Evidence-Based Medicine for Nonsurgical Facial Rejuvenation.

Options for nonsurgical facial rejuvenation treatment have increased significantly in both availability and popularity over the past two decades. However, there remains a paucity of clinical practice guidelines and evidence-based recommendations for these procedures. The purpose of this article is to assess the presence of current high-level research for various methods of nonsurgical facial rejuvenation using the Oxford Centre for Evidence-Based Medicine. Botulinum toxin injections remain the best-studied method, with several randomized controlled trials guiding recommendations for safety and efficacy. Several studies on injectable fillers document complications and recommendations to avoid these, but sample sizes are small and many are noncomparative. Deoxycholic acid has been well examined and Food and Drug Administration approved to address submental fat but has not been studied in other areas of the face. Although chemical peels, laser skin resurfacing, energy-based facial rejuvenation, microneedling, and platelet-rich plasma have a variety of facial rejuvenation applications with minimal side effect profiles, there is significant variability with treatment protocols, outcomes measures, and randomized controlled trials with extended follow-up to develop clinical practice guidelines.

Time to Mohs Reconstruction: A Systematic Review Comparing Complication Rates between Immediate and Delayed Repair.

Several known factors affect outcomes of Mohs facial defect reconstruction; however, the effect of repair timing on outcomes is ill-defined. The aim of this study was to determine postoperative complication rates between immediate and delayed repair of Mohs facial defects. Preferred Reporting Items of Systematic Reviews and Meta-Analyses guidelines were used. Articles were selected using PICO format-population: Mohs facial defect patients, intervention: defect repair, comparator: immediate (<24 hours), or delayed (>24 hours) repair, outcome: complication rate. PubMed/Medline (1946-2020), EMBASE (1947-2020), Scopus (1823-2020), Web of Science (1900-2020), Cochrane Library, and Clinicaltrials.gov were searched. Two independent reviewers screened abstracts; those in English with human subjects reporting repair timing and complication rates were included. Search criteria yielded 6,649 abstracts; 233 qualified for review. Data were gathered from six studies; they alone contained comparative data meeting inclusion criteria. While many well-written studies were encountered, reported results varied widely. A statistically sound meta-analysis could not be completed due to large heterogeneity between studies, biasing the analysis towards the largest weighted study. Clinically important differences may exist between immediate and delayed Mohs reconstruction, but small study numbers, large heterogeneity, and lack of standardized outcome measures limit definitive conclusions. More studies are needed to perform appropriate meta-analyses, including studies using standardized methods of reporting Mohs outcome data.

The Association of Same-Day CT Scan with Postoperative Outcomes in Isolated Orbital Fracture Repair.

The potential benefits to surgical outcomes of intraoperative and/or same-day computed tomography (CT) during isolated orbital fracture reconstruction are debatable, and previous research on this topic is limited by small sample size. This retrospective IBM MarketScan Commercial and Medicare Supplemental research database study examined patients undergoing isolated orbital reconstruction from January 1, 2012 to December 31, 2018, to assess whether same-day CT affected postoperative outcomes. The average age of the 5,023 participants was 37 (standard deviation [SD]: 16) years and 63% were males. The data revealed that 16.2% (815 of 5,023) patients underwent a same-day CT. Those who underwent a same-day CT scan exhibited reduced odds of postoperative enophthalmos (adjusted odds ratio [aOR]: 0.269; 95% confidence interval [CI]: 0.167-0.433) and diplopia (aOR: 0.670; 95% CI: 0.495-906). Interestingly, these patients also displayed a higher rate of revision surgeries (aOR: 2.721; 95% CI: 1.893-3.912). In summary, while same-day CT scans diminish certain postoperative complications of orbital fracture repair, they are also associated with an increased likelihood of subsequent surgical revision.

Comparison of Reconstructive Plastic Surgery Rates and 30-Day Postoperative Complications Between Patients With and Without Psychiatric Diagnoses.

BACKGROUND: Psychiatric comorbidity is associated with greater 30-day postoperative complication rates in various surgical specialties, but is not well characterized for reconstructive plastic surgery. OBJECTIVES: The aim of this study was to compare reconstructive plastic surgery rates and 30-day postoperative complications between patients with and without psychiatric diagnoses. METHODS: This was a retrospective cohort study comparing patients with and without psychiatric diagnoses. Data for January 1, 2007 to December 31, 2015 were collected from the IBM MarketScan Commercial and Medicare Supplemental Databases. Rates of reconstructive plastic surgery, demographic data, covariant diagnoses, and 30-day postoperative complications were collected. Differences between the 2 groups were assessed by multivariable logistic regression. RESULTS: Among 1,019,128 patients (505,715 with psychiatric diagnoses and 513,423 without psychiatric diagnoses) assessed, reconstructive plastic surgery rates were between 4.8% and 7.0% in those with psychiatric diagnoses, compared with 1.6% in patients without psychiatric diagnoses. The greatest odds of undergoing reconstructive plastic surgery were in patients with body dysmorphic disorder (BDD) (adjusted odds ratio [aOR], 3.16; 95% confidence interval [CI], 1.76-5.67) and anxiety disorder (aOR, 3.08; 95% CI, 2.97-3.17). When assessing 1,234,206 patients (613,400 with psychiatric diagnoses and 620,806 without psychiatric diagnoses), all of whom underwent reconstructive plastic surgery, 2-fold greater odds of any 30-day postoperative complication was associated with psychiatric diagnoses (aOR, 2.01; 95% CI, 1.28-3.11), as well as greater odds of specific complications (surgical site infection, bleeding, and hospital admission). Eating disorder diagnosis was associated with the greatest odds of a complication (aOR, 4.17; 95% CI, 3.59-4.86), followed by nasal surgery (aOR, 3.65; 95% CI, 2.74-4.89), and BDD (aOR, 3.16; 95% CI, 1.76-5.67). CONCLUSIONS: Diagnosis of a psychiatric condition is associated with greater rates of reconstructive plastic surgery, and 2-fold greater odds of 30-day postoperative complications.

Correlation of the Standardized Cosmesis and Health Nasal Outcomes Survey With Psychiatric Screening Tools.

BACKGROUND: Identifying mental health disorders, including body dysmorphic disorder (BDD), is important prior to rhinoplasty surgery; however, these disorders are underdiagnosed, and screening tools are underutilized in clinical settings. OBJECTIVES: The authors sought to evaluate the correlation of a rhinoplasty outcomes tool (Standardized Cosmesis and Health Nasal Outcomes Survey [SCHNOS]) with psychiatric screening tools. METHODS: Patients presenting for rhinoplasty consultation were prospectively enrolled and administered mental health instruments to assess depression (Patient Health Questionnaire-9), anxiety (Generalized Anxiety Disorder-7), and BDD (BDD Questionnaire-Aesthetic Surgery [BDDQ-AS]) as well as the SCHNOS rhinoplasty outcomes scale. Convergent validity of SCHNOS scores with these mental health instruments was assessed as well as calculation of an optimal SCHNOS-C score to screen for BDD. RESULTS: A total 76 patients were enrolled in the study. The average SCHNOS-O score (standard deviation) was 46.1 (34.0) and the average SCHNOS-C score was 61.1 (27.0). Five (7%) patients screened positive for depression, and 24 (32%) patients screened positive for mild, 5 (7%) for moderate, and 4 (5%) for severe anxiety. Twenty-four (32%) patients screened positive for BDD by BDDQ-AS scores. SCHNOS-O and SCHNOS-C did not correlate with Patient Health Questionnaire-9 or Generalized Anxiety Disorder-7 scores; SCHNOS-C did correlate with BDDQ-AS. A score of 73 or greater on SCHNOS-C maximized the sensitivity and specificity of also screening positive for BDD with BDDQ-AS. This score correlated with a sensitivity of 62.5%, specificity of 80.8%, and number needed to diagnose of 2.3, meaning for every 2 patients with a score of ≥73 on SCHNOS-C, 1 will have a positive BDDQ-AS score. CONCLUSIONS: SCHNOS-C correlates with BDDQ-AS and may help screen rhinoplasty patients at higher risk for BDD.

Relationship of Sociodemographic Factors and Outcomes in Functional Rhinoplasty.

The objective of this article was to compare the effect of such sociodemographic factors as gender, age, marital status, employment status, race, and income on short- and long-term rhinoplasty outcomes using a validated disease-specific instrument-Nasal Obstruction Symptom Evaluation (NOSE) scale, as well as complication and revision rates. Patients who underwent a functional (+/- cosmetic) rhinoplasty with the senior author between January, 1 2012, and September 9, 2017, and had both a preoperative and at least one postoperative NOSE score, were included in the study. Sociodemographic variables of binary gender, age, marital status, employment status, race, and income based on zip code were collected. The primary outcomes were the differences between the preoperative and postoperative NOSE scores with short-term (less than 3 months) and longer-term (greater than 3 months) follow-up. Secondary outcomes were general complications and specifically revision surgery. Standard descriptive statistics, as well as univariable linear and logistic regressions, were conducted with each outcome measure. A total of 341 patients were included in this study. No individual patient-level variables were found to significantly affect the short- or longer-term average change in NOSE scores, although older age trended toward significance in longer-term average change in NOSE scores (p = 0.07). No factors significantly affected the rate of complications or revision surgery in this cohort. The authors found improvement in NOSE scores after rhinoplasty was not related to factors of age, gender, race, employment status, income, and marital status. This cohort also did not demonstrate differential rates in complications or revision surgery based on sociodemographic variables.

Comparison of Primary and Secondary Anterior Septal Reconstruction: A Cohort Study.

This article compares outcomes in patients presenting for either primary or secondary (revision) anterior septal reconstruction (ASR) to treat caudal septal deviation. Patients undergoing ASR by senior author (S. P. M.) between January 1, 2012 and September 1, 2017, with both preoperative and postoperative Nasal Obstruction Symptom Evaluation (NOSE) scores documented in the chart were included. Data were compared between patients undergoing primary and secondary ASR by univariable and multivariable logistic regression. A total of 199 patients were included in this study; 128 (64%) underwent primary ASR and 71 (36%) underwent secondary ASR. After multivariable analysis, a greater ratio of females and autologous rib graft harvest in the secondary compared with primary ASR, and decreased odds of inferior turbinate reduction in the secondary group was found. There was no significant difference in NOSE scores between the primary and secondary group, and there were very few complications or revision surgeries. While outcomes are similar between primary and secondary (revision) ASR to treat caudal septal deviation, there was a significantly higher rate of autologous rib harvest, highlighting the importance of addressing deviations of the caudal septum at the primary procedure to reduce morbidity related to rib graft harvest and revision surgery.

Minimal Clinically Important Difference of the Standardized Cosmesis and Health Nasal Outcomes Survey.

BACKGROUND: The minimal clinically important difference (MCID) for the Standardized Cosmesis and Health Nasal Outcomes Survey (SCHNOS) has not been determined. OBJECTIVES: The authors sought to define the MCID for both domains of the SCHNOS questionnaire. METHODS: This prospective cohort study included patients who underwent functional, cosmetic, or combined rhinoplasty operation from June 2017 to June 2018 at a tertiary referral center. The average preoperative, postoperative, and change in scores were calculated for the nasal obstruction symptom evaluation scale (NOSE) and SCHNOS. Anchor-based MCIDs were estimated for both SCHNOS subscales to define change in obstruction and cosmesis perceived after the rhinoplasty. RESULTS: Eighty-seven patients (69% women, 31% males) with a mean age (standard deviation [SD]) of 38 years (14.7) at the time of surgery were included. The mean postoperative follow-up period (SD) was 145 days (117). The mean preoperative score (SD) for the NOSE was 52 (32), SCHNOS for nasal obstruction (SCHNOS-O) score was 55 (33), and SCHNOS for nasal cosmesis (SCHNOS-C) score was 50 (26) points. Postoperatively, the NOSE score was 23 (22), SCHNOS-O score was 24 (23), and SCHNOS-C score was 13 (18) points. The mean change in scores (SD) for NOSE, SCHNOS-O, and SCHNOS-C was -29 (37), -31 (38), and -37 (28), respectively. The calculated MCID for SCHNOS-O was 26 (16) and for SCHNOS-C was 22 (15) points. The MCID for NOSE was 24 (13) points. A sensitivity test for the patients with a follow-up ≥3 months showed only slightly different MCID estimates: 28 (17) for SCHNOS-O, 18 (13) for SCHNOS-C, and 24 (15) points for NOSE. CONCLUSIONS: For the obstruction domain SCHNOS-O, the MCID was 28 points. For the cosmetic domain SCHNOS-C, the MCID was 18 points.

Tongue-in-Groove Technique for Rhinoplasty: Technical Refinements and Considerations.

A key concept in successful rhinoplasty surgery is maintaining or increasing tip support, and addressing tip projection and rotation. The tongue-in-groove (TIG) technique is a method to achieve this goal using sutures to create a strong connection between the septum and medial crura to change tip rotation and projection. Criticisms of this method include that it may cause stiffness of the nasal tip and columellar retraction. TIG is routinely used by the authors during anterior septal reconstructions (a modified extracorporeal septoplasty technique), as well as in primary and revision aesthetic and functional rhinoplasties. Through this review, technical aspects of the TIG technique are discussed, as well as how pitfalls of the technique can be avoided, as illustrated by several rhinoplasty patient examples.

Principles of Nasal Reconstruction.

The rise in cutaneous malignancies over the past 20 years has led to significant advances in reconstructing the nose from an aesthetic and functional standpoint. The principles of nasal reconstruction center on application of the nasal subunit principle, three-layered reconstruction, nasal skin characteristics, and patient factors. Reconstructive planning starts with proper defect analysis, followed by application of the reconstructive ladder for soft-tissue repair, adequate structural support, and repair of nasal lining deficits. Optimal reconstructive methods depend on the location and size of the defect. Finally, refinement of the reconstruction is achieved through dermabrasion, scar revision, and flap thinning techniques.

Microneedling-Associated Procedures to Enhance Facial Rejuvenation.

Microneedling, also referred to as percutaneous collagen induction therapy, uses small needles to create mechanical injury to the skin, stimulating the wound-healing cascade and new collagen formation. Compared with other skin resurfacing techniques, microneedling preserves the epidermis and is nonablative, therefore reducing inflammation, downtime, and risk of dyspigmentation. In addition to increasing collagen production in fibroblasts, microneedling also helps normalize cell function of keratinocytes and melanocytes and can be used to increase absorption of topical medications, growth factors, or deliver radiofrequency directly to the dermis. The benefits of microneedling, associated procedures, indications for use, technical considerations, and potential complications are discussed.

Intraoperative Computed Tomography Use in Orbital Fracture Repair: A Systematic Review and Meta-Analysis.

Background: Intraoperative computed tomography (CT) allows surgeons to make adjustments during orbital fracture repair that may impact postoperative outcomes. Learning/Study Objectives: To determine the impact of intraoperative CT use on intraoperative revision and surgical outcomes for orbital fracture repair. Methods: A systematic review was performed in concordance with the Preferred Reporting Items of Systematic Reviews and Meta-Analyses (PRISMA) guidelines: the population was patients undergoing orbital fracture repair; intervention was use of intraoperative CT; comparison was patients not undergoing intraoperative CT; and outcomes were intraoperative revision rate, postoperative complications, and secondary revision surgeries. Meta-analysis was performed on the rate of intraoperative revision. Results: The search criteria yielded 790 articles, 377 were eligible for review, and 20 articles met criteria for analysis. In 19, intraoperative imaging led to immediate surgical corrections, with a random pooled effect size of 0.27 (0.20-0.35). Six studies reported secondary revision surgery rates (range 0-10.5%), and six studies reported postoperative complication rates (range 10-30%). Conclusions: Intraoperative imaging helps surgeons make precise, real-time adjustments in 27% of orbital fracture repair cases, which may improve surgical outcomes; however, more research is needed to investigate its impact on health care costs, operating time, and radiation exposure.

Shared Decision-Making in Patients Seeking Surgery for Facial Trauma: The Role of Decisional Conflict and Perceived Discrimination.

Background: Shared decision-making (SDM) may facilitate challenging discussions between patients with facial trauma and reconstructive surgeons. Objective: To determine among patients seeking surgical evaluation for facial trauma, whether patient demographics, decisional conflict (DC), or experiences of discrimination in health care are associated with patient perceptions of SDM, as measured by scored responses on the CollaboRATE-10 questionnaire. Methods: English-speaking adults who presented to the offices of five facial trauma surgeons were contacted by telephone after their visit to complete a cross-sectional survey. Results: After screening 247 patients, 131 patients were recruited (53.0%). DC and history of discrimination were associated with lower perceived SDM (p < 0.001 and p = 0.048, respectively). After adjusting for age, sex, race, education, initial emergency department presentation, DC, and past discrimination, patients of older age (odds ratio [OR] 1.1, 95% confidence interval [CI] 1.02-1.09) and non-White race (OR 3.5, 95% CI 1.1-11.4) had higher perceptions of SDM; patients with DC (OR 0.52, 95% CI 0.01-0.20) reported less SDM. Conclusions: Patients who present to clinic for surgical evaluation after facial trauma feel that their physicians involve them less when deciding on a treatment plan if they have experienced discrimination in health care settings in the past, or if they have significant difficulty deciding between treatment options.

Nasal Tip Support and Management of the Tip Tripod Complex.

Controlling the nasal tip to achieve excellent structural and cosmetic outcomes is challenging in rhinoplasty surgery. A strong foundation and understanding of the nasal tripod complex and the various methods for restoring tip support mechanisms when disrupted either from surgery or other means is critical. The columellar strut graft, septal extension graft, and tongue-in-groove suture technique are well-described methods to control and support the nasal tip. There are advantages and disadvantages to each method, but one should be comfortable with the nuances of each to master nasal tip surgery.

Microneedling-Associated Procedures to Enhance Facial Rejuvenation.

Microneedling, also referred to as percutaneous collagen induction therapy, uses small needles to create mechanical injury to the skin, stimulating the wound-healing cascade and new collagen formation. Compared with other skin resurfacing techniques, microneedling preserves the epidermis and is nonablative, therefore reducing inflammation, downtime, and risk of dyspigmentation. In addition to increasing collagen production in fibroblasts, microneedling also helps normalize cell function of keratinocytes and melanocytes and can be used to increase absorption of topical medications, growth factors, or deliver radiofrequency directly to the dermis. The benefits of microneedling, associated procedures, indications for use, technical considerations, and potential complications are discussed.

Examining Preoperative Expectations and Postoperative Satisfaction in Rhinoplasty Patients: A Single-Center Study.

Background: In Rhinoplasty, understanding patient expectations are pivotal in achieving an optimal surgical outcome. Objective: To understand preoperative expectations and postoperative satisfaction in patients undergoing rhinoplasty for functional, aesthetic, or both. Method: Adult patients undergoing functional, aesthetic, or combined rhinoplasty from March 2017 to June 2019 were prospectively enrolled. Only patients with complete preoperative functional and cosmetic expectation visual analog scales (VAS) and at least one postoperative functional and cosmetic satisfaction VAS were included. Nasal Obstruction and Symptom Evaluation Scale score and Standardized Cosmesis and Health Nasal Outcomes Survey score were also collected. Results: In the functional subgroup (mean preoperative functional expectation VAS score [17.98 (22.49)] higher mean (standard deviation) postoperative functional satisfaction VAS score were observed at postoperative time interval <2 months [29.59 (27.08), p = 0.008] and 8-12 months [31.43 (28.25), p = 0.035]. In the aesthetic subgroup mean preoperative cosmetic expectation VAS score [89.69 (17.74)], lower mean postoperative aesthetic satisfaction VAS scores were observed at <2 months [79.09 (20.01), p = 0.0001], 2-5 months [79.79 (20.79), p = 0.032], 5-8 months [72 (18.27), p < 0.0001], 8-12 months [78.15 (24.50), p = 0.021], and >12 months [75 (20.64), p = 0.00020]. In the combined subgroup (mean preoperative aesthetic expectation VAS score [85.85 (18.19)]), lower mean postoperative aesthetic satisfaction VAS scores were observed at 2-5 months [78.94 (20.88), p = 0.01] and at >12 months [75.86 (25.57), p = 0.01]. Conclusion: Although rhinoplasty patients tend to be less satisfied with aesthetic than the functional outcome of surgery, preoperative aesthetic expectations are higher in cosmetic rhinoplasty and functional and cosmetic rhinoplasty patients.

The Impact of Treatment Delay on Malunion and Nonunion After Open Reduction of Mandible Fractures.

Importance: Time to surgical intervention is an oft-investigated potentially modifiable risk factor for complications after mandible fracture. Objective: To identify novel risk factors for malunion/nonunion after mandible fracture and determine the impact of treatment delay on malunion and nonunion after open reduction of mandible fractures. Design: Retrospective cohort. Setting and Participants: Encounter billing records from the New York State Inpatient Databases, State Emergency Department Databases, and State Ambulatory Surgery Databases. Patients aged 18 years and older with isolated mandible fracture in the emergency department or inpatient setting from January 1, 2006 to September 30, 2015. Main Outcomes and Measures: Mandibular Malunion/Nonunion. Results: A total of 19,152 adults were diagnosed with isolated mandible fracture. After fracture, 247 patients (1.3%) developed mandibular malunion or nonunion. In multivariable analysis, patients with open fractures (odds ratio [OR] 1.93, confidence interval [95% CI] 1.40-2.65), body fractures (OR 2.00, 1.50-2.65), alcohol abuse (OR 1.61, 1.22-2.11), diabetes mellitus (OR 1.57, 1.02-2.42), and Medicaid insurance (OR 1.46, 1.03-2.07) had increased risk, whereas patients with subcondylar fractures had reduced risk (OR 0.45, 0.28-0.72) of mandibular malunion/nonunion. The risk of mandibular malunion/nonunion after open reduction increased with treatment delay until 6-7 days after presentation (OR 1.84, 1.11-3.06). Conclusion and Relevance: Although treatment delay is often unavoidable, these findings suggest that physicians should consider early intervention in patients requiring open reduction of mandible fractures when able.

Effect of Nasal Steroids on Nasal Obstruction in Septal Deviation: A Double-Blind Randomized Controlled Trial.

Objective: This study sought to prospectively determine the effect of intranasal steroids versus placebo on nasal obstruction in septal deviation. Methods: This was a single-center randomized placebo-controlled double-blind trial with crossover in which all study participants received 6 weeks of therapy with Nasacort (Chattem, Inc.) and with Ayr saline spray (B.F. Ascher). Participants were randomized to one of two groups with a 2-week washout period between drugs. Nasal Obstruction Symptom Evaluation (NOSE) scores were collected at baseline and after each study drug. A subset of patients subsequently underwent surgical intervention after both drugs and additional NOSE scores were collected postoperatively. Results: Forty-two patients completed both study drugs with NOSE scores collected. Thirty-two patients underwent surgery and postoperative NOSE scores were collected. There was no significant difference in baseline demographics between the groups. There was no significant difference in mean NOSE scores in either group from baseline to the completion of the first and second study drugs. There was no difference in the change in mean NOSE score from baseline to postsaline (-3.9) versus baseline to poststeroid (-5.8, p = 0.60). Surgery resulted in a significant change in NOSE score at all postoperative time points (mean of -50, range of -47.2 to -53.6). Conclusions: We found no significant effect of intranasal steroids on nasal obstruction as compared with placebo. Surgery, however, was associated with significant sustained improvement in nasal obstruction. These data suggest that in patients with nasal obstruction due to a fixed cause, medical therapy with intranasal steroids is unlikely to be beneficial.

Biportal transparotid dissection in the retromandibular approach for condylar fracture osteosynthesis: Efficacy of a novel technique.

OBJECTIVE: Facial nerve injury is a primary complication of open surgical management of condylar fractures. A new modification of the retromandibular transparotid approach, the "biportal transparotid dissection" (BTD), was developed to reduce these injuries in accidental nerve exposure. DESIGN: Prospective cohort study. SETTING: Tertiary referral center. METHODS: Patients managed by retromandibular transparotid approach for condylar fractures at Department of Otolaryngology - Head and Neck Surgery, Mansoura University were included between November 2015 and August 2019 with exclusion of cases managed endoscopically or by a closed approach. Three groups were identified: Group A included patients undergoing the BTD technique, which entails transparotid dissection above and below exposed nerve branches and minimal nerve retraction; Group B included patients undergoing traditional dissection and nerve retraction away from the surgical field; and Group C included patients with unidentified facial nerve branches. The function of facial nerve branches was documented postoperatively. RESULTS: Fifty-seven fractures were included in the study. Facial nerve branches' injury occurred in 13 cases (22.8%): two (of ten) in Group A (20%), seven (of ten) in Group B (70%) and four (of 37) in Group C (10.81%). Compared to patients with non-exposed branches, Groups A and B were found to have 2.06 (p = 0.447) and 19.25 (p = 0.001) greater odds of nerve injury, respectively. The results showed significant faster nerve recovery in the BTD group compared to traditional dissection (mean 5 versus 9 weeks) (p = 0.015). CONCLUSION AND RELEVANCE: Although avoiding facial nerve exposure minimizes injury the most, BTD approach reduces exposed nerve injury compared to the traditional method.