles related to flap selection.

Autologous Rib Grafts in the Management of the Crooked Nose.

Rhinoplasty is arguably one of the most challenging procedures a facial plastic surgeon performs. Numerous techniques have been developed since the inception of rhinoplasty to aid in correction of aesthetic and functional issues. Congenital, iatrogenic, and traumatic etiologies can all lead to a crooked nose. Autologous rib or costal cartilage grafting is a powerful tool that can aid the surgeon in successful correction of the crooked nose.

Trends in Maxillomandibular Fixation Technique at a Single Academic Institution.

Study Design: Retrospective chart review. Objective: Restoration of premorbid occlusion is a key goal in the treatment of mandibular fractures. Placement of the patient in maxillomandibular fixation (MMF) is performed during mandibular fracture repair to help establish occlusion. A number of techniques are available to achieve MMF. We sought to examine trends in MMF technique at our institution. Methods: A retrospective chart review was conducted to evaluate patients who underwent surgical treatment of mandibular fractures between January 1, 2011 and March 31, 2021. Data including fracture characteristics, mechanism of injury, patient demographics, complication rates, and MMF technique utilized were collected. Results: One hundred sixty-three patients underwent MMF (132 males). The most common etiology of fracture was assault (34%). There was an increasing preference for rapid MMF techniques over time, as opposed to standard Erich arch bars. No significant difference in obtaining adequate fracture reduction as determined by postoperative imaging or complications were noted between those who underwent MMF with newer rapid techniques vs traditional MMF techniques. Conclusions: Our institution has demonstrated changing trends in the technique utilized for establishing occlusion intraoperatively, more recently favoring rapid MMF techniques, with similar rates of complications and ability to adequately reduce fractures.

Guided Mindfulness Meditation for Pain Control After Septorhinoplasty: A Randomized-Controlled Pilot Study.

Background: Mindfulness meditation has been shown to alleviate pain and may be an appealing adjunctive pain management option. Objective: To compare measures of pain, mindfulness, and opioid usage, and collect evaluative feedback among patients undergoing septorhinoplasty with and without guided meditation. Methods: Patients undergoing septorhinoplasty were randomized to online-guided meditation postoperative days 0-3 versus standard care; all received the same pain medications. Primary outcome measures included pain intensity, opioid consumption, mindfulness scores, and evaluative feedback. Results: Twenty-one patients received guided meditation and 24 received standard care. No significant difference in opioid consumption or pain scores was seen with the exception of higher opioid use in patients with intranasal splints in the standard care group. Twenty out of 21 patients provided evaluative feedback; all recommended mindfulness meditation to friends undergoing nasal surgery, 90% reported it was beneficial, 85% believed it eased pain/discomfort, and 80% believed it aided with sleep. Conclusion: Although no objective difference was found in opioid consumption or pain scores, most patients reported that guided mindfulness meditation was beneficial to their recovery following septorhinoplasty.

Validation of the Modified Rhinoplasty Assessment Scale (Photographic).

OBJECTIVE: To validate the modified Rhinoplasty Assessment Scale (Photographic) (mRASP). STUDY DESIGN: Retrospective cohort study. METHODS: Study design-Photographs for 100 rhinoplasty patients from 2 facial plastic surgeons were compiled. Photos included 6 views. Each facial plastic surgeon reviewed all views. Nasal appearance was evaluated using the mRASP. Statistical analysis-A validation study was conducted, including descriptive statistics, reliability, and construct validity. Mean and standard deviations were used to describe the scores. RESULTS: Eighty female (mean RASP score = 14.89, SD = 7.04) and 20 male (mean RASP score = 19.83, SD = 10.09) patients were included. The mean of the total score on the instrument was 15.88 (SD = 7.98). Cronbach's alpha was .81, and inter-rater reliability measured as a Pearson product-moment correlation was .74. The CFA model fit the frontal view (χ2 = 32.47 (P = .04), CFI = .99, TLI = .99, RMSEA = .05, SRMR = .05), basal view (χ2 = 4.55 (P = .33), CFI = .98, TLI = .96, RMSEA = .03, SRMR = .23), and lateral view (χ2 = 39.52 (P = .40), CFI = 1.0, TLI = 1.0, RMSEA = .0, SRMR = .05) data well. CONCLUSION: The mRASP is a reliable instrument that can be used to assess nasal form via frontal, lateral, and basal photographs of patients. This provides facial plastic surgeons with a validated tool to evaluate rhinoplasty outcomes.

Google Search Analysis: What Do People Want to Know About Rhinoplasty and Where Do They Find the Answers?

Background: During online search queries, Google uses machine learning algorithms to provide frequently associated ("People Also Ask" [PAA]) questions with corresponding websites answering the question. We aimed to identify the most frequent questions about rhinoplasty asked online and the sources used to answer them. Materials and Methods: PAA questions were extracted for the terms "rhinoplasty," "nose surgery," and "nose job." Questions were categorized into specific topics. Websites were categorized by type and assessed for quality using Journal of the American Medical Association (JAMA) benchmark criteria. A search engine optimization tool determined search volume for individual questions and specific topics. Results: Internet searches for the PAA questions (n = 102) and associated websites were related to preoperative factors (46%), cost (35.7%), and recovery timeline (7.3%). Sources for the answers to PAA questions were single surgeon personal (39.3%) and medical practice (20.6%) websites. Conclusions: Surgeons may wish to emphasize specific patient education topics, including preoperative factors, cost, and recovery timeline, on their websites to address the most frequently sought-after information regarding rhinoplasty online.

Machine Learning Generated Synthetic Faces for Use in Facial Aesthetic Research.

Importance: A centralized repository of clinically applicable facial images with unrestricted use would facilitate facial aesthetic research. Objective: Using a machine learning neural network, we aim to (1) create a repository of synthetic faces that can be used for facial aesthetic research and (2) analyze synthetic faces according to contemporary aesthetic principles. Design, Setting, and Participants: Synthetic facial images were generated using an open source generative adversarial network. Images were refined and then analyzed using computer vision technology. Interventions: Not applicable. Main Outcomes and Measures: Synthetic facial images were created for use as a facial aesthetic research data set. Results: One thousand synthetic images were generated, and 60 images underwent analysis. Image attributes, including age, gender, image principle axis, facial emotion, and facial landmark points, were attained. Images demonstrated accordance with contemporary aesthetic principles of horizontal thirds and vertical fifths. Images demonstrated excellent correspondence when compared with real human facial photographs. Conclusions and Relevance: We have generated realistic synthetic facial images that have potential as a valuable research tool and demonstrate similarity to real human photographs while adhering to contemporary aesthetic principles.

Soft tissue fillers in the nose.

Using soft tissue fillers to correct postrhinoplasty deformities in the nose is appealing. Fillers are minimally invasive and can potentially help patients who are concerned with the financial expense, anesthetic risk, or downtime generally associated with a surgical intervention. A variety of filler materials are currently available and have been used for facial soft tissue augmentation. Of these, hyaluronic acid (HA) derivatives, calcium hydroxylapatite gel (CaHA), and silicone have most frequently been used for treating nasal deformities. While effective, silicone is known to cause severe granulomatous reactions in some patients and should be avoided. HA and CaHA are likely safer, but still may occasionally lead to complications such as infection, thinning of the skin envelope, and necrosis. Nasal injection technique must include sub-SMAS placement to eliminate visible or palpable nodularity. Restricting the use of fillers to the nasal dorsum and sidewalls minimizes complications because more adverse events occur after injections to the nasal tip and alae. We believe that HA and CaHA are acceptable for the treatment of postrhinoplasty deformities in carefully selected patients; however, patients who are treated must be followed closely for complications. The use of any soft tissue filler in the nose should always be approached with great caution and with a thorough consideration of a patient's individual circumstances.

Association of Skin and Cartilage Variables With Composite Graft Healing in a Rabbit Model.

IMPORTANCE: Composite grafting in nasal reconstruction involves transplanting auricular chondrocutaneous grafts, but the optimal design of these grafts is unknown. OBJECTIVES: To investigate the ideal ratio of skin to cartilage as well as study the importance of the perichondrial attachment for graft survival. DESIGN, SETTING, AND PARTICIPANTS: A New England white rabbit model was used in this study, performed at the Laboratory for Animal Research at University of Kansas Medical Center from January 25 to March 18, 2016. Four varying designs of chondrocutaneous auricular grafts were transplanted to dorsal back defects, with a total of 10 grafts per treatment arm completed. The following 4 chondrocutaneous circular grafts were designed: group A, 1.5-cm diameter graft of equal skin to cartilage ratio; group B, 2.0-cm diameter skin and 1.5-cm diameter cartilage; group C, 1.5-cm diameter skin and 2.0-cm diameter cartilage; and group D, 1.5-cm diameter skin and cartilage separated and placed back together in a layered fashion. Grafts were observed until postoperative day 21, harvested, and evaluated with visual observation as well as histopathologic assessment. MAIN OUTCOMES AND MEASURES: Visually graded areas of survival were marked by 2 blinded academic facial plastic surgeons and calculated for approximate survival. Hematoxylin-eosin-stained, paraffin-embedded 5-µm slides were evaluated for overall survival rate, rate of cartilage necrosis, and mean vessel density per high-power field. In both cases, observers were blinded as to the study group. RESULTS: Visual assessments of the 5 female rabbits showed significant agreement between surgeons and consistency, with a Spearman coefficient of 0.84 and an intraclass correlation of 0.98. Group D (skin and cartilage separation) was visually graded to have significantly decreased mean survival (45.4%; 95% CI, 23.3%-67.4%) compared with group A (mean survival, 97.4%; 95% CI, 94.8%-99.9%; P < .001), group B (mean survival, 87.6%; 95% CI, 69.9%-100%; P = .004), and group C (mean survival, 82.1%; 95% CI, 66.0%-98.1%; P = .008). Histopathologic assessment revealed that group D again showed significantly inferior overall survival, increased cartilage necrosis, and decreased mean vessel density compared with group A. Group C additionally showed significantly decreased cartilage survival compared with group A (65% vs 0%; P < .001) and group B (65% vs 35%; P = .02). CONCLUSIONS AND RELEVANCE: These results represent preliminary evidence that the attachment of skin to perichondrium in a composite graft plays an important role for graft survival. Clinicians performing nasal reconstruction with chondrocutaneous composite grafts should consider preserving attachments at this junction to improve graft survival. LEVELS OF EVIDENCE: NA.

Analysis of Facial Reanimation Procedures Performed Concurrently With Total Parotidectomy and Facial Nerve Sacrifice.

IMPORTANCE: Facial reanimation procedures share the same surgical field as a parotidectomy and are most easily accomplished at the time of facial nerve sacrifice. Early reanimation would also reduce the duration of paralysis and may lead to better functional outcomes. OBJECTIVE: To assess the incidence and types of facial nerve reanimation performed concurrently with total parotidectomy and facial nerve sacrifice using the American College of Surgeons National Surgical Quality Improvement Project (ACS-NSQIP) database. DESIGN, SETTING, AND PARTICIPANTS: This cross-sectional study identified 285 patients who underwent total parotidectomy with facial nerve sacrifice (Current Procedural Terminology code 42425) and evaluated the various types of facial reanimation procedures performed concurrently. Patients were identified from the ACS-NSQIP database encompassing 603 community and academic hospitals and underwent treatment from January 1, 2010, through December 31, 2015. Data were analyzed from September 20, 2017, through February 21, 2018. MAIN OUTCOMES AND MEASURES: Comparison of demographics in nonreanimation and reanimation groups and subgroups of nerve- and sling-type reanimation procedures. RESULTS: Of 285 patients who underwent total parotidectomy with facial nerve sacrifice (61.8% men; mean [SD] age, 64 [15] years), 89 (31.2%; 95% CI, 26.0%-37.0%) underwent at least 1 concurrent facial reanimation procedure. Of the facial nerve procedures performed, 41 (46.1%; 95% CI, 36.0%-56.0%) were nerve-type repairs, 31 (34.8%; 95% CI, 26.0%-45.0%) were sling-type repairs, and 17 (19.1%; 95% CI, 12.0%-29.0%) included both types. Patients treated with nerve-type repairs only were significantly younger than those treated with sling-type repairs only (mean [SD] age, 57.6 [16.0] vs 72.1 [13.8] years; P < .001). Forty-nine patients underwent free tissue reconstruction. Of those, 24 patients (49.0%) had concurrent facial reanimation procedure(s) performed; this proportion was significantly more than those who did not undergo free tissue reconstruction (65 of 236 [28.0%]; P = .003). CONCLUSIONS AND RELEVANCE: In patients undergoing total parotidectomy with facial nerve sacrifice, many are not receiving a concurrent facial reanimation procedure at the time of their tumor resection. Those patients who underwent free tissue reconstruction were significantly more likely to receive a concurrent facial reanimation procedure. These findings may reveal an opportunity for earlier facial reanimation in this patient population. LEVEL OF EVIDENCE: NA.

Suture biomechanics and static facial suspension.

BACKGROUND: Static facial suspension (SFS) continues to play a role for rehabilitation in patients with facial paralysis. We perform SFS almost exclusively with a suture technique in our practice. Monofilament polypropylene suture (Prolene) is commonly used for SFS, but we have witnessed occasional failure and some stretching with this material. The purpose of this study was to establish and compare the biomechanical properties of 3 suture types-polypropylene, polybutilate-coated braided polyester (PBCP) (Ethibond Excel), and braided polyester impregnated with polytetrafluoroethylene (PIP) (Tevdek)-to assess their suitability for SFS. METHODS: Six samples of 0, 2-0, and 3-0 polypropylene, PBCP, and PIP were tested. The mean load to failure was calculated for each suture type. Stiffness and elongation at specific loads were calculated to compare stretch between materials. RESULTS: The load to failure of PBCP and PIP was significantly greater than that for polypropylene for all suture sizes. In addition, PBCP and PIP had significantly less elongation than did polypropylene at clinically relevant loads. CONCLUSIONS: Both PBCP and PIP had superior load-bearing properties and decreased stretch when compared with polypropylene. These properties suggest that, for SFS with suture, use of PBCP or PIP may reduce the incidence of breakage and elongation, improving outcomes.

Correction of Nasal Fractures.

Nasal fractures are the most frequently fractured facial bone from blunt facial trauma resulting in a significant number of patients seeking treatment. Proper evaluation and treatment in the acute setting can minimize secondary surgeries, lower overall health care costs, and increase patient satisfaction. Nasal fracture management, however, varies widely between surgeons. The open treatment of isolated nasal fractures is a particularly controversial subject. This review seeks to describe the existing literature in isolated nasal fracture management.

Masseteric to buccal branch nerve transfer.

PURPOSE OF REVIEW: To review recent literature pertaining to the use of masseteric-facial nerve neurorrhaphy (MFNN) for facial reanimation in patients with facial paralysis. RECENT FINDINGS: First, MFNN effectively restores some midface tone and function, including the ability to smile. Second, use of the masseteric nerve minimizes synkinesis, dysarthria, and dysphagia that frequently occur after hypoglossal-facial nerve neurorrhaphy. Third, concurrent cable grafting to the zygomatic branch from an intact proximal facial nerve remnant - when available - can restore dynamic eye closure. SUMMARY: Masseteric nerve transfer is an alternative to hypoglossal nerve transfer that improves midface appearance and function for properly selected patients with facial paralysis.

Flap Basics II: Advancement Flaps.

A mastery of advancement flap design, selection, and execution greatly aids the surgeon in solving reconstructive dilemmas. Advancement flaps involve carefully planned incisions to most efficiently close a primary defect in a linear vector. Advancement flaps are subcategorized as unipedicle, bipedicle, V-to-Y, and Y-to-V flaps, each with their own advantages and disadvantages. When selecting and designing an advancement flap, the surgeon must account for primary and secondary movement to prevent distortion of important facial structural units and boundaries.