Different Surgical Strategies in the Prevention of Frey Syndrome: A Systematic Review and Meta-analysis.

OBJECTIVE/HYPOTHESIS: To define the best surgical technique able to reduce Frey syndrome (FS) incidence after parotidectomy. STUDY DESIGN: Systematic review and network meta-analysis. METHODS: An arm-based network analysis was conducted using a Bayesian hierarchical model. The primary and secondary outcomes were the incidence of subjective (clinical) and objective (positive starch-iodine test result) FS, respectively. RESULTS: A total of 3830 patients with a median age of 50.35 years (n = 2323; IQR 44.25-54.18) were included for six interventions [temporoparietal fascia (TPFF), free fat graft (FFG), acellular dermal matrix (ADM), sternocleidomastoid muscle (SCM) flap, and superficial musculoaponeurotic system (SMAS) flap]. If compared to no treatment, the greatest reduction of subjective (clinical) FS incidence was measured for the TPFF (OR: 0.07, CI: 0.004-0.57), the ADM (OR: 0.09, CI: 0.02-0.35), and the FFG (OR: 0.11, CI: 0.03-0.42) techniques. However, a significant difference was measured also for the SCM flap (OR: 0.38, CI: 0.18-0.73) and for the SMAS flap (OR: 0.42, CI: 0.19-0.97). All treatments showed a significant reduction of the objective FS incidence if compared to no treatment (FFG, OR: 0.06, CI: 0.002-0.62; TPFF, OR: 0.07, CI: 0.01-0.33; ADM, OR: 0.11, CI: 0.03-0.44; SMAS, OR: 0.36, CI: 0.17-0.71; SCM, OR: 0.40, CI: 0.19-0.74). CONCLUSIONS: TPFF, ADM, and FFG seem to be the best treatment strategies to prevent FS after parotidectomy. Further randomized controlled trials comparing these techniques should be conducted to define specific indications. Laryngoscope, 131:1761-1768, 2021.

Use of a Cervicofacial Flap in Closing Large Defects Following Wide Local Excision of Complicated Preauricular Lesions.

PURPOSE: To describe innovative surgical technique for closure of large defect following complicated preauricular cyst excision secondary to prior failed excision attempts, infections, and drainage procedures. Preauricular cysts must be widely excised including any fistulous tracts in order to reduce recurrence rates; however, the resultant large local excision poses cosmetic challenges. METHODS: Retrospective chart review of 3 patient cases who underwent excision of recurrent preauricular lesions involving cervical parotid flap closure. All three cases demonstrate complicated preauricular congenital cysts which were infected and had prior drainage, excision attempts, or sclerotherapy. A cervicoparotid flap was used to close all defects cosmetically with no facial nerve weakness and without distortion to the oral commissure or lateral canthus. RESULTS/CONCLUSIONS: There is a high recurrence rate seen with wide local congenital cyst excisions that have been previously excised, infected, and drained; as well as, cosmetically unfavorable outcomes utilizing traditional repair. Utilizing our closure technique which involves reconstructive local regional flap with cervicoparotid approach our 3 patients have had no reoccurance of cyst or infection. Our approach also maximizes cosmetic outcomes, with reduced scar visibility. Pre and postoperative photos will be shown.

Nuances in Superficial Musculoaponeurotic System Rhytidectomy.

Rhytidectomy techniques have evolved since the early 1900s. As the understanding of facial anatomy and the aging process expanded, the superficial musculoaponeurotic system (SMAS) became a focal point in developing longer-lasting, natural results. Further evolution led to various approaches in repositioning the SMAS layer, including subperiosteal, composite, and deep plane rhytidectomies. This article describes the nuances of SMAS rhytidectomy, the biplanar SMAS imbrication technique, and adjuvant procedures used. This biplanar SMAS technique has been refined over more than 25 years and has proved to be a reliable and safe technique that leads to high patient satisfaction with minimal complications.

Neurotized Platysma Graft: A New Technique for Functional Reanimation of the Eye Sphincter in Longstanding Facial Paralysis.

BACKGROUND: In 1984, Terzis reported on the potential use of a free platysma muscle transfer to reanimate the orbicularis oculi in longstanding paralysis of this unit. However, the vascularized platysma flap proved difficult to transfer, and this technique is not widely used today. In the present study, the authors have described the technique involving grafting of the platysma muscle to restore eyelid function and retrospectively discussed its clinical outcomes. METHODS: This retrospective analysis included patients with longstanding facial paralysis who underwent orbicularis oculi reconstruction with neurotized platysma grafts. The authors have described the surgical technique and its retrospective clinical outcomes. RESULTS: Between 1992 and 2015, 38 consecutive patients underwent this procedure; of them, 34 [16 men (47 percent) and 18 women (53 percent)] completed the follow-up. The time between the first and second surgical stages was a mean 8.6 months (range, 6 to 22 months). The surgical results were good in 18 patients (53 percent) and the recovery was satisfactory in 13 (38 percent). CONCLUSIONS: This study confirmed the feasibility and effectiveness of grafted muscle functional recovery and the efficiency of neuromuscular neurotization. The presented surgical technique is safe and effective for treating longstanding facial palsy of the orbicularis oculi muscle. This is the only technique that is easy and reproducible, leads to facial nerve recovery, and places a similar muscle at the original site of the paralyzed muscle for functional recovery. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Surgical Denervation of Platysma Bands: A Novel Technique in Rhytidectomy.

Prominent platysma bands in the neck are one of the first signs of aging. There is increasing demand for surgical facial rejuvenation, including procedures to tighten skin and muscle in the neck; however, obtaining long-lasting results is a challenge. The aim of this study was to characterize the efficacy and safety of platysma muscle denervation for this indication. The authors performed surgical platysma denervation, involving selective cervical branch section simultaneously performed with rhytidectomy, in eight patients with unilateral facial paralysis (as a solution for visible platysma bands on the unaffected side of the face) and in one patient requiring aesthetic rhytidectomy (bilateral surgery). Patients were monitored for at least 3 months after surgery (in some cases, for up to 21 months). There were no major postoperative complications. Eight of the patients were unable to contract the platysma following surgery, leading to an improvement in the platysma band appearance. This study demonstrated the effectiveness and safety of the platysma denervation technique. Sectioning the cervical branch of the facial nerve provides a permanent solution to improve the cosmetic appearance of platysma bands and can be combined with rhytidectomy. CLINICAL QUESTION/LEVEL OF EVIDENCE:: Therapeutic, IV.

Ethnic differences in platysmal perforators and its relevance for the platysma myocutaneous flap.

BACKGROUND: Variable flap loss rates for the platysma myocutaneous flap have been reported for the Caucasian and the Asian population, which are 10.1% and 1.6%, respectively. This study was designed to investigate ethnic differences in the number and location of platysmal perforators that influence flap survival rates. METHODS: The number and location of platysmal perforators were investigated in a total of 60 platysma muscles: bilaterally in 20 Caucasian (13 males and 7 females) and 10 Asian (5 males and 5 females) specimens using cadaveric dissections. Adjustment for inter-individual variability in platysma length and width was performed by standardizing each x-value to mandibular length and each y-value to mandibulo-clavicular distance. RESULTS: A total of 64% of all detected platysmal perforators were found in the medial half of the muscle following the pathway of the external carotid artery. Individuals of Caucasian ethnicity had a mean number of 7.60 ± 2.0 perforators per side, whereas individuals of Asian ethnicity had a mean number of 13.05 ± 1.76 perforators per side (p < 0.001). Individuals of Asian ethnicity had a statistically significant increased number of platysmal perforators in the medial middle (2.95 ± 1.05 vs. 1.60 ± 1.08; p < 0.001) and lower (1.60 ± 1.35 vs. 0.73 ± 0.85; p = 0.003) regions of the platysma compared to those of Caucasian individuals. CONCLUSION: A significantly higher number of platysmal perforators were identified in the investigated Asian population. This provides a potential explanatory model for the reported lower platysma myocutaneous flap loss rates in the Asian population than in the Caucasian population.

A modified V-shaped incision combined with superficial musculo-aponeurotic system flap for parotidectomy.

BACKGROUND: V-shaped incision (VSI) for parotidectomy had been introduced for cosmetic purpose. Despite having aesthetic superiority, it required excessive retraction or an additional hairline incision for adequate surgical exposure. To overcome these problems, we conceptualized a modified VSI approach combined with a separate superficial musculo-aponeurotic system flap. AIMS: This study aimed to propose this approach and evaluate its technical feasibility and efficacy for excision of parotid tumors. MATERIALS AND METHODS: This is a prospective, nonrandomized study involving 74 patients with small-to-medium (<4 cm), benign parotid tumors located superficially. The patients were divided into two groups based on the incision techniques used: modified VSI and modified Blair incision (MBI). The clinical outcomes of both approaches for parotidectomy were analyzed. RESULTS: Thirty-four patients underwent modified VSI approach, while 40 underwent MBI. All parotidectomies with modified VSI were successfully completed without any further incision, and no facial nerve injury or intraoperative tumor rupture complication was reported. There were no significant differences in the complications between both approaches, such as hematoma, infection, wound dehiscence, skin necrosis, sialocele, or sensory disturbance. The modified VSI group showed better cosmetic satisfaction results than did the MBI group (9.2 and 7.8, respectively; p < .001). CONCLUSIONS AND SIGNIFICANCE: The modified VSI approach is safe and feasible for small-to-medium benign parotid tumors. This approach could be a possible option for patients with a high cosmetic demand. LEVEL OF EVIDENCE: 4. STUDY DESIGN: Prospective pilot study.

Tracheostomy scar management by repositioning platysma muscle and applying an acellular dermal substitute.

BACKGROUND: A depressed tracheostomy scar can be esthetically unacceptable. We describe a new technique for managing tracheostomy scars using platysma muscle repositioning and the application of an acellular dermal substitute. METHODS: Seventeen patients with depressed tracheostomy scars were identified for scar management. The time between tracheostomy tube removal and scar management was 29 months. Before and after the surgery, the scar was rated using the Vancouver Scar Scale (VSS). RESULTS: After surgery, tracheal tug was eliminated in all patients and the appearance of the scar was much improved. The mean total VSS score improved from 8.265 to 2.324 (P < 0.0001). The follow-up period was 33.3 months. CONCLUSIONS: The management of tracheostomy scars by repositioning platysma muscle and applying an acellular dermal substitute is simple and efficient. The technique recovers the lost deep tissue volume, corrects tracheal skin tug, and enables tension-free skin closure to restore the normal contour of the neck.

Technique Tip: Platysma-flap Approach to the Clavicle.

The surgical treatment of a displaced fracture of the clavicular shaft generally consists in an open reduction and plate fixation. The most common complications of the classic direct "transplatysma" approach are hardware related. These consist of simple hardware irritations requiring secondary plate removal but also feared wound healing problems ranging from dehiscence to superficial and deep wound infections. In the present article, we describe the so-called "platysma-flap" approach in which the platysma muscle is entirely preserved and distally raised as a flap. This modified exposure allows to cover the osteosynthesis with a viable, well perfused soft tissue envelope and is a safe alternative to the standard "transplatysma" approach.

Reanimation of the paralyzed lids by cross-face nerve graft and platysma transfer.

Alterations of facial muscles may critically humper patients' quality of life. One of the worst conditions is the reduction or abolition of eye blinking. To prevent these adverse effects, surgical rehabilitation of eyelid function is the current treatment choice. In the present paper, we present a modification of the technique devised by Nassif to recover lids from long-standing paralysis. In our modification, the upper lid is rehabilitated by a platisma graft innervated by the contralateral facial nerve branches using a cross-face sural nerve graft. The lower lid is pulled upward by a fascia lata string suspension. Fourteen patients with unilateral facial paralysis were operated on consecutively. For each patient, two sets of frontal photographs with open and closed eyes were available, before and after the surgical rehabilitation. On average, eyelid lumen with closed eyes decreased by 2.6 mm (SD 2.4) after surgical rehabilitation (37% of the initial value). With open eyes, the decrement was 1.5 mm (SD 1.6, 15%). The modifications were highly significant (p < 0.01), with very large effect sizes. Reanimation of the paralyzed eye by mean of cross-face nerve graft followed by platisma neurotization can restore natural eyelid closure and blink reflex.

Long-term Analysis of Lip Augmentation With Superficial Musculoaponeurotic System (SMAS) Tissue Transfer Following Biplanar Extended SMAS Rhytidectomy.

IMPORTANCE: To our knowledge, long-term, objective results of lip augmentation using superficial musculoaponeurotic system (SMAS) tissue transfer beyond 1 year have not been previously described. OBJECTIVE: To evaluate the efficacy, longevity, and safety of lip augmentation using SMAS tissue transfer. DESIGN, SETTING, AND PARTICIPANTS: A retrospective single-blind cohort study was designed to evaluate all patients who underwent surgical lip augmentation using SMAS following rhytidectomy between January 1, 2000, and November, 16, 2015, at a private facial plastic surgery practice in Birmingham, Alabama. Preoperative photographs of each patient served as controls and were compared with postoperative photographs at 3 months, 1 year, and 5 years after lip augmentation. A total of 104 images (from 26 individual patients) were reviewed by 12 blinded observers using a validated lip augmentation grading scale. EXPOSURES: Lip augmentation using SMAS. MAIN OUTCOMES AND MEASURES: Median lip volumes of all patients at each postoperative interval (3 months, 1 year, and 5 years) compared with preoperative lip volumes. Secondary outcome measures included postoperative complications. RESULTS: A total of 423 patients were identified who underwent surgical lip augmentation using SMAS. Sixty patients with approximately 5 years or more of postoperative photographs were reviewed for complications. Twenty-six patients had 3-month, 1-year, and 5-year postoperative follow-up photographs and were included in the photographic evaluation. The mean age of these patients at the time of surgery was 54.6 years (range, 41.2-80.6 years. Fifty-nine of the 60 patients (98.3%) were female. Two of 60 patients (3.3%) with 5 years or more of postoperative follow-up developed complications requiring intervention. Both the superior lip and the inferior lip showed statistically significant increases in volume at 3 months, 1 year, and 5 years (P ≤ .004 for the superior lip after 5 years; P ≤ .001 for all other comparisons) after SMAS lip augmentation. The greatest median increase was observed in the superior lip at 3 months, while the smallest median increase was observed for the inferior lip at 5 years. The degree of increase in median volume seemed to weaken slightly over time, but remained statistically significant even at 5 years. CONCLUSIONS AND RELEVANCE: SMAS lip augmentation is an effective and safe method for lip augmentation that can yield natural, long-lasting results with minimal risk. The degree of augmentation tends to fade slightly over time, but remains significant for at least 5 years postoperatively. LEVEL OF EVIDENCE: 3.

The superficial musculoaponeurotic system flap in the prevention of Frey syndrome: A meta-analysis.

OBJECTIVES/HYPOTHESIS: Evaluate the difference of the incidence in clinical Frey syndrome in studies comparing classical parotidectomy and parotidectomy with superficial musculoaponeurotic system (SMAS) flap elevation and suturing through meta-analysis methodology. STUDY DESIGN: Meta-analysis of controlled studies with and without SMAS flap. METHODS: Database search with the following key word combination: "Frey syndrome" and "SMAS." INCLUSION CRITERIA: parotidectomy, SMAS flap and control groups, minimal follow-up of 1 year. The outcome was the presence of clinical Frey syndrome. RESULTS: Eleven studies, mostly retrospective and not randomized. According to the fixed-effect model, SMAS technique is associated with a decrease of clinical Frey syndrome with an odds ratio (OR) of 0.42 (confidence interval [CI] 0.32-0.56). With the random-effect model, the difference remains significant (P = 0.006) with an OR of 0.25 (CI 0.09-0.66). The heterogeneity index I(2) is very high (85%). CONCLUSION: The use of SMAS flap and suturing is associated with a decreased incidence of Frey syndrome. Laryngoscope, 126:1581-1584, 2016.

Effectiveness of platysma muscle flap in preventing Frey syndrome and depressive deformities after parotidectomy.

BACKGROUND: Frey syndrome (FS) or depressive deformity (DD) occurring after parotidectomy significantly reduces a patient's quality of life. However, there seems to be no effective treatment strategy against these complications. In this study, we report our experience of using platysma muscle flap (PMF) to prevent the development of FS and DD after parotidectomy, and evaluate its effect subjectively and objectively. METHODS: Superficial parotidectomy was performed for eight cases of parotid gland tumor, and a PMF was transferred to cover the site. The incidence of FS and DD were evaluated subjectively, using a questionnaire to the patients and board-certified reconstructive surgeons, and objectively, using Minor's starch-iodine test. RESULTS: In seven patients, the defect could be completely covered with PMF, and none of them developed FS or obvious DD. However, in one patient, the defect could be only partially covered, and the patient developed complications in the exact site that the flap did not cover. Overall scores from the questionnaire were high in relation to both cosmetic and functional perspectives from most of the patients and all the surgeons. No patients had major postoperative complications requiring revision. CONCLUSIONS: PMF can be useful to cover the defect and prevent complications after parotidectomy. PMF is relatively easy to perform with fewer complications; however, a complete coverage of the defect should be ensured to obtain optimal results.

An "oxhorn"-shaped V-Y advancement flap unilaterally pedicled on a nasal superficial musculoaponeurotic system for nasal reconstruction.

BACKGROUND: Laterally based nasalis myocutaneous flaps pedicled on the superior nasal superficial musculoaponeurotic system (SMAS), which contains the bilateral dorsal nasal arteries, have not been utilized for the reconstruction of nasal defects. METHODS: According to the location and size of the nasal defects, a V-Y advancement nasalis myocutaneous flap was designed along the proximal alar groove and nasolabial fold. The flap was superficially elevated from the perichondrium, and the nasal SMAS above the flap was dissected as the unilateral pedicle. After the flap was rotated and advanced to the defect, the secondary defect was primarily closed. RESULTS: A total of 20 cases of nasal defects, including six cases of nasal dorsum, five cases of nasal tip, four cases of nasal tip-alar junctions and five cases of nasal tip-dorsum junctions, were reconstructed using this method. The defect size ranged from 0.8 × 0.8 cm to 2 × 1.8 cm. All of the flaps survived with satisfactory aesthetics and function. All of the patients were postoperatively followed up for 6-12 months. CONCLUSION: Application of the V-Y advancement nasalis myocutaneous flaps pedicled on a nasal SMAS is appropriate for the reconstruction of small to medium sized nasal tips and peri-tip defects, and it can achieve satisfactory results due to its simple design, convenient transfer, reliable blood supply and concealed incision.

Submandibular artery: bilobed platysma myocutaneous flap for total lower lip reconstruction.

BACKGROUND: Lower lip reconstruction following cancer resection includes a variety of clinical and microsurgical options. OBJECTIVE: We have developed a myocutaneous flap for full thickness reconstruction with a functioning muscle. TECHNIQUE: In all patients, the submandibular artery was outlined using computerized tomographic angiography and Doppler. The flap was designed after resection. The first lobe was designed to fill the defect and was outlined 90° from the defect margin, with the submandibular artery in the center of the flap. A second lobe was then outlined 90° from the first lobe. The flap was raised along with the platysma muscle and artery, with the first lobe rotated to the lip and the second lobe inset into the first lobe site, permitting neck closure without skin redundancy. RESULTS: From January to May 2012, 17 patients were treated with this flap, and all flaps survived. All of the patients had oral continence at sixteen months, and electromyography documented platysma function. CONCLUSION: The flap provides single-stage lower lip reconstruction with functional muscle.