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.

Cross-Facial Nerve Grafting Used Independently in Facial Reanimation: A Narrative Review.

Importance: Cross-Facial Nerve Grafting (CFNG) for facial palsy offers potential to restore spontaneous facial expression, but specific indications and associated outcomes are limited. Updates to this technique have aided in its successful employment in select cases. This review aims to explore the context in which CFNG has been successfully utilized as a primary modality. Observations: Literature review was performed auditing all studies investigating CFNG as a primary modality, which reported outcomes. A total of 326 cases reporting outcomes for primary CFNG were included. Eye closure outcomes were 83.3% successful at ages 0-18, 77.3% successful at ages 19-40, and 57.1% successful at ages 41+. Smile outcomes were 73.7% successful at ages 0-18, 81.5% successful at ages 19-40, and 52.8% successful at ages 41+. For synkinesis, 89% of cases were considered successful; 100% successful at ages 0-18, and 78.4% successful in adults. Conclusions and Relevance: CFNG may offer return of spontaneous facial function in select cases. Higher percentages of successful outcomes are observed in younger patients, when performed in two stages, and when performed earlier from the onset of FP in cases of eye closure restoration. In the modern era, CFNG has been more commonly employed as an adjunctive procedure to other reanimation techniques.

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.

Giant PMMA Foreign Body Granulomas with Imaging.

Filler complications have a wide array of presentations including early and late manifestations. A rare late complication is the foreign body granuloma or granulomatous foreign body reaction. We present a case of giant foreign body granulomas developing 7 years after polymethylmethacrylate (PMMA) filler injection. The patient had an excellent response to a single intralesional injection of triamcinolone acetonide and 5-fluorouracil. The unique opportunity to have pretreatment and posttreatment magnetic resonance imaging (MRI) allows for appreciation of the multidirectional expansion of these granulomas as well as the response in this case. Updated treatment recommendations based on the literature review support the use of oral antibiotics, oral steroids, and intralesional therapies. Surgical excision is reserved as an absolute last resort due to potential complications.

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.

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.

Interfacility Transfer Guidelines for Isolated Facial Trauma: A Multidisciplinary Expert Consensus.

BACKGROUND: The objective of this study was to develop guidelines for the transfer of patients with isolated craniomaxillofacial trauma. METHODS: A national, multidisciplinary expert panel was assembled from leadership in national organizations and contributors to published literature on facial reconstruction. The final panel consisted of five plastic surgeons, four otolaryngologist-head and neck surgeons, and four oral and maxillofacial surgeons. The expert panelists' opinions on transfer guidelines were collected using the modified Delphi process. Consensus was predefined as 90 percent or greater agreement per statement. RESULTS: After four Delphi consensus building rounds, 13 transfer guidelines were established, including statements on fractures of the frontal sinus, orbit, midface, and mandible, as well as soft-tissue injuries. Twelve guidelines reached consensus. CONCLUSIONS: The decision to transfer a patient with craniomaxillofacial trauma to another facility is complex and multifactorial. While a percentage of overtriage is acceptable to promote safe disposition of trauma patients, unnecessarily high rates of secondary overtriage divert emergency medical services, increase costs, delay care, overload tertiary trauma centers, and result in tertiary hospital staff providing primary emergency coverage for referring hospitals. These craniomaxillofacial transfer guidelines were designed to serve as a tool to improve and streamline the care of facial trauma patients. Such efforts may decrease the additional health care expenditures associated with secondary overtriage while decompressing emergency medical systems and tertiary emergency departments.

Using Ultrasound to Evaluate Nasal Septal Cartilage.

Importance: Having a noninvasive tool that quantifies the amount of remaining septal cartilage in the setting of prior septoplasty would be useful for surgical planning and patient counseling. Objective: The objective of this pilot study is to determine if endocavitary ultrasound can be used to evaluate the presence and thickness of septal cartilage in vivo. Design, Setting, and Participants: A small prospective observational study was designed to assess the feasibility of using intranasal ultrasound to verify the presence and measure the thickness of septal cartilage. Imaging was undertaken by the principle investigator using a protocol developed by the research team. Six healthy volunteers were enrolled including three subjects who have had prior septoplasty. Images and measurements of the nasal septum were obtained. Main Outcomes: Confirming the presence of the nasal septum was the main outcome with a secondary outcome of measurement of septum thickness. Results: The endonasal ultrasound probe was able to identify the septum and resected areas. The mean thickness of the septum in subjects without surgery was 1.0 mm and those with prior septoplasty was 0.8 mm. Student's t-test show a statistically significant difference in septum thickness between these two groups with a p-value of 0.0093. Conclusions and Relevance: This study demonstrates a novel method of determining the presence of septal cartilage after septoplasty surgery. This information may be useful for operative planning in revision rhinoplasty.

Using a Systematic Approach to Teach Analysis of the Aging Face.

OBJECTIVE: To assess the efficacy of a novel systematic approach aimed at improving a resident physician's ability to perform analysis of the aging face. STUDY DESIGN: Prospective randomized case-control study. SETTING: Accreditation Council for Graduate Medical Education accredited Otolaryngology-Head and Neck Surgery residency program. METHODS: Twenty otolaryngology-head and neck surgery residents were randomized into 2 groups with even representation in each postgraduate year level in each cohort. One group used traditional materials (textbooks), and the other group was given exclusive access to the online learning module featuring a systematic approach to aging-face analysis. Both groups completed preactivity, postactivity, and retention assessments to gauge their ability to perform a comprehensive analysis of the aging face. RESULTS: When compared with a matched control cohort, the residents who used the systematic approach performed more comprehensive facial aging assessments immediately after the intervention and at a retention time point. CONCLUSION: A systematic approach delivered via an 11-minute online module can significantly improve a resident physician's ability to perform analysis of the aging face. This systematic approach could be easily integrated into other online or traditional educational curriculums. Moreover, this methodology could be applied to additional areas in which residents have limited exposure but must develop expertise.

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.

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.

Masticatory diplopia.

We report a case of diplopia that was exacerbated by chewing in a patient who had sustained facial fractures in a motorcycle crash. The diplopia was corrected surgically 1 year following the accident. To the best of our knowledge, masticatory diplopia as a result of adhesion of the temporalis muscle to the periorbita secondary to facial trauma has not been previously reported.

Cartilage Graft Donor Site Morbidity following Rhinoplasty and Nasal Reconstruction.

Although surgical techniques for rhinoplasty and nasal reconstruction are well established, prospective research on postoperative morbidity remains limited. The aim of this pilot study was to assess costal and auricular cartilage donor site pain and morbidity in patients undergoing rhinoplasty and nasal reconstruction. In this prospective cohort study, we enrolled 55 patients undergoing nasal surgery that required costal or auricular cartilage harvest from February 2015 through May 2016. Each patient was given a symptom-specific patient survey that assessed general pain, nasal pain, graft donor site pain, graft donor site itching, color variation, skin stiffness and thickness, and graft donor site appearance at 1, 4, and 12 weeks after surgery. Our patient group was 55% female ( n = 30); the mean age was 47 years. Rib cartilage graft patients had significantly greater nasal pain than cartilage donor site pain. There was no significant difference in rib versus ear cartilage donor site pain. Nearly all patients reported that they were not at all concerned about their scar appearance or ear shape and appearance. No prior studies compare cartilage donor site morbidity in patients undergoing nasal surgery. Our findings challenge the conventional wisdom that utilizing auricular and costal cartilage results in high levels of donor site pain. Surgeons should have a low threshold to harvest rib or ear cartilage when it can improve surgical outcome.

Immediate Gore-Tex sling suspension for management of facial paralysis in head and neck extirpative surgery.

OBJECTIVE: We sought to evaluate the functional and aesthetic outcomes of immediate facial reconstruction with a Gore-Tex (expanded polytetrofluoroethylene) sling in irradiated patients undergoing large head and neck tumor extirpation with facial nerve resection. STUDY DESIGN AND SETTING: We conducted a retrospective study of 17 patients at two academic institutions who underwent extirpative surgery with immediate Gore-Tex sling reconstruction and completed radiotherapy. Functional and aesthetic results were evaluated at three intervals. RESULTS: All patients had excellent immediate results and good or excellent intermediate-term results. At long-term follow-up, results were good to excellent in 47% and unacceptable in 35% of patients. CONCLUSION: In irradiated patients undergoing total parotidectomy with immediate facial reconstruction using Gore-Tex slings, early results are excellent, but there is a high incidence of major wound complications and unacceptable results in long-term follow-up. SIGNIFICANCE: There is a high rate of late complications associated with immediate facial reconstruction with Gore-Tex slings in irradiated patients.

Endoscopic repair of orbital blowout fractures: use or misuse of a new approach?

OBJECTIVE: To evaluate the successes and challenges of endoscopic orbital floor fracture repairs. METHODS: We analyzed 53 orbital floor repairs and recorded the indications for surgery, factors that complicated the endoscopic repair or necessitated conversion to an open approach, and outcomes for each. RESULTS: Forty-five procedures were completed endoscopically. Repairs of smaller injuries confined entirely to the medial floor were readily accomplished, particularly when entrapment was the primary indication for surgery. Endoscopic repair became very difficult and often not possible when a large amount of soft tissue was herniated through the floor defect and when dissection medially onto the lamina papyracea and lateral to the infraorbital nerve was required for implant placement. Duration of follow-up was short for some patients, but no adverse trends in outcomes were identified. CONCLUSIONS: Blowout fractures can be approached endoscopically. However, the technical challenge of working from below with a telescope tends to increase the difficulty of many repairs without improving results. Most blowout fractures are probably still best treated through an open approach, assuming that the lower eyelid incision is correctly performed.