Comparing Lateral Rhytidectomy With and Without Neck Suture Suspension.

Background: Characteristic aesthetic changes of the aging neck include skin laxity and rhytid formation, submental fat deposition, plastysmal banding, and ptosis of underlying structures that lead to the development of an obtuse cervicomental angle (CMA). Cervical rejuvenation techniques that aim to restore the CMA are widely discussed in the literature, and share variable outcomes. The aim of this study is to compare the restoration of the CMA in patients undergoing the addition of midline platysmal plication using a modified Giampapa stitch with absorbable PDS suture, to those patients undergoing standard deep plane lateral rhytidectomy alone. Methods: A retrospective cohort study was performed by a single surgeon in a private facial plastics practice. 264 patients undergoing rhytidectomy were included in the study. Pre and postoperative measurement differences in CMA degree and depth were compared in patients undergoing only traditional deep plane lateral rhytidectomy (TDPLR) in isolation, with those who also had modified suture suspension and platysma plication (MSSPP). The primary outcome in the study was the change in the degree of the CMA taken from standardized preoperative and postoperative surgical photos in the Frankfort profile view. Secondary outcomes include the change in the depth of the CMA as determined by the hyomental distance between study and control groups. Results: A total of 264 patients were identified who met the study criteria. A total of 134 (123 female; 11 male; average age, 62.66 ± 8.19) underwent TDPLR with MSSPP, and 130 (127 female; 3 male; average age, 63.09 ± 7.75) underwent TDPLR alone. All patients in the study underwent preoperative photographic evaluation in Frankfurt profile view and the same postoperative photographic evaluation at an average of 436.56 days (14.4 months) after surgery. Patients in the cohort study group were found to have a statistically significant increase in the depth of the CMA by an average of 13.9 degrees ± 6.26 and increase in the hyomental distance of 1.38 cm ± 0.87, compared to the control group who underwent traditional lateral rhytidectomy with an average CMA change of 6.87 degrees ± 6.7 (P = .00146) and hyomental distance increase of 0.75 ± 0.68 (P = .00031), respectively. Statistical significance was taken at P < .05. Conclusions: The results from this study indicate that the addition of a relatively minimally invasive approach to neck rejuvenation using a modified Giampapa stitch with absorbable PDS suture is helpful in restoring the CMA in an aging neck.

Contexte: Les modifications esthétiques caractéristiques du cou vieillissant sont notamment la laxité de la peau et la formation de rides, le dépôt sous-mentonnier de tissu adipeux, la formation de bandes du muscle platysma et la ptose des structures sous-jacentes qui mènent au développement d'un angle cervico-mentonnier (ACM) obtus. Les techniques de rajeunissement du cou visant à restaurer l'ACM font l'objet de nombreuses discussions dans les publications avec des résultats variables. Le but de cette étude était de comparer la restauration de l'ACM chez des patients subissant l'ajout d'un pli du platysma sur la ligne médiane au moyen d'une suture modifiée de Giampapa avec un fil résorbable en PDS par rapport à des patients bénéficiant d'une rhytidectomie latérale plane profonde standard seule. Méthodes: Une étude de cohorte rétrospective a été réalisée par un seul chirurgien dans un établissement privé de chirurgie plastique du visage. L'étude a inclus 264 patients subissant une rhytidectomie. Les différences de mesures de degrés et de profondeur pré et postopératoires de l'ACM ont été comparées entre les patients subissant une rhytidectomie latérale plane profonde traditionnelle (RLLPT) seule et les patients avec suspension de suture modifiée et un pli du platysma (SSMPP). Le critère d'évaluation principal de l'étude était la variation du nombre de degrés de l'ACM mesuré sur des photographies chirurgicales pré et postopératoires standardisées sur un profil de type Frankfort. Les critères de jugement secondaires étaient, notamment, la variation de profondeur de l'ACM mesurée par la distance hyomentale entre le groupe d'étude et le groupe contrôle. Résultats: Un total de 264 patients satisfaisant les critères de l'étude a été identifié: 134 patients [123 femmes, 11 hommes, d'âge moyen 62.66 ± 8.19] ont eu une RLLPT avec SSMPP et 130 patients [127 femmes, 3 hommes, d'âge moyen 63.09 ± 7.75] ont eu une RLLPT seule. Une évaluation photographique préopératoire avec vue de profil de type Francfort a été réalisée pour tous les patients de l'étude; la même évaluation photographique a été réalisée en postopératoire, en moyenne 436.56 jours (14.4 mois) après l'opération. Les patients du groupe d'étude de la cohorte avaient une augmentation statistiquement significative de la profondeur de l'ACM, en moyenne de 13.9 ± 6.26 degrés et une augmentation de la distance hyomentale de 1.38 ± 0.87 cm comparativement aux patients ayant subi une rhytidectomie latérale traditionnelle chez lesquels la variation d'ACM était de 6.87 ± 6.7 degrés [P = .00146] et l'augmentation de la distance hyomentale de 0.75 ± 0.68 cm [P = .00031]. La signification statistique était fixée à P < .05. Conclusions: Les résultats de cette étude indiquent que l'ajout d'une approche peu invasive à la technique de rajeunissement du cou usant une suture modifiée de Giampapa est utile pour restaurer l'ACM dans un cou vieillissant.

Arcade Sutures to Minimize Ear Displacement in Rhytidectomy.

Ear deformities after rhytidectomy are not uncommon and have a significant impact on cosmetic success. We postulate the use of horizontal mattress suspension sutures in the anterior face anchored to the deep temporalis fascia (DTF) during rhytidectomy allows for a vertical lift while minimizing the risk to the frontal branch of the facial nerve and decreasing forward rotation of the ear. To compare auricular displacement during rhytidectomy using an arcade of horizontal mattress suspension sutures anchored to the DTF instead of the preauricular pre-parotid fascia, and evaluate outcomes with this modification at 1 year. This was a proof of concept prospective cohort study of 20 patients (40 sides) undergoing rhytidectomy by a single plastic surgeon (level of evidence 4). Intraoperative measurements were taken to determine the amount of auricular displacement with suspension sutures placed in the preauricular fascia compared with the DTF. To confirm longevity, we compared ear position preoperatively and at 1 year after rhytidectomy with our technique. There was significantly less auricular displacement when superficial musculoaponeurotic system (SMAS) suspension sutures were placed in the DTF 0.75 ± 0.69 mm compared with the preauricular fascia 9.71 ± 2.57 mm (p < 0.00001). With our technique at an average follow-up of 370.3 days, there was no significant change in auricular rotation compared with preoperative photos (p = 0.125).Our simple rhytidectomy modification allows for vertical resuspension of the SMAS in the anterior face in a safe manner while minimizing displacement of the auricle.

The Effect of Platelet-Rich Fibrin Matrix on Skin Rejuvenation: A Split-Face Comparison.

BACKGROUND: Despite the increasingly popular use of platelet-rich fibrin matrix (PRFM) for facial rejuvenation, no studies have evaluated its effects on skin. OBJECTIVES: The aim of this study was to determine the effect of PRFM on skin quality as measured by the Canfield VISIA Complexion Analysis System. METHODS: This was a 12-week randomized, placebo-controlled trial conducted at a single center comparing 2 groups. Thirty patients received a PRFM injection in the mid-cheek region and nasolabial fold on one side of the face and saline on the contralateral side. The primary outcome measure was the difference between pre- and posttreatment total VISIA skin scores for each group at 6 and 12 weeks. The change in subscores for each skin parameter was also calculated. RESULTS: There were 30 participants, with a mean [standard deviation] age of 49.9 [13.9] years. At 6 weeks, the median change in total VISIA score (interquartile range) was -1.77 (2.36) in the PRFM group and -0.73 (2.09) in the saline group (P = 0.003). The only skin parameter that had a significantly different change in score between the groups was texture (P = 0.004). At 12 weeks, the change in median score was -1.31 (3.26) in the PRFM cohort and -0.76 (2.21) in the saline cohort (P = 0.34). There was no statistical significance in the change in score for any of the individual skin parameters. CONCLUSIONS: PRFM can objectively improve skin quality compared with placebo. Texture was the only skin parameter that significantly improved, which is consistent with PRFM's role as a filler agent. The results appear to persist for at least 6 weeks.

House Dust Mite Related Allergic Rhinitis and REM Sleep Disturbances.

PURPOSE: Sleep disturbances are common in patients with allergic rhinitis (AR). Perennial allergens like house dust mites (HDM) are difficult to avoid and have nocturnal impacts on the respiratory system and Quality of Life (QOL). The Rapid Eye Movement (REM) sleep stage is associated with memory, cognition, dreams, and overall restfulness, which can be impaired in AR patients with Sleep Disordered Breathing (SDB) even when normal all-night apnea-hypopnea (AHI) or respiratory disturbance (RDI) indices are noted on polysomnography (PSG). We hypothesized that AR HDM allergen positive patients would show REM-specific SDB reflected in their objectively elevated REM-RDI values. MATERIALS AND METHODS: This retrospective analysis of 100 patients included 47 with HDM positive allergy testing. All patients underwent PSG testing calculating the RDI during REM. Multivariate logistic regression models evaluated relationships between allergic statuses and sleep parameters while controlling for potential confounders. RESULTS: Compared with allergy negative patients, HDM allergen positive patients were significantly more likely (OR 4.29, 95%CI 1.26-14.62) to have a REM-RDI in the moderate/severe range (≥15 events/h). CONCLUSIONS: Our study highlighted the significance of respiratory allergies to HDM in patients with SDB. We revealed a significant relationship between HDM allergen positivity and SDB characterized by elevated REM-RDI regardless of all-night AHI, RDI, or REM-AHI values. Clinical implications of knowing about disturbed REM and/or HDM allergenicity include better preparation, treatment, outcomes, and QOL for allergic, SDB, and upper airway surgery patients.

Open Versus Closing Wedge Osteotomy and Application to Mandibular Reconstruction.

PURPOSE: To review the specific techniques of closing wedge osteotomy and open osteotomy, compare their clinical and radiographic outcomes, and apply these findings to mandibular reconstruction. METHODS: A thorough review of the otolaryngology, facial plastic and reconstructive surgery, oral and maxillofacial surgery, and orthopedic surgery literature was conducted in the Ovid MEDLINE, EMBASE, and Google Scholar databases using the terms 'osteotomy' and 'mandibular reconstruction.' RESULTS: Traditionally, open osteotomies were thought to result in greater rates of malunion. However, multiple meta-analyses within the orthopedic literature have refuted this. Closing wedge osteotomies, on the other hand, may increase the chance of damaging a perforator. Again, no studies have evaluated the relationship between type of osteotomy and flap survival or wound healing. The particular type of osteotomy performed often depends on the type of osseous flap being utilized. CONCLUSIONS: Open osteotomies are a viable and even preferred alternative, particularly in flaps without consistent perforators, such as scapular free flaps.

Analyzing Our International Facial Reconstructive Mission Work: A Review of Patients Treated by American Academy of Facial Plastic and Reconstructive Surgery Sanctioned Trips.

IMPORTANCE: To identify ways to improve care to underserved international populations. OBJECTIVE: To analyze the authors' data in hopes of meeting further needs. DESIGN: This is a retrospective review of medical missions using data from the American Academy of Facial Plastic and Reconstructive Surgery (AAFPRS) Face to Face) Database. SETTING: International sites of AAFPRS approved surgical mission trips. PARTICIPANTS: One thousand six hundred forty-six patients who were seen by an AAFPRS mission trip between January 12, 2010 and April 27, 2017. OUTCOMES/MEASURES: Patient and mission data, procedure data, characteristics of cleft patients, patient follow-up data, repeat patient data, and factors affecting whether a patient was provided service were all evaluated. RESULTS: Patients were seen over the course of 26 trips to 6 different countries. Patients (n, mean, median age) who underwent a primary cleft lip repair only (175, 2.5 years, 0.6 years) and those who underwent a primary cleft palate repair only (268, 6.4 years, 3.6 years) were significantly older than what is identified as the upper range of normal in surgical literature (Wilcoxon Signed-Rank test Z = -4.3, P < 0.001 for lip and Z = -10.1, P < 0.001 for palate). Patients (n, median, mean rank) receiving a primary cleft palate repair were significantly younger in Peru (160, 3.0 years, 126) compared with patients in other countries (108, 5.0 years, 147) (Z = -2.1, P < 0.05). The odds of a patient returning unplanned were 2.8 (OR, 95% CI 1.52-4.98; P < 0.01) times higher if they were diagnosed with a cleft palate only and 0.91 (OR, 95% CI 0.90-0.93; P < 0.05) times lower if they were diagnosed with combined cleft lip with cleft palate at their first visit. Patients (median age, mean rank) who were provided a service (6.0 years, 724.70) were younger than patients who were not provided a service (8.0 years, 637.23) at their first visit (Mann-Whitney, U = 164,275; P < 0.001). CONCLUSION/RELEVANCE: This data indicates that disparities exist among patients treated on mission trips compared with those in higher income countries. Furthermore, the authors' data indicate that multiple mission trips to the same country within the same year decrease some of these disparities. Additionally, isolated cleft palate patients are most likely to return unplanned indicating need for standardized postoperative visits. The preferential care of younger patients with unrepaired clefts as compared with older patients and those with palatal fistulas indicates a need for additional resource allocation.

Thromboprophylaxis in Head and Neck Microvascular Reconstruction.

Head and neck patients undergoing microvascular reconstruction are at high risk for thromboembolism. While the prevention of thromboembolism has become an essential aspect of care, within the field of microsurgery, concern for anastomotic complications have hindered the creation of an accepted regimen. The aim of this review was to evaluate the risks and benefits of prophylactic agents for thromboprophylaxis. A literature search was conducted in MEDLINE, Cochrane Library, and PubMed/NCBI databases. Articles discussing thromboprophylaxis in otolaryngology, head and neck surgery, or microvascular reconstruction were considered in the review from the past 30 years. The majority of patients undergoing microvascular surgery have multiple risk factors for thrombus formation. Several consensus guidelines exist for the prophylaxis in patients who are critically ill, undergoing surgery, or with malignancy. Significant evidence supports the routine use of mechanical means, such as early mobilization and pneumatic compression along with subcutaneous heparin. Low-molecular-weight heparin is also frequently utilized, although results are largely divided. Data on aspirin remain equivocal. Studies on microvascular failure and flap loss have demonstrated little to no association with chemoprophylaxis. The evidence for postoperative thromboprophylaxis regimens in patients undergoing head and neck free tissue transfer is variable. Multiple studies have supported the use of unfractionated heparin or low-molecular-weight heparin. There appears to be an expert consensus for the combined use of mechanical prophylactic methods and chemical prophylaxis. Prospective randomized trials are required to validate the most effective combination of chemoprophylaxis agents.

Prosthetics in Facial Reconstruction.

Reconstruction of the head and neck can be a challenging undertaking owing to numerous considerations for successful rehabilitation. Although head and neck defects were once considered irretrievably morbid and associated with a poor quality of life, advances in surgical technique has immensely contributed to the well-being of these patients. However, all patients are not suitable surgical candidates and many have sought nonsurgical options for functional and cosmetic restoration. As such, the advent of prostheses has ameliorated those concerns and provided a viable alternative for select patient populations. Prosthetic reconstruction has evolved significantly over the past decade. Advances in biocompatible materials and imaging adjuncts have spurred further discovery and forward progress. A multidisciplinary approach to head and neck reconstruction focused on appropriate expectations and patient-centered goals is most successfully coordinated by a team of head and neck surgeons, maxillofacial surgeons, and prosthetic specialists. The aim of this article is to provide a comprehensive review of the current trends for prosthetic rehabilitation of head and neck defects, and further elaborate on the limitations and advancements in the field.

Clinical associations between allergies and rapid eye movement sleep disturbances.

BACKGROUND: Allergic rhinitis, an immunoglobulin E inflammatory condition including nasal congestion, obstruction, sneezing, pruritus, and fatigue symptoms, has significant impact on quality of life and impairs sleep. Sleep-disordered breathing (SDB) patients often have normal all-night apnea-hypopnea (AHI) or respiratory-disturbance (RDI) indices on polysomnography (PSG). We hypothesized that the rapid eye motion-respiratory disturbance index (REM-RDI) may be a novel predictor of allergic status. METHODS: A retrospective analysis of 100 patients compared REM-RDI results in 67 allergen-positive patients with 33 nonallergic patients who presented with nasal blockage. Subjects completed STOP-Bang©, 22-item Sino-Nasal Outcome Test (SNOT-22)©, and Epworth Sleepiness Scale© questionnaires and underwent skin-prick testing (SPT) and PSGs including REM-RDI values. Using multivariate logistic regression models, we evaluated relationships between allergic status and sleep parameters while controlling for possible confounders including body mass index (BMI). RESULTS: Using REM-RDI as the outcome of interest, allergen-positive patients were 3.92 times more likely to have REM-RDI values in a moderate/severe range (≥15 events/hour); and patients with moderate/severe REM-RDI values were more likely to be allergen positive (p < 0.05). Allergic status was not significantly related to all-night AHI, RDI, or REM-AHI. BMI was not significantly related to REM-RDI. STOP-Bang© was related to allergy status (p = 0.02) and REM-RDI (p < 0.01). Allergic patients had increased REM latency and less total amount of REM. CONCLUSION: We revealed significant bidirectional associations between allergen positivity and increased REM-RDI values independent of BMI, AHI, RDI, and REM-AHI. Allergic inflammation and REM-RDI data may play important roles in diagnosing and treating fatigued SDB patients and as objective perioperative safety and outcomes measures.

Locoregional and Microvascular Free Tissue Reconstruction of the Lateral Skull Base.

The goals of reconstruction following any oncologic extirpation are preservation of function, restoration of cosmesis, and avoidance of morbidity. Anatomically, the lateral skull base is complex and conceptually intricate due to its three-dimensional morphology. The temporal bone articulates with five other cranial bones and forms many sutures and foramina through which pass critical neural and vascular structures. Remnant defects following resection of lateral skull base tumors are often not amenable to primary closure. As such, numerous techniques have been described for reconstruction including local rotational muscle flaps, pedicled flaps with skin paddle, or free tissue transfer. In this review, the advantages and disadvantages of each reconstructive method will be discussed as well as their potential complications.

Introduction of the American Academy of Facial Plastic and Reconstructive Surgery FACE TO FACE Database.

The American Academy of Facial Plastic and Reconstructive Surgery FACE TO FACE database was created to gather and organize patient data primarily from international humanitarian surgical mission trips, as well as local humanitarian initiatives. Similar to cloud-based Electronic Medical Records, this web-based user-generated database allows for more accurate tracking of provider and patient information and outcomes, regardless of site, and is useful when coordinating follow-up care for patients. The database is particularly useful on international mission trips as there are often different surgeons who may provide care to patients on subsequent missions, and patients who may visit more than 1 mission site. Ultimately, by pooling data across multiples sites and over time, the database has the potential to be a useful resource for population-based studies and outcome data analysis. The objective of this paper is to delineate the process involved in creating the AAFPRS FACE TO FACE database, to assess its functional utility, to draw comparisons to electronic medical records systems that are now widely implemented, and to explain the specific benefits and disadvantages of the use of the database as it was implemented on recent international surgical mission trips.

Multiflap closure of scalp defects: Revisiting the orticochea flap for scalp reconstruction.

Reconstruction of the scalp following oncologic resection is a challenging undertaking owing to the variable elasticity of the soft tissue overlying the calvarium and the limited amount of tissue available for recruitment. Defect size, location, and skin characteristics heavily influence the reconstructive options available to the surgeon. Reconstruction options for scalp defects range from simple direct closure, to skin grafting, to adjacent tissue transfer with local flaps, and ultimately to free tissue transfer. Dermal regeneration templates have also gained popularity in the recent past. Often times a primary closure with multiple local flaps can be a prime choice in these scenarios. One such modality of multi-flap closure, the Orticochea flap, is an excellent option for scalp reconstruction as it decreases operative time, may provide hair-bearing skin, and potentially avoids the risks of general anesthesia in debilitated patients. We present an interesting case of a patient with a large scalp defect following melanoma excision that was successfully reconstructed with an Orticochea flap. A review of scalp reconstruction and uses of the Orticochea flap will follow the case presentation.

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.

Current concepts in nonablative radiofrequency rejuvenation of the lower face and neck.

With the multitude of treatment options and emerging technology available for rejuvenation of the lower face and neck, it is often difficult to determine which specific treatment would benefit an individual patient. Monopolar radiofrequency (MRF) nonablative skin rejuvenation is a promising new procedure that is utilized to tighten and contour nonsurgically mild to moderate laxity of the skin of the lower face and neck in patients without significant underlying structural ptosis. In these selected patients and others who wish to avoid surgical treatment modalities, MRF treatment offers a noninvasive method of tightening skin and soft tissue, causing softening of the nasolabial lines, tightening of the jowl, and improving the definition of the cervicomental angle, all without significant recovery time or complications. Further development of MRF technology and refinement of treatment protocols may allow even greater tightening of the skin and more dramatic modulation of underlying deeper structures, making the treatment more universally applicable for patients desiring facial rejuvenation.