Facial Plastic Surgery & Aesthetic Medicine

Patients with facial synkinesis may have jaw tightness and swallow discomfort despite chemodenervation of facial mimetic musculature, and the posterior belly of the digastric (PBD) muscle is a logical target to treat these symptoms.

To compare patient-reported outcomes of botulinum toxin (BT) chemodenervation of the posterior belly of digastric muscle in patients with postparalytic facial synkinesis.

Retrospective review.

Patients with facial synkinesis who underwent electromyography (EMG)-guided PBD BT chemodenervation in addition to their baseline therapeutic regimen were included. Pre- and post-treatment Synkinesis Assessment Questionnaires (SAQ) and a two-question survey regarding jaw tightness and swallow discomfort were administered.

Twenty-nine patients were included. An average of 5 U of BT-A was injected into the PBD, and 46.5 U across all facial muscles. From pre- to post-injection, patients demonstrated improvement in jaw tightness at rest (3.02 vs. 1.98/5.0, p < 0.001), with swallow (2.78 vs. 1.94/5.0, p < 0.001), and total SAQ (64.3 vs. 51.2/100, p < 0.001). Patients rated subjective benefit from PBD injection compared with prior treatments without PBD injection as 4.5/5.0.

Synkinesis patients with jaw tightness or swallow discomfort may benefit from the addition of PBD injections to the therapeutic regimen.

Although classically described and routinely performed, alar base reduction remains nuanced without consensus as to the gold standard.

To compare the measurement of alar base reduction among three techniques and the incidence of postoperative dermabrasion in rhinoplasties performed for 35 years.

A retrospective cohort study of patients who underwent rhinoplasty with alar base reduction between 1983 and 2020 by one surgeon. Dermabrasion rates for visible incisions were evaluated based on patient demographics and surgical technique.

Of 312 patients, 82% (258) were women. The mean age was 33 years (SD 11.9). Patients self-identified as White (54.5%), Hispanic (22.4%), African American (8.3%), Middle Eastern, (5.2%), Asian (4.8%), Indian (2.2%), Mediterranean (1.3%), or unspecified (1.3%). Alar flare reduction was used alone in 202 (64.7%) patients. Eighty-two (26.3%) patients underwent postoperative dermabrasion to visible incisions. Patients self-reporting Middle Eastern race were offered dermabrasion at a rate 3.7 × higher than other race groups (OR = 3.73, CI 1.23–11.194, p = 0.02).

Alar flare reduction, sill reduction, and V-to-Y advancement are techniques that can be used to narrow the alar base. Visible incisions are the most common downside but can be addressed with postoperative interventions including dermabrasion.

Injectable hyaluronic acid (HA) fillers are commonly used to provide tissue augmentation and combat the effects of facial aging. Ovine and human recombinant formulations of the enzyme hyaluronidase (HAse) are used interchangeably; however, it is unknown if there exists a difference in their ability to degrade HA.

To compare rates at which ovine and human recombinant forms of HAse degrade various HA fillers in vitro.

Increasing amounts of either ovine or human recombinant HAse were added to fixed amounts of nine unique HA filler products. Degradation rates were then analyzed using a colorimetric method by measuring absorbance levels of degraded product.

Human recombinant HAse degraded more HA when compared with ovine HAse overall (p = 0.014, confidence interval [−0.015 to −0.0018]).

Human recombinant HAse was found to be more effective on average in degrading HA fillers when compared with ovine HAse in vitro.

Facial palsy patients face significant challenges. Gracilis free flap transfer is a key procedure in facial reanimation.

This study aims to analyze oral commissure excursion improvement after gracilis free flap transfer and the differences regarding donor nerve: cross-facial nerve graft (CFNG), hypoglossal or spinal accessory nerves, motor nerve to masseteric (MNTM), and most recently, double anastomosis using both the MNTM and CFNG.

A systematic review and meta-analysis were conducted of studies reporting oral commissure excursion improvement after free gracilis muscle transfer. Pooled proportions were calculated using a random-effects model.

Eighteen studies, 453 patients, and 488 free gracilis flaps were included. The mean change in perioperative oral commissure excursion was 7.0 mm, for CFNG 7.2 mm, for MNTM 7.7, and for double anastomoses 5.5 mm.

There is a significant improvement in oral commissure excursion after gracilis muscle-free flap. Unfortunately, we could not make definitive conclusions regarding the optimal choice of donor nerve.

Reconstruction of the orbital floor after maxillectomy can result in significant functional and aesthetic morbidity.

To measure eyelid position, self-reported visual outcomes, and complications in patients undergoing concurrent maxillectomy and reconstruction with a patient-specific orbital reconstruction implant (PSORI).

Case series.

Case series including 12 patients who received PSORI for orbital floor reconstruction after tumor extirpation. Primary outcomes gathered were diplopia, ectropion, and wound healing complications.

The majority of patients were men (75%) and the mean age was 53.3 years. Ten patients underwent free flap reconstruction with the majority receiving fibula free flaps (n = 6). Median follow-up was 415.5 days. Three patients (25%) experienced long-term complications, including diplopia (n = 1) and hardware extrusion (n = 3). Each of these occurred in the context of total maxillectomy and radiation. This prompted subsequent use of a modified implant design for the final six patients and the preferential use of a midface-degloving approach. These interventions eliminated extrusions in subsequent patients.

PSORIs can be used for orbital floor reconstruction following maxillectomy in combination with free tissue transfer. Implant design is critical to reduce complications. The use of a midface degloving approach and a modified low-profile design was associated with a low rate of complications.

The nasolabial fold (NLF) greatly contributes to facial aesthetics; changes to NLF depth and vector are disfiguring in patients with facial paralysis (FP). NLF parameters are integral to clinician-graded outcomes, but automated programs currently lack NLF identification capabilities.

To incorporate an automated NLF identification and quantification function into the facial landmark program, Emotrics, and to compare new Emotrics-derived NLF data to clinician-graded electronic facial paralysis assessment (eFACE) data for accuracy.

Photographs of 135 patients with FP were marked bilaterally, using identification markers manually placed on each NLF. A machine learning model was trained to automatically localize the markers using these data. Once Emotrics accurately identified the NLF and its corresponding vector, photographs of 20 additional patients who underwent facial reanimation procedures were assessed by the algorithm.

The enhanced Emotrics algorithm successfully identified the NLF, and measured the vector from midline, in a series of patients with FP. NLF vector data closely matched corresponding eFACE parameters. Furthermore, changes in NLF presence and vector were detected following facial reanimation procedures.

The Emotrics program now provides critical NLF data, providing objective parameters for clinicians interested in changing NLF dynamics after FP.

Facial filler is an effective nonsurgical treatment option for improving facial symmetry in patients with facial paralysis (FP).

To compare the effects of filler among patients with FP that is self-perceived as major or minor asymmetry, by measuring psychosocial distress.

In this prospective cohort study of patients with FP undergoing filler at a tertiary academic center, patients were classified as having minor or major self-perceived asymmetry using a visual analog scale (VAS). FACE-Q Appearance-Related Psychosocial Distress was administered before and after filler. Descriptive statistics and a random-effects generalized linear model assessed the relationship between perceived facial asymmetry and change in psychosocial distress.

A total of 28 patients participated. Twenty-five (89%) patients were female with median age of 54 (interquartile range [IQR]: 49–66). Median VAS score was 2 (IQR: 1–3.5, 0 = completely asymmetric, 10 = no asymmetry). Psychosocial distress improved in all patients after filler. In multivariable modeling, patients with major asymmetry experienced 2.45 (confidence interval: 0.46–4.44, p = 0.016) points more improvement in psychosocial distress than patients with minor asymmetry. Age, gender, and FP duration were not associated with change in psychosocial distress.

Facial filler treatment was seen to improve psychosocial distress in patients with FP, especially by those with more self-perceived deficit.

Identifying stable anatomical landmarks during facial expressions is necessary to register and align three-dimensional (3D) data, determine the common origin and motion axis, and calculate displacement, velocity, and acceleration of relative motion.

Our study aimed to determine the stable anatomical landmarks during facial expressions.

We included 30 volunteers in our study and asked them to perform resting, mouth opening, showing teeth, clenching teeth, eye closure, smiling, whistling, eyebrow raising, and disgusted facial expressions. We recorded the 3D movements of passive reflective markers with optoelectronic cameras, which we attached to 10 bilateral and 8 midline landmarks.

We determined that the inner corner of the eye while mouth opening, the hairline superior while showing teeth, the infraorbital rim while clenching teeth, the alare while eye closure, the inner corner of the eye while smiling, the mideyebrow while whistling, corners of the mouth while eyebrow raising, and hairline superior while disgust are the most stable anatomical landmarks.

Our study identified immobile soft tissue landmarks specific to facial expression.

The unilateral cleft lip deformity is associated with nasal deformities with secondary functional and aesthetic challenges.

Compare the change in nasal symmetry before and incrementally after primary endonasal cleft rhinoplasty concurrent with lip repair.

This is a retrospective chart review of infants undergoing unilateral cleft lip repair. Data collection included demographics, surgical history, and pre- and postoperative alar and nostril photographs analyzed with Image J. Statistical analysis was done using linear and multivariable mixed effect models.

Twenty-two patients with a near even gender distribution (46% female) and primarily left-sided cleft lips underwent unilateral lip repair at a mean age of 3.9 months (median 3.0, range 2–12). Mean pre- and postoperative alar symmetry ratios were 0.099 (standard error [SE] 0.0019) and −0.0012 (SE 0.0179), with zero representing perfect symmetry and negative values indicating overcorrection. These values at 1, 2–4, 5–7, 8–12, 13–24, and 25+ months were 0.026, 0.050, 0.046, 0.052, 0.049, and 0.052 (SE range: 0.0015–0.0096), respectively, demonstrating stability of the alar symmetry 4 months postrepair.

In this study, patients who underwent an overcorrective primary cleft rhinoplasty concurrent with lip repair had an initial regression of symmetry within the first 4 months postoperatively, followed by observed stabilization.

Functional facial reanimation remains challenging and the quest for optimization continues.

To characterize the anatomical conditions of the plantaris muscle for facial reanimation.

Forty-two plantaris muscle specimens were obtained from 23 post-mortem chemically fixed cadavers. The muscles were dissected, evaluated, and measured. Mock facial reanimation was performed on three cadaver heads.

The plantaris muscle was a consistently available muscle. Mean muscle belly length was 10.1 cm (standard deviation [SD] 1.4), and mean width was 1.7 cm (SD 0.4). The mean tendon length of 30.1 cm (SD 2.8) is unique in the human body. The main artery supplying the muscle had a mean length of 1.4 cm (SD 0.4). The mean nerve length was 2.2 cm (SD 0.7). Sixteen variations of vascular supply were identified. Mock facial reanimations demonstrated a good size match, and great versatility of the long tendon for oral fixation.

The plantaris muscle as a free flap for facial reanimation could offer new possibilities in terms of oral fixation and volumetric aesthetic conditions.

The nasal tip projection, rotation, and support are essential components to address during rhinoplasty surgery.

To describe a novel combined septal extension–columellar strut autologous cartilage graft for use in rhinoplasty to control tip projection, shape, and rotation while restoring strength to the nasal tip.

Surgical pearls—description of a novel surgical technique.

An academic practice.

Patients who underwent the operation.