Facial Plastic Surgery & Aesthetic Medicine

A grafting technique that uses diced cartilage without fascia, which improves formability while maintaining long-term stability, would be a welcome addition to the rhinoplasty armamentarium.

A diced cartilage glue graft was recently introduced as the Tasman technique. The technique has been used by one of us (A.-J.T.) in 28 patients who were monitored clinically for 4 to 26 months. Sonographic morphometry of the graft was used in 10 patients with a maximum follow-up of 15 months, and 2 biopsies were obtained for histologic examination.

Fashioning the diced cartilage glue graft reduced operating time compared with the diced cartilage fascia graft and allowed for a wide variety of transplant shapes and sizes, depending on the mold used. All grafts were used for augmentation of the nasal dorsum or radix and healed uneventfully. Sonographic cross-section measures of the grafts changed between 6% and –29% (median, –5%) in the early postoperative phase and 8% and –7% (median, –2%) between 3 and 15 months after insertion. Histologic examination of the graft biopsies revealed viable cartilage with signs of regeneration.

The diced cartilage glue graft may become an attractive alternative to accepted methods for dorsal augmentation, the diced cartilage fascia graft in particular.

To describe our technique of using septal bone grafts for correction and stabilization of caudal septal deviation and to evaluate the effectiveness of this technique in the treatment of the deviated caudal septum.

A retrospective review of 81 patients who underwent open septorhinoplasty using septal bone grafts for correction of a caudal septal deviation or deformity and nasal obstruction. We reviewed medical records to determine postoperative outcomes in nasal obstruction and caudal septal position.

Of the 81 patients, we included 66 with adequate follow-up information in the analysis. Follow-up duration ranged from 1 to 72 (mean, 8) months. Postoperative examination revealed a midline septum in 55 of the 66 patients (83%). Fifty-seven patients (86%) reported resolution of nasal obstruction; 49 (74%) had a midline septum and resolved nasal obstruction at the longest follow-up. Nine patients (14%) reported postoperative nasal obstruction, of whom only 3 required revision surgery.

Nasal septal bone grafts can be an effective tool in stabilizing severe cartilaginous deformities or deviations and correcting caudal septal deviation.

To aid the aesthetic surgeon in midface analysis and selection of treatment plans offering the greatest likelihood of success in midface rejuvenation.

We performed a retrospective review of all patients who underwent surgical midface rejuvenation by a single surgeon. We recorded demographics, history, procedures, outcomes, and complications. Results of physical examination and photography were used to classify patients by volume loss, midface ptosis, skin elasticity, and skeletal anatomy. Outcome was determined by patient satisfaction at the 12-month follow-up; unsatisfactory results were further analyzed by a blinded independent expert with more than 15 years' experience.

We included 150 patients. Mean patient age was 51 years; 93.3% were women, and 20.7% had undergone previous procedures, including malar implants, autologous fat grafting, rhytidectomy, midface-lift, and extended lower blepharoplasty. Multimodality treatment was used in 34.0%. Patient dissatisfaction was encountered in 14.0% of cases; the expert concurred in each case. Autologous fat grafting alone demonstrated the greatest propensity for dissatisfaction (4 of 12 cases [33%]). Rate of dissatisfaction was significantly higher with malar hypoplasia (41% vs 7%; P < .001) or loss of elasticity (16% vs 3%; P = .01) but was not highly correlated with age (r = 0.15).

Successful midface rejuvenation requires accurate diagnosis and avoidance of anatomic pitfalls. Many patients require multimodality therapy, including lifting and volumizing techniques. Unsatisfactory results are most common when midfacial aging is accompanied by skeletal insufficiency or loss of elasticity. Respective consideration of these defects should be given to placement of malar implants and rhytidectomy approaches targeting the midface.

To describe common patterns of facial asymmetry and to augment the facial analysis paradigm for improved preoperative counseling and surgical planning.

We conducted a frontal photographic analysis of 50 patients who were seeking various types of facial cosmetic surgical procedures. The horizontal zonal thirds of the face were analyzed, and the bilateral data points were compared in regard to brow height, width of midface at maximum distance, malar eminence height, nasal alar height, and mandible width measured from the oral commissure to the gonial angle.

Forty-five patients demonstrated measurable asymmetry of the midface. The malar eminence was found to be more superiorly positioned and defined on the narrower side of the face in all cases. In contrast, the contralateral wider side of the face appeared flatter, with a more hypoplastic, inferiorly positioned malar eminence. Also, the wider side of the face more often demonstrated a wider mandibular dimension and a superiorly displaced ala. The upper third of the face, in regard to brow height, was the most variable and showed little correlation to the lower two-thirds of the face.

This facial analysis exercise can assist the surgeon in (1) preoperative counseling, (2) managing expectations, (3) choosing appropriate-sized implants for improved symmetry, and (4) offering a more detailed assessment during the counseling of patients before face-lift surgery.

(1) To describe repair of complex orbital fractures using computer planning with preoperative virtual reconstruction, mirror image overlay, endoscopy, and surgical navigation. (2) To test the hypothesis that this technique improves outcomes in complex orbital fractures.

A series of 113 consecutive severe orbital fracture cases was analyzed, 56 of which were performed with mirror image overlay guidance, and 57 of which were repaired without. Data were collected on patient characteristics, fracture severity, diplopia and globe position outcomes, complications, and need for revision surgery.

The mirror image overlay group showed decreased postoperative diplopia in all fracture types (P = .003); the effectiveness was maximal for fractures that involved 3 or 4 walls or the posterior one-third of the orbital floor (P < .001). The need for revision surgery was greatly reduced in this cohort (4% vs 20%; P = .03).

The efficacy of mirror image overlay navigation and orbital endoscopy was studied in one of the largest series of complex orbital fractures in the literature. Based on statistically significant improved outcomes in postoperative diplopia and orbital volume, as well as the decreased need for revision surgery, we accept the hypothesis that mirror image overlay guidance improves outcomes in complex orbital reconstruction and recommend its use for complex orbital fracture repair.

To review our experience with miniplate fixation of fractures of the symphyseal and parasymphyseal regions of the mandible.

A retrospective review of all mandible fractures treated from July 1, 1999, through July 31, 2011, by one of us (Y.D.) was performed. Intraoral, open rigid fixation of noncomminuted symphyseal and parasymphyseal fractures was performed using a combination of 2 miniplates that were either a 4-hole or a 6-hole miniplate using monocortical screws. The miniplates were 1-mm thick with a 2-mm screw diameter.

A total of 218 patients with noncomminuted symphyseal and parasymphyseal mandible fractures were included in this study. Eighteen patients (8.3%) with concurrent panfacial fractures and other indications were left in postoperative maxillomandibular fixation (MMF), whereas 200 patients (91.7%) did not require postoperative MMF. All patients in this series achieved bony union. The following complications were noted: plate exposure, 2.3%; malocclusion, 1.4%; wound infection, 1.4%; and tooth root injury, 0.9%. The use of postoperative antibiotics and either a nonlocking or locking system was not associated with significant differences in the rates of complications.

For noncomminuted symphyseal and parasymphyseal mandible fractures, the application of 2 miniplates with monocortical screws offers good surgical outcomes in most patients with minimal complications. The advantages of using miniplates include easy plate adaptability, no need for MMF unless indicated, small screw diameter, and provision of adequate load-sharing rigid fixation for simple, noncomminuted symphyseal and parasymphyseal mandible fractures.

To determine the safety and efficacy of the endoscopic management of isolated orbital floor fractures.

A systematic review was performed using electronic databases. Studies investigating the reconstruction of isolated orbital floor fractures using an endoscopic approach were considered for inclusion. Two investigators independently reviewed all results. Study quality was assessed using the Methodological Index for Nonrandomized Studies scale. Primary outcomes were the resolution of diplopia and enophthalmos. Secondary outcomes were postoperative complications, including blindness, paresthesias, sinusitis, infection, conversion to external approach, and need for revision surgery.

Nine studies capturing 172 patients met the inclusion criteria for systematic review. Two studies were comparative and 7 were case series. Study quality was poor, lacking prospective data and reliable assessment of outcomes. Strong reviewer agreement was observed (intraclass correlation, 84%; 95% CI, 35%-96%). Diplopia resolved in 102 of 118 patients (86%) and enophthalmos resolved in 41 of 43 (95%). No complications of blindness, sinusitis, or conversion to external approach were reported. Thirteen patients (8%) had transient cheek numbness. Two patients (1%) required revision surgery.

Reconstruction of isolated orbital floor fractures through an endoscopic approach appears to be safe and effective. High-level evidence prospectively comparing endoscopic and external approaches, however, is lacking.

To evaluate the aesthetic and functional outcomes of a full-thickness skin graft and a separately harvested auricular cartilage graft for nasal alar defects created by Mohs micrographic surgery.

Twenty patients with deep Mohs micrographic surgery defects of the nasal ala who underwent reconstruction with a full-thickness skin graft and an auricular cartilage graft were prospectively studied at a single tertiary care institution between 2010 and 2011 in a nonrandomized, nonblinded study. An ordinal 5-point Likert scale evaluation of overall outcomes was performed by 4 independent surgeon raters.

The mean outcome for use of the full-thickness skin and auricular cartilage graft construct was a score of 2.3 on a scale of 1 through 5, with 1 being excellent and 5 being poor. The mean duration of follow-up was 6 months, with a range of 5 weeks to 23 months. There were no clinically meaningful losses of constructs in the patients studied.

A full-thickness skin graft and a separately harvested auricular cartilage graft are valuable and reliable tools for reconstructing deep nasal alar defects that require support to prevent alar retraction or collapse, particularly when a single-stage procedure is preferred or necessary because of medical comorbidities.

To report outcomes in free flap reconstructive surgery in the setting of calcified arteriosclerosis affecting the flap pedicle.

Retrospective review, including a detailed analysis of medical records, histopathologic findings, and a comprehensive review of the literature.

A total of 1329 consecutive microvascular free tissue transfers were performed by 2 reconstructive surgeons at a university-affiliated tertiary care medical center from January 1, 1996, through December 31, 2011. Clinical notes, operative notes, and pathology reports were systematically reviewed to identify 44 patients (3%) with calcified arteriosclerosis involving the flap vascular pedicle. A comprehensive medical record review was performed for the included patients, detailing patient-related characteristics, flap survival, and incidence of perioperative complications.

A history of arteriosclerosis was identified preoperatively in 18 patients (41%). Eight patients (18%) were specifically recognized clinically and histologically to have a variant of arteriosclerosis known as Mönckeberg medial calcific sclerosis. In total, fibula osteocutaneous free flap was performed in 30 patients, radial forearm in 8 patients, rectus abdominus in 3 patients, latissimus dorsi in 2 patients, and parascapular in 1 patient. Perioperative complications occurred in 17 patients (39%), with the most common being pulmonary (14%) and cardiac (9%). Patient follow-up ranged from 3 to 137 months, with a mean postoperative follow-up of 21 months. The mean length of hospital stay was 12 days. There was a 0% incidence of total flap failure and a 7% incidence of partial flap necrosis.

Although technically challenging, successful microvascular free flap reconstruction can be achieved despite the presence of vascular calcifications affecting the flap vascular pedicle.

To describe denervation features of facial musculature following facial nerve injury in a rodent model.

Six Wistar-Hannover rats underwent unilateral transection and immediate repair of the facial nerve. After 8 weeks, muscular bundles consisting of dilator naris and levator labii superioris from both sides were analyzed for mean muscle cell diameter and the percentage of muscle cell cross-sectional area using image processing software. The atrophic features of facial muscles were quantified and compared with the contralateral, healthy side of the face.

Weekly postoperative whisking assessment demonstrated the anticipated course of recovery. We observed significant differences between the normal side and the manipulated side, respectively, in the percentage of muscle specimen cross-sectional area attributable to muscle cell profiles (57% vs 29%; P = .006) and total fiber counts (1346 vs 794; P = .02). The mean cross-sectional area of individual muscle fibers was higher on the normal side (1129 vs 928 μm²; P = .39); however, this difference was statistically nonsignificant.

The objective, quantitative measures of muscle microstructure used in this report provide a valuable point of comparison for whisking function and electrophysiologic measures and can be used in future studies to assess muscle atrophic features associated with facial nerve injury and repair techniques.