Clarification of a Suspension Technique for Unstable Nasal Bones

To the Editor We read the article “Suspension Technique for Unstable Nasal Bones” (and related video) by Hunter and Tasman.1 We congratulate the authors on their work; however, some aspects may be underlined in their article.1

First, the suspension technique proposed by the authors seems very similar to the one reported by Maliniac in 1946 (Figure).2 In Maliniac’s technique, the internal support (pressure pads rather than silicon sheeting) is combined with an external device by means of transcutaneous suspension. As in the procedure described by Hunter and Tasman,1 Maliniac introduced the pads through transcutaneous bridle sutures, which were used to fix them in place. Certainly an outdated device was used, even though the concept seems identical to that reported by Hunter and Tasman.

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Clarification of a Suspension Technique for Unstable Nasal Bones—Reply

In Reply Many thanks for the letter and comments relating to the recently published Surgical Pearl.1 We are very grateful to you for drawing our attention to the work of Maliniac,2 of which the authors were unaware. I remember during my higher surgical training once being told that if I thought I had had an original idea, I should check the German literature. Although that is not completely accurate in this case, the point is well made.

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Measuring Outcomes of Mohs Defect Reconstruction Using Eye-Tracking Technology

Key Points

Question  Does surgical reconstruction of Mohs facial defects normalize facial attention?

Findings  This case series finds that Mohs defects alter causal observer attention, distracting from other important facial features such as the eyes; the degree of distraction is a factor of defect size and location, with larger and more centrally located defects drawing the most attention. Surgical reconstruction is associated with normalized attentional distraction for many patients, restoring a normal pattern of observer attention.

Meaning  Eye tracking allows objective measurement of how Mohs defects and their reconstruction change facial attention; while facial defects are associated with altered normal facial attention, reconstructive surgery has the potential to normalize facial attention in many cases.

Importance  Objectively measuring how Mohs defect reconstruction changes casual observer attention has important implications for patients and facial plastic surgeons.

Objective  To use eye-tracking technology to objectively measure the ability of Mohs facial defect reconstruction to normalize facial attention.

Design, Setting, and Participants  This observational outcomes study was conducted at an academic tertiary referral center from January to June 2016. An eye-tracking system was used to record how 82 casual observers directed attention to photographs of 32 patients with Mohs facial defects of varying sizes and locations before and after reconstruction as well as 16 control faces with no facial defects. Statistical analysis was performed from November 2018 to January 2019.

Main Outcomes and Measures  First, the attentional distraction caused by facial defects was quantified in milliseconds of gaze time using eye tracking. Second, the eye-tracking data were analyzed using mixed-effects linear regression to assess the association of facial defect reconstruction with normalized facial attention.

Results  The 82 casual observers (63 women and 19 men; mean [SD] age, 34 [12] years) viewed control faces in a similar and consistent fashion, with most attention (65%; 95% CI, 62%-69%) directed at the central triangle, which includes the eyes, nose, and mouth. The eyes were the most visually important feature, capturing a mean of 60% (95% CI, 57%-64%) of fixation time within the central triangle and 39% (95% CI, 36%-43%) of total observer attention. The presence of Mohs defects was associated with statistically significant alterations in this pattern of normal facial attention. The larger the defect and the more centrally a defect was located, the more attentional distraction was observed, as measured by increased attention on the defect and decreased attention on the eyes, ranging from 729 (95% CI, 526-931) milliseconds for small peripheral defects to 3693 (95% CI, 3490-3896) milliseconds for large central defects. Reconstructive surgery was associated with improved gaze deviations for all faces and with normalized attention directed to the eyes for all faces except for those with large central defects.

Conclusions and Relevance  Mohs defects are associated with altered facial perception, diverting attention from valuable features such as the eyes. Reconstructive surgery was associated with normalized attentional distraction for many patients with cutaneous Mohs defects. These data are important to patients who want to know how reconstructive surgery could change the way people look at their face. The data also point to the possibility of outcomes prediction based on facial defect size and location before reconstruction. Eye tracking is a valuable research tool for outcomes assessment that lays the foundation for understanding how reconstructive surgery may change perception and normalize facial deformity.

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Spontaneity Assessment in Dually Innervated Gracilis Smile Reanimation Surgery

Key Points

Question  Can a video time-stamping method be used to measure spontaneity of smile after dually innervated gracilis smile reanimation surgery?

Findings  In this cohort study of 25 patients treated with dually innervated gracilis free muscle transfers vs 24 patients treated with masseteric nerve–driven transfers (n = 11) or cross-face nerve graft–driven gracilis (n = 13), a spontaneous smile was present in a median of 33% of smiles, which was more than was present in masseteric nerve–driven transfers (20%) but less than in cross-face nerve graft–driven smile reanimation surgery (75%).

Meaning  Dual innervation may improve synchronicity compared with masseteric nerve transfer but not to the level of cross-face nerve graft–driven gracilis free muscle transfer.

Importance  Surgeons have sought to optimize outcomes of smile reanimation surgery by combining inputs from nerve-to-masseter and cross-face nerve grafts. An objective assessment tool could help surgeons evaluate outcomes to determine the optimal neural sources for smile reanimation.

Objective  To evaluate the use of a novel video time-stamping method and standard outcome measurement tools to assess outcomes of facial reanimation surgery using various innervation strategies.

Design, Setting, and Participants  Cohort study assessing the outcomes of dually innervated gracilis free muscle transfers vs single-source innervated gracilis transfer performed at a tertiary care facial nerve center between 2007 and 2017 using a novel, video time-stamping spontaneity assessment method. The statistical analyses were performed in 2018.

Interventions  Dually innervated gracilis free muscle transfers or single-source innervated gracilis transfer.

Main Outcomes and Measures  Spontaneous smiling was assessed by clinicians and quantified using blinded time-stamped video recordings of smiling elicited while viewing humorous video clips.

Results  This retrospective cohort study included 25 patients (12 men and 13 women; median [range] age, 38.4 [29.3-46.0] years) treated with dually innervated gracilis free functional muscle graft for unilateral facial palsy between 2007 and 2017. Smile spontaneity assessment was performed in 17 patients and was compared with assessment performed in 24 patients treated with single-source innervated gracilis transfer (ie, nerve-to-masseter–driven or cross-face nerve graft–driven gracilis [n = 13]) (demographic data not available for NTM and CFNG cohorts). The use of time-stamped video assessment revealed that spontaneous synchronous oral commissure movement in a median percentage of smiles was 33% in patients with dually innervated gracilis (interquartile range [IQR], 0%-71%), 20% of smiles in patients with nerve-to-masseter–driven gracilis (IQR, 0%-50%), and 75% of smiles in patients with cross-face nerve graft–driven gracilis (IQR, 0%-100%). Clinicians graded smile spontaneity in dually innervated cases as absent in 40% (n = 6 of 15), trace in 33% (n = 5 of 15) and present in 27% (n = 4 of 15). No association was demonstrated between clinician-reported spontaneity and objectively measured synchronicity.

Conclusions and Relevance  Dually innervated gracilis free muscle transfers may improve smile spontaneity compared with masseteric nerve–driven transfers but not to the level of cross-face nerve graft–driven gracilis transfers. Quantifying spontaneity is notoriously difficult, and most authors rely on clinical assessment. Our results suggest that clinicians may rate presence of spontaneity higher than objective measures, highlighting the importance of standardized assessment techniques.

Level of Evidence  4.

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Functional Outcomes, Quantitative Morphometry, and Aesthetic Analysis of Articulated Alar Rim Grafts in Septorhinoplasty

Key Points

Question  Is the articulated alar rim graft (AARG) associated with improved function of the nasal airway and aesthetic outcomes?

Findings  This case series of 90 patients examined the creation, placement, and function of the AARG. A retrospective review showed statistically significant improvement in Nasal Obstruction Symptom Evaluation Survey scores in patients who had AARGs placed; aesthetic analysis by raters on a Likert scale showed cosmetic improvement in patients with a deep alar margin furrow; and morphometric analysis of preoperative and postoperative nasal base shapes showed a trend toward a more equilateral ideal shape.

Meaning  The AARG may improve the functional airway in select patients and the aesthetics of the nose in patients with a significant alar margin furrow or a pinched-appearing nasal tip.

Importance  The design, use, and indications for the articulated alar rim graft (AARG) and the functional and aesthetic improvements that can be achieved have not been fully characterized.

Objective  To analyze the functional and aesthetic outcomes of AARG placement on nasal airway function, nasal base shape change, and appearance.

Design, Setting, and Participants  A case series study of patients who underwent septorhinoplasty with placement of AARG at University of California, Irvine Medical Center, from 2015 to 2018 was carried out. Surgical data recorded included stage of rhinoplasty (primary vs revision), use of spreader grafts, rim grafts (and dimensions), caudal septal extension graft (CSEG), lateral crural tensioning (LCT), and turbinate reductions.

Main Outcomes and Measures  Preoperative and postoperative Nasal Obstruction Symptom Evaluation Survey (NOSE) surveys were analyzed and correlated with AARG geometry, use of CSEG, and the LCT maneuver. Preoperative and postoperative alar base views were evaluated by fitting base shape to a parametric numerical model to categorize each to 1 of 6 shape categories. Blinded reviewers rated alar furrow severity and the alar ridge presence using a Likert scale for both preoperative and postoperative images to subjectively gauge aesthetic outcomes.

Results  Overall, 90 patients with both preoperative and postoperative NOSE scores who underwent septorhinoplasty and placement of an AARG were included. Of the 90 patients, 60 were women (mean age, 38.2 years). Patient NOSE scores (70.4 preoperatively to 25.1 postoperatively) significantly improved from preoperation to postoperation (P < .001), regardless of AARG size, CSEG, or LCT. Alar base shape parametric analysis showed preoperative to postoperative improvements were significant for anterior-to-posterior ratio mass distribution (95% CI, −0.16 to 0.02; P = .05) and vertical projection-to-horizontal base width ratio (95% CI, 0.01-0.32; P = .02) in flat noses and cloverleafing for narrow noses (95% CI, −0.05 to −0.01; P = .001); enhancement approached significance for reduction in lateral scalloping in cloverleaf noses (P = .06). Aesthetic analysis showed that there was a statistically significant improvement for the alar furrow (95% CI, −0.68 to −0.29 for rater 1; −0.54 to −0.27 for rater 2; and −0.59 to −0.27 for rater 3; P < .001) for all raters and for the alar ridge (95% CI, 0.16-0.48; P < .001) for 1 rater.

Conclusions and Relevance  To our knowledge, this is the first study to demonstrate that AARG use is associated with statistically significant improvement in NOSE scores. Placement of AARGs may improve posterior mass ratios in flat noses and lateral cloverleafing in narrow noses as suggested by quantitative shape change parameter analysis. The placement of AARGs was associated with aesthetic and functional enhancement in the cloverleaf deformity, which is associated with a prominent alar furrow, and often external nasal valve collapse. Patient selection is key when placing AARGs.

Level of Evidence  NA.

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November/December 2019 Issue Highlights

In this prospective case series study of 104 patients who underwent cosmetic and/or functional rhinoplasty, Gadkaree and colleagues examined the association between patient-reported pain outcomes, objective opioid use, and perception of surgical success. They found a negative association between perception of pain and perception of outcome in purely functional rhinoplasty, but among patients who underwent rhinoplasty with cosmetic changes, no association between pain and perception of surgical success was found.

Govas et al conducted a randomized clinical trial including 87 patients to assess the efficacy of vibration during cutaneous anesthetic injection for dermatologic surgery for patients who catastrophize pain. They found that those who catastrophized pain reported significantly higher Numeric Rating Scale scores during local anesthetic injection than patients who did not. The addition of vibration resulted in a 25.5% reduction of Numeric Rating Scale scores during local anesthetic injection in patients who catastrophized pain and a 79.4% reduction in patients who did not catastrophize pain.

In this population-based cohort study of 294 039 adult patients, Olds and colleagues examine how frequently antibiotics are prescribed after nasal and oculoplastic procedures, and if antibiotic use was associated with reduced postoperative infection rates. Overall, 45.2% of patients filled antibiotic prescriptions after nasal and oculoplastic procedures; these patients were at significantly decreased risk of postoperative infections compared with those who did not fill antibiotic prescriptions.

Vincent and coinvestigators conducted a case series review of 7 patients who underwent masseter-to-facial nerve transfer with selective neurectomy for synkinesis. They found that these patients experienced a statistically significant improvement in multiple eFACE domains including smile, dynamic function, synkinesis, midface and smile function, and lower face and neck function at 1-year mean follow-up. Their findings suggest that masseteric-to-facial nerve transfer with selective neurectomy may provide significant smile improvement.

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Association of Smoking and Other Factors With the Outcome of Mohs Reconstruction

Key Points

Question  Is smoking associated with an increased risk of acute and long-term postoperative complications after Mohs reconstruction with a flap or graft?

Findings  In this case-control study of 1008 patients undergoing Mohs reconstruction repaired by flap or graft, both current and former smoking were associated with an increased risk of acute complications. However, there was not a similar association between smoking status and long-term complications.

Meaning  This study suggests that smoking is an important lifestyle factor to consider for preoperative planning; these results may allow the surgeon to better quantify the magnitude of risk.

Importance  Smoking, a common lifestyle trait, is considered by many surgeons to be a major risk factor for postoperative complications. However, in the literature on local reconstruction, the association between smoking and the rate of postoperative complications after cutaneous tissue transfer is not well characterized.

Objective  To study the outcomes of flaps and grafts used in Mohs micrographic surgery reconstruction with respect to smoking status and patient-specific and surgery-specific variables.

Design, Setting, and Participants  This retrospective case-control study was conducted at a single tertiary referral center among 1008 patients who underwent Mohs reconstruction repaired by flap or graft between July 1, 2012, and June 30, 2016, and were selected via consecutive sampling. Cases with incomplete records or those in which a single flap or graft was used to repair multiple defects were excluded. Data analysis was performed from September 2017 to January 2018.

Main Outcomes and Measures  Postoperative acute and long-term complications. Acute complications included postsurgical infection, dehiscence, hematoma, uncontrolled bleeding, and tissue necrosis that required medical counseling or intervention. Long-term complications included functional or cosmetic outcomes that prompted the patient to request or the surgeon to offer additional intervention.

Results  Of the 1008 patients included in the study (396 women and 612 men), the median (SD) age was 70 (12) years (range, 21-90 years). A total of 128 patients (12.7%) were current smokers, 385 (38.2%) were former smokers, and 495 (49.1%) were never smokers. On multivariate logistic regression, current smoking (odds ratio [OR], 9.58; 95% CI, 3.63-25.3), former smoking (OR, 3.64; 95% CI, 1.41-9.38), larger defect size (OR, 2.25; 95% CI, 1.58-3.20), and the use of free cartilage graft (OR, 8.19; 95% CI, 2.02-33.1) were associated with increased risks of acute complications. For long-term complications, central face location (OR, 25.4; 95% CI, 6.16-106.5), use of interpolation flap or flap-graft combination (OR, 3.49; 95% CI, 1.81-6.74), larger flap size (OR, 1.42; 95% CI, 1.09-1.87), and basal cell carcinomas or other basaloid tumors (OR, 3.43; 95% CI, 1.03-11.5) were associated with an increased risk, whereas increased age (OR, 0.66 per 10-year interval; 95% CI, 0.54-0.80) was associated with decreased risk.

Conclusions and Relevance  This study suggests that both current and former smokers are at increased risk for acute postsurgical complications but that smoking status is not associated with long-term complications. These findings may allow the surgeon to better quantify the magnitude of risk and provide helpful information for patient counseling.

Level of Evidence  3.

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Social Perception of the Nasal Dorsal Contour in Male Rhinoplasty

Key Points

Question  What are the social perception consequences of male rhinoplasty when specific modifications of the male nasal dorsal contour are carried out?

Findings  In this web-based survey study of 503 participants featuring 12 computer-simulated nasal dorsal contours of a male volunteer, the man in the photograph featuring the nose with the ski slope dorsal shape, nasofrontal angle of 130°, and nasolabial angle of 97° was deemed most attractive; this profile was also among the most frequently selected for other positive characteristics. Subset analyses also revealed statistically significant dorsal contour preferences by observers’ gender and age.

Meaning  This study’s results may potentially better inform rhinoplasty surgeons and their male patients on how changes to the nasal dorsal contour may not only affect the overall perception of a man’s social attributes, but also perception by observers’ sociodemographics.

Importance  The social perception of nasal dorsal modification for male rhinoplasty is poorly understood.

Objective  To investigate the association of modifying the male nasal dorsum with the perception of such social attributes as youth, approachability, healthiness, masculinity/femininity, intelligence, successfulness, and leadership.

Design, Setting, and Participants  Using computer simulation software, 12 images with varied combinations of the nasal dorsal shape, nasofrontal angle (NFA), and nasolabial angle (NLA) were generated from a photograph of a male volunteer’s face in profile. These photographs were then sent to participants at a university clinic who were English-speaking adult internet users who were masked to the purpose of the study, which asked them to value different social attributes regarding the face in the photograph in a 16-question survey. The study was conducted in September 2018 and the data were analyzed thereafter until March 2019.

Exposures  Twelve photographs embedded in a 16-question survey.

Main Outcomes and Measures  Population proportions of responses and χ2 test and graphical analysis based on 95% confidence intervals.

Results  Of 503 respondents (survey provision rate, 100%), 412 (81.9%) were women, 386 (76.7%) were white, 32 (6.4%) were Hispanic or Latinx, 63 (12.5%) were black/African American, 10 (2.0%) were Asian/Pacific Islander, and the median age was 46 years (interquartile range, 32-61 years). The man with ski slope–shaped nose with an NFA of 130° and NLA of 97° was often associated with frequently perceived positive characteristics; specifically, he was judged to be the most attractive (95% CI, 18%-26%; P < .001). Participants also often associated superlative youth (95% CI, 15%-24%; P < .001), approachability (95% CI, 13%-20%; P = .002), and femininity (95% CI, 14%-22%; P < .001) with dorsal contours that did not feature a dorsal hump. The man with a dorsal hump–shaped nose with an NFA of 140° and NLA of 105° was associated by the highest proportion of participants with being the oldest (95% CI, 35%-44%; P < .001), least approachable (95% CI, 27%-35%; P < .001), least attractive (95% CI, 37%-42%; P < .001), and least healthy (95% CI, 26%-34%; P < .001). Subset analyses also revealed statistically significant dorsal contour preferences by observers’ age, gender, and race/ethnicity.

Conclusions and Relevance  A reduced dorsal slope combined with more acute NFAs and NLAs was associated with positively perceived social attributes. The results may be of interest to rhinoplasty surgeons and their male patients when planning changes to the nasal dorsal contour.

Level of Evidence  NA.

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Comparison of Myelin-Associated Glycoprotein and Vincristine for Nerve Inhibition in a Transgenic Thy1-Gfp Rat Model

Key Points

Question  What is the neuroinhibitory potential of myelin-associated glycoprotein in comparison with vincristine, as measured via quantification of fluorescent intensity of the facial nerve after an axotomy injury?

Findings  In this laboratory experiment on 12 rats transgenic for the Thy-1 Gfp gene, myelin-associated glycoprotein significantly reduced fluorescent intensity in comparison with saline at weeks 3, 4, and 5 after an initial injury. Myelin-associated glycoprotein demonstrated similar intensity results as vincristine at weeks 4 and 5.

Meaning  These findings suggest that myelin-associated glycoprotein may have potential as a specific neuroinhibitor for patients with lower facial asymmetry after facial nerve injury.

Importance  Aberrant synkinetic movement after facial nerve injury can lead to prominent facial asymmetry and resultant psychological distress. The current practices of neuroinhibition to promote greater facial symmetry are often temporary in nature and require repeated procedures.

Objective  To determine whether myelin-associated glycoprotein (MAG), a specific neuroinhibitor, can prevent neuroregeneration with efficacy comparable with that of vincristine, a well-established neurotoxin.

Design, Setting, and Participants  Rats transgenic for Thy-1 cell surface antigen–green fluorescent protein (Thy1-Gfp) were randomized into 3 groups. Each rat received bilateral crush axotomy injuries to the buccal and marginal mandibular branches of the facial nerves. The animals received intraneural injection of saline, MAG, or vincristine.

Main Outcomes and Measures  The animals were imaged via fluorescent microscopy at weeks 1, 3, 4, and 5 after surgery. Quantitative fluorescent data were generated as mean intensities of nerve segments proximal and distal to the axotomy site. Electrophysiological analysis, via measurement of compound muscle action potentials, was performed at weeks 0, 3, 4, and 5 after surgery.

Results  A total of 12 rats were included in the study. Administration of MAG significantly reduced fluorescent intensity of the distal nerve in comparison with the control group at week 3 (mean [SD], MAG group: 94 [11] intensity units vs control group: 130 [11] intensity units; P < .001), week 4 (MAG group: 81 [19] intensity units vs control group: 103 [9] intensity units; P = .004), and week 5 (MAG group: 76 [10] intensity units vs control group: 94 [10] intensity units; P < .001). In addition, rats treated with MAG had greater fluorescent intensity than those treated with vincristine at week 3 (mean [SD], MAG group: 94 [11] intensity units vs vincristine group: 76 [6] intensity units; P = .03), although there was no significant difference for weeks 4 and 5. At week 5, both MAG and vincristine demonstrated lower distal nerve to proximal nerve intensity ratios than the control group (control group, 0.94; vs MAG group, 0.82; P = .01; vs vincristine group; 0.77; P < .001). There was no significant difference in amplitude between the experimental groups at week 5 of electrophysiological testing.

Conclusions and Relevance  Lower facial asymmetry and synkinesis are common persistent concerns to patients after facial nerve injury. Using the Thy1-Gfp rat, this study demonstrates effective inhibition of neuroregeneration via intraneural application of MAG in a crush axotomy model, comparable with results with vincristine. By potentially avoiding systemic toxic effects of vincristine, MAG demonstrates potential as an inhibitor of neural regeneration for patients with synkinesis.

Level of Evidence  NA.

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Is There a Selfie Epidemic?

Chen et al1 should be commended for this novel study, which attempts to directly relate the current landscape of social media to the acceptance of cosmetic surgery. Their findings that social media investment had a positive effect on the consideration of surgery corroborates the rising trend noticed among facial plastic surgeons.2 The discussion provided on the negative effect of social media and, more specifically, selfies highlights the need to better understand the underlying motives and characteristics of our patients.

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