Injectable Fillers for Lower Face Rejuvenation

The lower face is an integral component of a beautiful face. Age-related changes in this region are so significant that they are often easily appreciated by patients. The aging process not only includes volume loss or downward fat repositioning, but also soft tissue laxity, skin changes, and even bony resorption. In the lower face, this results in sagging of the soft tissue leading to the formation of jowling, loss of an attractive well-defined jaw line, and a retruded chin. Both surgical and non-surgical options are available to reverse the aging signs; however, the popularity of non-surgical treatment has dramatically increased in last 2 decades.

Biplanar approach to the transfollicular forehead and brow lift: a technical note

The forehead and brow lift is one of the most commonly performed surgical cosmetic procedures for the rejuvenation of the upper third of the face. Various surgical techniques have been developed to achieve maximum aesthetic results alongside minimum complications; each method has its advantages and disadvantages. Therefore, the ideal surgical approach for each patient should be selected based on careful preoperative evaluation and proper case selection. This article presents a novel modification of the transfollicular forehead and brow lift using a simultaneous biplanar approach to the subcutaneous and sub-periosteal tissue planes. This technique is beneficial to the patient by taking advantage of both the endoscopic and transfollicular methods.

Facial Cosmetic Surgery in Male Patients: Trends and Experience From an Academic Esthetic Oral-Maxillofacial Surgery Practice

Cosmetic procedure, both invasive and noninvasive have been increasing dramatically in our country. Top surgical and nonsurgical procedures have not changed over the past several years. Although women make up the great majority of patients seeking these types of procedures, men are increasingly interested and seeking similar cosmetic procedures. This manuscript evaluates trends and experiences of men seeking cosmetic procedure at a university-based cosmetic oral-maxillofacial surgery practice.

Transcutaneous Alar Rim Graft: An Effective Technique to Manage Alar Deformity

Rhinoplasty is one of the most challenging cosmetic surgical procedures. Although different techniques have been introduced for grafting the osteocartilaginous part of the nose, the alar rim remains vastly unexamined. The form and strength of the alar rim are crucial in nasal tip esthetics and function. External valve collapse may occur owing to trauma, congenital weakness, or malposition of the lower lateral cartilage (LLC). Alar pinching and collapse are possible outcomes if there is any over-resection of the cephalic portion of the LLC. Traditionally, the closed technique creates a tunnel, dissected along an incision made in the soft triangle lining near the most anterior portion of the nostril rim. Alar rim grafts also can run through the marginal incision. The main goal of this study was to introduce a straightforward and effective technique for alar rim grafting, which can help surgeons with more precise placement. A total of 84 patients (61 female and 13 male patients) underwent transcutaneous alar rim grafting. After the alar base resection, a 2-mm stab incision was made in the bulk of the incised alar, using a No. 11 blade. Thereafter, a pocket was created through the alar fibrofatty tissue, which crossed the ala up to near the dome, and a cartilage graft was inserted in the tunnel. Transcutaneous alar rim grafting is a simple and effective approach to provide support for the external nasal valve and increase alar harmony. If the nasal tip analysis shows malpositioned LLC, alar flaring, an over-projected nasal tip, mild retraction, or contour asymmetries, this type of grafting may prove effective in primary or secondary rhinoplasty.

Obese Tracheostomy: A Challenging Path From Surgery to Decannulation

PURPOSE

Well-defined or standardized tracheostomy decannulation guidelines are not available, and the long-term data on the outcomes in the obese are limited. The purpose of the present study was to determine the outcomes associated with tracheostomy for obese patients from surgery to decannulation. The specific aims were to measure 1) the rate of successful tracheostomy downsize; 2) the rate of successful tracheostomy decannulation; and 3) the associated pre-, intra-, and postoperative subject variables with tracheostomy downsizing and decannulation success.

PATIENTS AND METHODS

A retrospective cohort study was implemented to determine the outcomes associated with downsizing and decannulation after obese tracheostomy. The predictive value of the independent variables from the subjects' pre-, intra-, and postoperative periods were evaluated as they related to successful downsizing and decannulation. The included subjects had undergone tracheostomy from April 2016 to December 2018. The primary outcomes were successful downsizing and successful decannulation. A downsize checklist was created with the following yes/no criteria that should reasonably be met before downsizing a tracheostomy in an obese subject. The secondary analysis was the association between the checklist criteria and successful downsize and decannulation. The data were analyzed using the χ² test, analysis of variance, t test, likelihood ratio, Kaplan-Meier analysis with Cox regression, and logistic binary regression, with statistical significance set at P < .05.

RESULTS

The study sample included 82 obese subjects (body mass index [BMI] >30 kg/m²), with a mean age of 55.7 ± 15.0 years; 56% were men. Only 62 of the subjects could be downsized (75.6%) and 39 (47.6%) could be decannulated. The general trend showed that an increased BMI resulted in an increased time to decannulation, long-term tracheostomy dependence, and less successful downsize and decannulation. For patients with a BMI of 30 kg/m² or more, the downsize success rate was 93.5% and the decannulation success rate was 89.7%.

CONCLUSIONS

Obese patients have a greater likelihood of complications and an increased risk of remaining tracheostomy dependent. Consideration of the patient's BMI is crucial when initiating the decannulation progression.

Balcony genioplasty: a novel technique for better esthetic results in patients with deep mentolabial fold

Background

To introduce a novel technique for advancement genioplasty helping surgeons to avoid soft tissue difficulties especially in short-faced patients with deep mentolabial fold and everted lower lip.

Case presentation

In a trapezius-shaped, osteotomy was performed in the chin region. The mobilized segment was advanced, and the existing gap was grafted using interpositional allograft materials. Each side had been fixated by three-hole plates and two screws. The outcomes revealed no change in lower anterior teeth vitality. The patients did not report any changes of sensation in lower lip and chin either. The measurements indicated no increase in depth of mentolabial fold in patients undergoing this surgical technique. The postoperative evaluation showed a successful esthetic outcome for the patient and the surgeon concurrently.

Conclusion

Based on our experience, the authors concluded that the Balcony technique is a simple and reliable procedure for patients with a deep mentolabial fold.

Quantitative analysis of facial soft tissue perfusion during hypotensive anesthesia using laser-assisted indocyanine green fluorescence angiography

The aim of this study was to quantitatively evaluate the efficacy of induced hypotensive anesthesia in decreasing facial soft tissue perfusion during orthognathic surgery using laser-assisted indocyanine green fluorescence angiography. This retrospective study involved the evaluation of 16 patients who underwent orthognathic surgery. Data collection included facial tissue perfusion of the bilateral cheeks and chin at normotension and with pharmacologically induced hypotensive anesthesia. There were statistically significant differences in the facial tissue perfusion at normal and depressed levels of blood pressure (P<0.001). This study used an objective measure to demonstrate the long-standing belief that hypotensive anesthesia is efficacious in reducing tissue perfusion in the surgical field. The data suggest that pharmacologically depressing the level of mean arterial pressure by 18% may result in a 41-52% decrease in facial soft tissue perfusion. This study reports a novel method of quantitative analysis.

Free Bone Grafts for Mandibular Reconstruction in Patients Who Have Not Received Radiotherapy: The 6-cm Rule-Myth or Reality?

Bony reconstruction of the mandible after surgical resection results in improved rehabilitation and aesthetics. Composite tissue transfer has transformed reconstruction, particularly in patients who have received radiotherapy. However, there is morbidity related to free tissue transfer. Free nonvascularized bone grafts have much lower morbidity. Surgeons believe that free bone grafts greater than 6.0 cm are prone to failure. The aims of this study was to assess whether bone grafts greater than 6.0 cm in length have a high risk of failure. A retrospective study was performed on all patients who had free bone grafts greater than 6.0 cm in length at Birmingham, UK, and Florida, the United States. None of the patients received radiotherapy. A total of 14 patients had undergone bone grafts for mandibular defects greater than 6.0 cm in length; 13 of the bone grafts were successful. Of these 13, none were infected and there was radiographic evidence of bony union. Some of the patients have been dentally rehabilitated with implants. Contrary to much of the literature and many surgeons belief, our study has shown that long mandibular defects (>6.0 cm) are not a contraindication to the use of free bone grafts. Key principles to achieve success are discussed in this article.

Augmentation of the infraorbital rim in orthognathic surgery

Mid-face augmentation via a Le Fort I osteotomy is a commonly performed operation. Advancement of the upper jaw and associated structures (nose, lower cheek areas) can certainly improve function as well as facial aesthetics and harmony. Often, in patients with severe mid-face deficiency, hypoplasia of the maxilla extends all the way up to the infraorbital rims. The receding infraorbital rim contributes to the negative vector of the globes. In patients with this level of mid-face hypoplasia, while advancing the maxilla at the Le Fort I level satisfies all of the requirements for orthognathic surgery, the deficient infraorbital rim remains unchanged and can actually accentuate the negative vector of the globes. This article explains our approach in augmentation of the deficient infraorbital rim using alloplastic silicone implants at the time of a Le Fort I osteotomy.

An aesthetic approach in the repair of anterior frontal sinus fractures

The management of upper facial trauma is a common responsibility of surgeons taking care of maxillofacial injuries. Historically, the most commonly used surgical approach has been the bi-temporal (coronal) incision. As is well known, the coronal incision carries some inherent complications such as hair loss, long scars, and increased length of hospital stay. The purpose of this article is to describe an aesthetic approach, similar to an endoscopic brow lift, for the repair of anterior wall fractures of the frontal sinus without the need for long incisions or fixation devices.

Incidence of retrobulbar hemorrhage in the emergency department

Retrobulbar hemorrhage is a rare but potentially devastating complication of midface trauma. Management of this entity requires prompt diagnosis and medical and surgical interventions. The incidence of retrobulbar hemorrhage has been cited to be lower than 1%; however, despite a low rate of occurrence, lack of immediate care can lead to major morbidity for the patient. This report presents a retrospective evaluation of the incidence and management of post-traumatic retrobulbar bleed in the emergency department by an oral and maxillofacial surgery service at a tertiary care trauma center.

Septoplasty: thoughts and considerations

PURPOSE

Septoplasty has been around for thousands of years. It is considered an extremely valuable procedure to address multiple issues and patient complaints. The purpose of this manuscript is to detail exact surgical procedure, as well as different variations available to the practitioner. Terminology and nomenclature used in this procedure will also be highlighted.

METHODS

Various types of septoplasty including access and incision variations were discussed and evaluated in this manuscript. Benefits of each method as well as specific surgical approach were described.

RESULTS

Each specific method of performing a septoplasty has its own benefits and advantages. Irrespective of the method, septoplasty is a valuable procedure in nasal surgery.

CONCLUSION

Septoplasty is an extremely useful surgical procedure. There are multiple different methods of performing this operation.

Considerations in revision rhinoplasty: lessons learned

This article is intended to deal with the difficult subject matter of revision rhinoplasty. Since there is consensus that rhinoplasty is one of the most difficult aesthetic surgery procedures, one would make the inference that a revision rhinoplasty should also be one of the more difficult revision surgeries. The intent of this article is to share with the readers a few pearls and lessons learned dealing with revision rhinoplasty.

Reoperative soft tissue trauma

Trauma remains the leading cause of death in the first 4 decades of life and is surpassed only by cancer and atherosclerotic disease as the overall leading causes of death in the United States. Many of the injuries involve the facial region, including soft tissue trauma. This article highlights the current available modalities used in the management of unsightly scars or those scars whose location and appearance compromise function.

Utility of the pericranial flap in frontal sinus and anterior cranial fossa trauma

Complex injuries to the frontal bar of the upper face can cause significant damage to the anterior cranial fossa. One of the biggest challenges in the repair of such injuries is the prevention of a cerebrospinal fluid leak and separation of the brain from the nasal cavity. Although many autogenous and alloplastic materials can be used for this purpose, the pericranial flap offers a viable alternative. This axially based flap is readily available, does not require an extra harvest site, and can be fashioned appropriately to obliterate the frontal sinus and/or line the anterior cranial base to decrease the possibility of cerebrospinal fluid leaks. The authors' experience with this flap in complex frontal sinus and anterior cranial fossa injuries is described.

Three Important Considerations in Posttraumatic Rhinoplasty

Introduction:

Many factors must be considered when performing a posttraumatic rhinoplasty. Since nasal fractures are the most common fractures in the adult facial skeleton, many patients who suffer midface trauma also suffer from nasal deformity/deviation and nasal airflow impedance. There are three specific regions within the nose which may impede airflow: nasal septum, internal nasal valves, and inferior turbinates. Each component of functional and posttraumatic rhinoplasty has been studied independently. However, a review of posttraumatic rhinoplasty procedures in which multiple regions of the nasal anatomy were addressed, when indicated, has not been elucidated much in the literature.

Materials and Methods:

A retrospective review of the medical charts and operative reports of 42 consecutive patients who underwent a post-traumatic rhinoplasty from July 2002 to December 2006 by the same surgeon was undertaken to determine which specific regions of the nose required secondary repair. Postoperative results were then reviewed to determine objective complications and subjective complaints. The specific techniques employed in the each operative procedure were then analyzed and objective complications and subjective complaints were recorded.

Results:

The most common preoperative patient complaint included difficulty breathing and nasal complex deformity followed by difficulty breathing alone and isolated deviation/deformity. The most common preoperative objective findings included airflow obstruction and nasal deformity, followed by isolated airflow obstruction, and isolated deviation/deformity with no air flow disturbance. All patients underwent a secondary posttraumatic septorhinoplasty. Septoplasty was performed in 78.6% of the patients; spreader grafts were used in 74% of the patients, and inferior turbinate surgery was done in 62% of the patients. Postoperatively, subjective findings revealed no complaints in 38 patients (90.5%). Two patients had complaints of persistent nasal deformity and air flow obstruction; 1 patient had persistent nasal deformity, and another patient had persistent air flow obstruction. Objectively, 5 patients had persistent nasal deformity, 2 patients had persistent air flow obstruction, and two patients had persistent airflow obstruction and nasal deformity.

Conclusion:

When indicated, by appropriately addressing the key regions of the nasal complex, including the septum, internal nasal valves, and inferior turbinates, the majority of patients (90.5%) will have no subjective complaints of difficulty breathing or a nasal complex deformity.

Endoscopic Repair of Isolated Orbital Floor Fracture With Implant Placement

PURPOSE

This study was designed to assess the use of the endoscopic transmaxillary approach to correcting orbital blowout fractures (OBFs) with placement of alloplastic implants.

MATERIALS AND METHODS

This was a prospective study of patients treated in the Division of Oral and Maxillofacial Surgery, University of Florida College of Medicine, Jacksonville over a 6-month period, July to December 2005. Ten patients (7 males, 3 females, age range 19 to 47 years [average age 37.3 years]) met the inclusion criteria for the study and consented to undergo surgical repair. The injury was most commonly secondary to assault (6 cases); the remainder were secondary to motor vehicle collisions. The time from injury to correction ranged from 3 to 36 days (average, 10.9 days). A computed tomography scan with axial and coronal views was obtained in each patient at the time of presentation. All patients who met the inclusion criteria for the study underwent an endoscopic-assisted transmaxillary repair of their OBF with placement of a Medpor implant (Porex Surgical Products, Newnan, GA).

RESULTS

Of the 10 patients, 9 presented with diplopia preoperatively and 4 had associated entrapment on upward gaze. One patient did not have entrapment or diplopia but had a fracture larger than 2 cm(2). All patients underwent successful OBF repair with placement of a Medpore implant through the endoscopic transmaxillary approach, and all experienced resolution of preoperative diplopia and/or entrapment. None of the patients developed enophthalmos at a mean follow-up of 12.7 weeks.

CONCLUSIONS

The endoscopic transmaxillary approach to correcting OBF is an excellent alternative to the transconjunctival approach. This approach carries a very low morbidity and may be used in circumstances in which conventional approaches are not feasible.

Repair of nasal complex fractures and the need for secondary septo-rhinoplasty

PURPOSE

This study was undertaken to evaluate the efficacy of closed reduction of nasal fractures and determine the incidence of the need for post-traumatic septo-rhinoplasty in the management of residual nasal deformities.

PATIENTS AND METHODS

Medical records of all patients with nasal fractures evaluated and treated by the Division of Oral and Maxillofacial Surgery at the University of Florida Health Science Center, Jacksonville, FL between January 2001 and October 2004 were retrospectively evaluated. Out of a total of 344 patients, 50 patients met the inclusion criteria. Forty-four patients (group A) underwent closed reduction of nasal bones and septum along with a septoplasty if needed within 2 weeks of initial injury. Six patients (group B) could not tolerate any surgical intervention because of multisystem injury or comorbidities. All 50 patients were then followed up in the Division of Oral and Maxillofacial Surgery to determine overall efficacy of the initial treatment modality, as well as the need for secondary post-traumatic septo-rhinoplasty. Group A was then further subdivided into groups A1 and A2. Group A1 consisted of patients who underwent a closed reduction of their nasal complex fracture without a residual deformity or the need for a secondary post-traumatic septo-rhinoplasty. Group A2 consisted of patients who underwent a closed reduction of their nasal complex fracture and developed a secondary nasal deformity significant enough to require a septo-rhinoplasty.

RESULTS

The follow-up period ranged from 1 week to 12 months. Nine patients in group A were lost to follow-up. Patients in group A1 (31 patients) were pleased with their results and did not require a secondary surgery. Four patients developed a post-traumatic nasal deformity requiring a post-traumatic septo-rhinoplasty (group A2). All patients in group B required post-traumatic septo-rhinoplasty.

CONCLUSION

Closed reduction of nasal fractures appears to be an effective method of treatment as long as careful attention is paid to the key regions in the nasal complex, including the septum at the initial time of treatment. Ideal results are obtained when surgery is performed within 2 weeks of initial injury. Factors such as timing of surgery, the status of the nasal septum, delay in treatment, and other associated injuries may influence the overall result.

Comparison of 2 preferred methods used for frontal sinus obliteration

PURPOSE

This study was undertaken to compare total operating room cost, total operating time, and potential complications in frontal sinus obliteration using 2 different techniques.

PATIENTS AND METHODS

Hospital records of all patients with frontal sinus fractures treated by the Division of Maxillofacial Surgery at the University of Florida, Jacksonville between October 1998 and December 2003 were reviewed. Twelve patients required frontal sinus obliteration based on the severity and location of injury. All cases were caused by traumatic etiology. Patients were divided into group A or B. Six patients (group A) were treated using autogenous abdominal fat for obliteration purposes, while the other 6 patients (group B) underwent frontal sinus obliteration using a hydroxyapatite cement. Total operating cost, total operating time, and any complications were recorded and analyzed for each group and then statistically evaluated using a t test.

RESULTS

Follow-up ranged from 2 weeks to 6 months. Patients in group A had a lower total operating cost compared with group B. This cost difference was statistically significant. Total operating time was slightly greater in group A versus group B, although this was not statistically significant.

CONCLUSION

Frontal sinus obliteration using autogenous abdominal fat appears to be more cost effective compared with hydroxyapatite cement. The slight difference in total operating time was not statistically significant and this factor alone should not be a deterrent from performing this surgical procedure.