Masseteric-zygomatic nerve transfer for the management of eye closure-smile excursion synkinesis.

OBJECTIVE: The purpose of this study is to illustrate the efficacy of masseteric-to-zygomatic nerve transfer to address eye closure-smile excursion synkinesis after facial nerve paralysis. BACKGROUND: Synkinesis after facial nerve paralysis represents a wide range of facial movement disability. One manifestation is involuntary smiling with eye closure and a concomitant reduction of oral commissure movement with attempted smile ("frozen smile") - arising as a result of aberrant fibers populating the zygomatic branch-muscle complex. This is a particularly difficult area to treat with conservative management. We propose a single-stage procedure to sever the dysfunctional zygomatic nerve and perform a masseteric-zygomatic nerve coaptation to recover a voluntary smile. METHODS: We present a case series of eight patients with eye closure/smile excursion synkinesis who underwent single-stage masseteric-zygomatic nerve transfer by a single surgeon. The surgical technique and indications for surgery were reviewed. Patients underwent facial movement analysis using Emotrics. RESULTS: We analyzed the pre- and post- surgical photographic images of 8 patients with synkinesis (7 female, 1 male). Masseteric-facial nerve transfer was performed from 18 months to 22 years after the initial facial paralysis. Eyelid and brow positioning were more symmetric after surgery, with discrepancy between affected and unaffected side decreasing from 2.1 to 1.0 mm (p < .05) and 1.74 to 1.29 mm (p < .05), respectively. Symmetry of smile excursion postoperatively was also improved with commissure excursion discrepancy decreasing from 8.8 to 3.78 mm (p < .05). Discrepancy in the smile angle when comparing affected to unaffected side improved postoperatively from 10.3 to 5.2 degrees (p < .05). Improvement in oral commissure height was noted, but not statistically significant. CONCLUSIONS: The masseteric-zygomatic nerve transfer is a useful technique for the treatment of eye closure/smile excursion synkinesis after failure of chemodenervation and/or physical therapy.

Temporoparietal Fascia Free Flap for Nasoseptal Perforation Repair.

Nasoseptal perforations can be a challenging defect for the reconstructive surgeon, with repair limited by the surrounding tissue availability and the defect size. In patients with a history of cocaine use, often the integrity of surrounding vasculature is questionable and large defects may not be well suited for local reconstruction. In the otolaryngology literature, several reconstructive options using local tissue and synthetic materials have been described, but there have been no reports of microvascular free flaps utilized in this regard. We present a unique case of a 37-year-old woman with a 3.0 cm × 3.5 cm nasoseptal perforation secondary to cocaine use successfully reconstructed with a temporoparietal fascia free flap anastomosed to the facial artery and vein. Postoperatively, the patient had a well-healed septal defect from the free flap reconstruction This new technique shows promise as a feasible option for patients with large defects and for those with limited local reconstructive options. The ease of harvest and low donor-site morbidity make the temporoparietal fascia flap a suitable option for repair of complex nasoseptal defects.

Rejuvenation of the lower lid and periocular area from above.

Rejuvenation of the periocular region, specifically the lower eyelid region, can be performed with a variety of methods. One finding of the aging lower eyelid region is the "Y-deformity." Elevation of the midface is a powerful tool that can significantly improve the appearance of the lower eyelid. This article addresses the elevation of the midface through two approaches: the meloplication and the subperiosteal midface-lift. In addition to midface elevation, a short discussion on canthopexy is included. Although the lower eyelid can be addressed in a variety of ways, rejuvenation of the periocular region from above should be considered in all patients, as these approaches yield good results.

Endoscopic forehead and brow-lift.

The endoscopic method of rejuvenating the brow-forehead complex has evolved into the procedure of choice for many aesthetic surgeons. Safe and reliable application of the endoscopic technique depends on several important factors. These include technical expertise with the endoscopic equipment, understanding of the surgical goals in patients seeking rejuvenation in the forehead region, and detailed comprehension of the steps involved in altering forehead anatomy during endoscopic lifting. In this article, the senior author reviews his experience with the endoscopic forehead-lift and delineates a stepwise approach to this technically challenging operation. The text also highlights important details with respect to patient care, endoscopic equipment, and surgical anatomy. "Keller's rules of fours" are introduced to summarize surgical pearls of the endoscopic forehead- and brow-lift.

Middle Eastern rhinoplasty.

The ethnic appearance of the Middle Eastern nose is defined by several unique visual features, particularly a high radix, wide overprojecting dorsum, and an amorphous hanging nasal tip. These external characteristics reflect distinct structural properties of the osseo-cartilaginous nasal framework and skin-soft tissue envelope in patients of Middle Eastern extraction. The goal, and the ultimate challenge, of rhinoplasty on Middle Eastern patients is to achieve balanced aesthetic refinement, while avoiding surgical westernization. Detailed understanding of the ethnic visual harmony in a Middle Eastern nose greatly assists in preserving native nasal-facial relationships during rhinoplasty on Middle Eastern patients. Esthetic alteration of a Middle Eastern nose follows a different set of goals and principles compared with rhinoplasties on white or other ethnic patients. This article highlights the inherent nasal features of the Middle Eastern nose and reviews pertinent concepts of rhinoplasty on Middle Eastern patients. Essential considerations in the process spanning the consultation and surgery are reviewed. Reliable operative techniques that achieve a successful aesthetic outcome are discussed in detail.

Endoscopic forehead and brow lift.

Endoscopic method of rejuvenating the brow-forehead complex has evolved into the procedure of choice for many aesthetic surgeons. Safe and reliable application of the endoscopic technique depends on several important factors. These include technical expertise with the endoscopic equipment, understanding of the surgical goals in patients seeking rejuvenation in the forehead region, and detailed comprehension of the steps involved in altering forehead anatomy during endoscopic lifting. In this manuscript, the senior author reviews his experience with the endoscopic forehead lift and delineates a stepwise approach to this technically challenging operation. The text also highlights important details with respect to patient care, endoscopic equipment, and surgical anatomy. "Keller' rules of fours" are introduced to summarize surgical pearls of the endoscopic forehead and brow lift.

Pearls in facelift management.

Facelift surgery is complex and requires a significant commitment from both patient and surgeon. This article provides a collection of surgical tips and pearls that can be applied to most facelift procedures, no matter the surgical technique. A holistic approach to patient care is discussed regarding preoperative, perioperative, and postoperative management. Within this article the authors outline details so facial plastic surgeons can provide their patients with the smoothest surgical experience and recovery.

The utility of ultrasound in the evaluation of submental fullness in aging necks.

OBJECTIVES: To evaluate the submental region of the aging neck with high-frequency ultrasound and to assess the relative contribution of its various components to the appearance of age-related soft-tissue ptosis. METHODS: Ten patients with submental soft-tissue excess were recruited from the senior author's (G.S.K.) private practice. The subcutaneous fat compartment, the subplatysmal fat compartment, and the anterior bellies of the digastric muscles were imaged with high-frequency ultrasound and measured in the cephalocaudal dimension. Pseudoherniation of subplatysmal fat, judged in relation to the inferior surface of the digastric muscles, was also assessed from acquired images. RESULTS: A clear delineation of submental anatomy was obtained with ultrasound in all patients (N = 10, 100%). Hypertrophied digastric muscles (n = 1, 10%) and excessive subplatysmal fat (n = 5, 50%) adversely contributed to the appearance of submental fullness in 6 patients (60%). These findings would not have been predicted with the same degree of accuracy from the physical examination alone. CONCLUSIONS: High-frequency ultrasound provides useful imaging of the submental region and its components. Deeply situated subplatysmal fat and anterior bellies of the digastric muscles, both of which may be difficult to assess on physical examination, can be readily evaluated with ultrasound. When sufficiently enlarged and ptotic, deep tissues of the submental space necessitate an open submentoplasty to restore a youthful neck contour. Preoperative ultrasonography can assist with anatomical imaging of the submental space and help in planning a targeted operative intervention in patients with submental soft-tissue excess.

Nerve injuries and treatment in facial cosmetic surgery.

Surgical intervention remains a popular choice in patients seeking facial rejuvenation. Although uncommon, temporary or permanent peripheral nerve injury may complicate almost any type of invasive aesthetic procedure of the face, resulting in functional and psychological consequences for patients. Prompt recognition and appropriate intervention are necessary to avoid the long-term sequelae and improve the chances of complete neurologic recovery. Depending on the type of injury, various interventions may range from observation and close follow-up to interposition nerve grafting. This article reviews the pertinent anatomy of nerves at risk in facial cosmetic surgery and discusses various management strategies for inadvertent injury to peripheral nerves of the face.

Aesthetic management of external skin paddles following microvascular reconstruction of the head and neck.

Microvascular free tissue transfer has become a popular reconstructive option for a wide range of complex head and neck defects. Although highly effective in achieving wound closure, this technique frequently introduces skin paddles with inherent differences in thickness, color, and texture. In resurfacing of cutaneous facial defects, such disparity often leads to inferior aesthetic results. For patients, poor appearance following head and neck reconstruction can become a significant source of distress and add additional burden to their recovery. This article describes several options available in the postoperative setting to improve the appearance of transferred skin paddles. Regional tissue rearrangement with the submental and posterior scalping flaps is discussed in detail.

Monopolar radiofrequency skin tightening.

The development of nonablative monopolar capacitive radiofrequency technology (ThermaCool System, Thermage, Inc., Hayward, California) has contributed to the noninvasive trend in facial skin rejuvenation. In contrast to traditional ablative resurfacing techniques, the ThermaCool System protects the skin surface from injury while selectively heating the underlying dermis. Preservation of epidermal integrity minimizes recovery and the risk of complications. Published clinical evidence documents the efficacy of monopolar capacitive radiofrequency skin tightening and supports its use for mild to moderate facial skin laxity and rhytides. Currently, monopolar capacitive radiofrequency represents the gold standard of treatments designed to tighten skin in a noninvasive fashion.

Aesthetic reconstruction of the auricle.

Repair of auricular defects can be a challenging endeavor due to a broad variety of clinical presentations and available reconstructive options. Acquired auricular deformities most commonly result from a wide range of traumatic injuries and following Mohs' extirpation of cutaneous malignancies. A choice of repair ultimately depends on patient factors, amount of soft tissue loss, and location of the auricular defect. Meticulous re-establishment of proper physical dimensions, smooth external contour, and complex surface landmarks ensures satisfactory aesthetic outcomes for surgeons and their patients.

Malignant cylindroma of the external auditory canal.

OBJECTIVE: This report describes a case of a malignant cylindroma arising in the external auditory canal. STUDY DESIGN: Retrospective surgical case review. SETTING: Tertiary care teaching hospital. INTERVENTION: Wide local excision with margin control. RESULTS: Local control of disease at 2-year follow-up. CONCLUSION: To our knowledge, this is the first report describing a malignant degeneration of cylindroma in the external auditory canal. This tumor represents an extremely rare cutaneous neoplasm, thus raising diagnostic and therapeutic challenges.