Cranioplasty in facial feminization surgery (FFS) contours the frontal bone to achieve an improved feminine appearance of the forehead. The surgery was first described in 1986 by Whitaker et al1 and then in 1987 by Ousterhout.2 Since then, multiple articles have focused on the technique and the clinical outcomes of the surgery specific to FFS.3,4 In general, the frontal bone is approached via a coronal incision to contour frontal bossing and the orbital rims. Variable techniques to address frontal bossing are reported, including using a burr alone, onlay implants, and osteoplastic flap setback. One critical component of frontal cranioplasty is the ability to safely and effectively reduce bony prominence overlying the frontal sinus/absent frontal sinus. Previously, the amount of bone reduction was based on the external appearance with or without imaging. Interestingly, frontal sinus transillumination for estimation of frontal sinus configuration in osteoplastic flap surgery is described in the context of rhinologic disease but not FFS.5,6 Here, we describe the use of frontal sinus transillumination in cranioplasty during FFS (Video 1).
Alopecia is an increasingly recognized adverse effect of deoxycholic acid treatment. A retrospective review of 66 male patients demonstrated an incidence of alopecia of 15% (8 patients).1 The alopecia was first noticed approximately 4 weeks after injection and in this series, 5 of the 8 patients reported improvement or complete resolution of the alopecia. Review of the literature identified 4 other cases with varying degrees of regrowth observed.2–4 Herein, we report a case of alopecia following deoxycholic acid treatment.
Question Is masseteric-to-facial nerve transfer combined with selective neurectomy associated with improved synkinetic smile?
Findings In this case series, 7 patients underwent masseter-to-facial nerve transfer with selective neurectomy for synkinesis. 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.
Meaning Masseteric-to-facial nerve transfer with selective neurectomy may provide significant smile improvement with a long-term decrease in synkinesis for patients.
Importance Synkinesis is the involuntary movement of 1 area of the face accompanying volitional movement of another; it is commonly encountered in patients affected by facial palsy. Current treatments for synkinesis include biofeedback for muscular retraining and chemodenervation via the injection of botulinum toxin. Chemodenervation is effective in reducing unwanted muscle movement, but it requires a commitment to long-term maintenance injections and may lose effectiveness over time. A permanent solution for synkinesis remains elusive.
Objective To evaluate masseteric-to-facial nerve transfer with selective neurectomy in rehabilitation of the synkinetic smile.
Design, Setting, and Participants In this case series, 7 patients at a tertiary care teaching hospital underwent masseteric-to-facial nerve transfer with selective neurectomy for synkinesis between September 14, 2015, and April 19, 2018. The medical records of these patients were retrospectively reviewed and demographic characteristics, facial palsy causes, other interventions used, and changes in eFACE scores were identified.
Intervention Masseteric-to-facial nerve transfer.
Main Outcomes and Measures Changes in eFACE scores (calculated via numeric scoring of many sections of the face, including flaccidity, normal tone, and hypertonicity; higher scores indicate better function and lower scores indicate poorer function) and House-Brackmann Facial Nerve Grading System scores (range, 1-6; a score of 1 indicates normal facial function on the affected side, and a score of 6 indicates absence of any facial function [complete flaccid palsy] on the affected side).
Results Among the 7 patients in the study (6 women and 1 man; median age, 49 years [range, 41-63 years]), there were no postoperative complications; patients were followed up for a mean of 12.8 months after surgery (range, 11.0-24.5 months). Patients experienced a significant improvement in mean (SD) eFACE scores in multiple domains, including smile (preoperative, 65.00 [8.64]; postoperative, 76.43 [7.79]; P = .01), dynamic function (preoperative, 62.57 [15.37]; and postoperative, 75.71 [8.48]; P = .03), synkinesis (preoperative, 52.70 [4.96]; and postoperative, 82.00 [6.93]; P < .001), midface and smile function (preoperative, 60.71 [13.52]; and postoperative, 78.86 [14.70]; P = .02), and lower face and neck function (preoperative, 51.14 [16.39]; and postoperative, 66.43 [20.82]; P = .046). Preoperative House-Brackmann Facial Nerve Grading System scores ranged from 3 to 4, and postoperative scores ranged from 2 to 3; this change was not significant.
Conclusion and Relevance This study describes the application of masseteric-to-facial nerve transfer with selective neurectomy for smile rehabilitation in patients with synkinesis, with statistically significant improvement in smile symmetry and lower facial synkinesis as measured with the eFACE tool. This technique may allow for long-term improvement of synkinesis and smile. This study is only preliminary, and a larger cohort will permit more accurate assessment of this therapeutic modality.
Level of Evidence 4.
Question How does nasal soft-tissue envelope (STE) thickness vary in our patient population, and can facial plastic surgery clinicians predict nasal STE thickness based on visual examination of the nose?
Findings This study of 190 patients found that the STE is thickest at the sellion, thinnest at the rhinion, thickened over the supratip and nasal tip, and thinned over the columella; thickness followed a near-normal distribution for each measured subsite, with the majority of patients in a medium thickness range. The 4 study experts accurately predicted nasal STE thickness from clinical photographs, with the highest accuracy at the nasal tip.
Meaning Experts can accurately predict nasal STE thickness based on visual examination of the nose, which has implications for surgical planning in rhinoplasty.
Importance Preoperative assessment of nasal soft-tissue envelope (STE) thickness is an important component of rhinoplasty that presently lacks validated tools.
Objective To measure and assess the distribution of nasal STE thickness in a large patient population and to determine if facial plastic surgery clinicians can predict nasal STE thickness based on visual examination of the nose.
Design, Setting, and Participants This retrospective review and prospective assessment of 190 adult patients by 4 expert raters was conducted at an academic tertiary referral center. The patients had high-resolution maxillofacial computed tomography (CT) scans and standardized facial photographs on file and did not have a history of nasal fracture, septal perforation, rhinoplasty, or other surgery or medical conditions altering nasal form. Data were analyzed in March 2019.
Main Outcomes and Measures Measure nasal STE thickness at defined anatomic subsites using high-resolution CT scans. Measure expert-predicted nasal STE thickness based on visual examination of the nose using a scale from 0 (thinnest) to 100 (thickest).
Results Of the 190 patients, 78 were women and the mean (SD) age was 45 (17) years. The nasal STE was thickest at the sellion (mean [SD]) (6.7 [1.7] mm), thinnest at the rhinion (2.1 [0.7] mm), thickened over the supratip (4.8 [1.0] mm) and nasal tip (3.1 [0.6] mm), and thinned over the columella (2.6 [0.4] mm). In the study population, nasal STE thickness followed a nearly normal distribution for each measured subsite, with the majority of patients in a medium thickness range. Comparison of predicted and actual nasal STE thickness showed that experts could accurately predict nasal STE thickness, with the highest accuracy at the nasal tip (r, 0.73; prediction accuracy, 91%). A strong positive correlation was noted among the experts’ STE estimates (r, 0.83-0.89), suggesting a high level of agreement between individual raters.
Conclusions and Relevance There is variable thickness of the nasal STE, which influences the external nasal contour and rhinoplasty outcomes. With visual analysis of the nose, experts can agree on and predict nasal STE thickness, with the highest accuracy at the nasal tip. These data can aid in preoperative planning for rhinoplasty, allowing implementation of preoperative, intraoperative, and postoperative strategies to optimize the nasal STE, which may ultimately improve patient outcomes and satisfaction.
Level of Evidence NA.
Question Do patients who catastrophize pain, defined as patients who anticipate higher pain levels on the 11-point Numeric Rating Scale (score >4), receive equal benefit from a vibratory stimulus during local anesthetic injection as patient who do not catastrophize pain (Numeric Rating Scale score ≤4)?
Findings In this randomized clinical trial of 87 patients who experienced 101 unique events, patients 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.
Meaning Patients who catastrophize pain can be identified in the clinical setting with assessment of anticipation of pain levels (Numeric Rating Scale score >4), and these patients benefit from the addition of vibration during local anesthetic injection.
Importance Vibration has been shown to decrease injection site pain in patients; however, to date, this effect has not been assessed for patients who catastrophize pain (ie, patients who anticipate a higher pain level). The anticipation of a pain score greater than 4 on the 11-point Numeric Rating Scale (NRS) has been associated with an increase in a patient’s perception of procedural pain.
Objective To assess the efficacy of vibration during cutaneous anesthetic injection for dermatologic surgery for patients who catastrophize pain (NRS score >4) and patients who do not (NRS score ≤4).
Design, Setting, and Participants Randomized, parallel-group clinical trial from June 19 to September 4, 2018, at a tertiary dermatologic surgery clinic among 87 adults undergoing cutaneous cancer removal surgery. Patients completed a preprocedural questionnaire detailing their baseline pain, anticipated pain, and drug use. Analysis was performed on an intent-to-treat basis.
Interventions Use of a vibratory anesthetic device (VAD) on the treatment site prior to anesthetic injection in the on (VAD ON) or off (VAD OFF) mode.
Main Outcomes and Measures Pain was reported using the 11-point NRS (where 0 indicates no pain and 11 indicates the worst pain imaginable). A minimum clinically important difference of 22% or more and a substantial clinically important difference of 57% or more were used to assess the efficacy of vibration in patient-reported NRS score during anesthetic injection (iNRS score).
Results A total of 87 patients were included, with 101 unique events reported (among the unique events, 37 were reported in women and 64 were reported in men; mean [SD] age, 66.0 [11.3] years). The mean (confidence level [CL]) iNRS score for patients who catastrophized pain was 2.27 (0.66) compared with 1.44 (0.39) for patients who did not (P = .03). A 38.9% decrease in mean (CL) iNRS score was reported with VAD ON compared with VAD OFF in all participants (1.24 [0.38] vs 2.04 [0.54]). Patients who catastrophized pain reported a 25.5% decrease in mean (CL) iNRS score with VAD ON vs VAD OFF (1.91 [0.99] vs 2.57 [0.98]), and patients who did not reported a 79.4% decrease (1.02 [0.40] vs 1.84 [0.66]). VAD ON was the only statistically significant variable to affect iNRS score (F statistic, 2.741; P = .03).
Conclusions and Relevance This trial demonstrates that those who catastrophize pain prior to a procedure report a higher perceived level of pain. The application of vibration during local anesthetic injection resulted in a minimum clinically important difference in pain level for patients who catastrophize pain and a substantial clinically important difference in pain level for patients who do not.
Level of Evidence 2.
Trial Registration ClinicalTrials.gov identifier: NCT03467685
Question In rhinoplasty surgery is there an association between postoperative pain and perception of surgical success?
Findings In this prospective case series survey study of 104 patients who underwent cosmetic and/or functional rhinoplasty, a statistically significant negative association was found between perception of pain and perception of outcome (breathing improvement) in purely functional rhinoplasty. In contrast, among patients who underwent rhinoplasty with simultaneous cosmetic changes, no association between pain and perception of surgical success was found.
Meaning This prospective study highlights important results that may help guide preoperative rhinoplasty counseling because patients who are interested in purely functional improvement (without cosmetic change) may warrant additional pain-specific counseling to optimize patient satisfaction.
Importance In light of the current opioid crisis, there exists a demonstrated need to balance adequate postrhinoplasty pain control with measured use of narcotics. If pain is inadequately controlled, patients may be unsatisfied with their elective surgical experience.
Objectives To characterize the association between patient-reported pain outcomes, objective opioid use, and perception of surgical success.
Design, Setting, and Participants A case series survey study was conducted from July 2018 to January 2019. Consecutive patients who underwent cosmetic and/or functional rhinoplasty by 2 facial plastic surgeons (D.A.S. and L.N.L.) at an academic medical center were surveyed 1 month after surgery.
Main Outcomes and Measures The number of oxycodone tablets taken, patient-reported pain outcomes, number of narcotic prescription refills, and patient-reported functional and cosmetic outcomes were recorded. Perception of pain, surgical outcome, and oxycodone intake were also evaluated by sex. Demographic information and perception of surgical results were recorded. Statistical analysis was performed using STATA statistical software (version 12.0, STATA Corp). Spearman rank order correlation was used for ordinal, monotonic variables with P < .05 being considered statistically significant.
Results Overall, 104 patients were surveyed; 6 were lost to follow-up. Of the participants included, 50 were women with a mean (SD) age of 38 (16.0) years and 48 were men with a mean (SD) age of 38 (16.7) years. Although patients were prescribed a range of 10 to 40 tablets of oxycodone, patients took a mean (SD) of 5.2 tablets (range, 0-23). There were no significant sex differences in perception of pain, perception of outcome, or narcotic use. Among patients undergoing purely functional rhinoplasty, a statistically significant negative association between perception of pain and perception of functional outcome (breathing improvement) was evident. Patients who experienced less pain than they expected had a greater perception of functional improvement (rs = −0.62, P = .001). In contrast, among patients who underwent rhinoplasty with cosmetic improvement, no association was found between pain and perception of surgical outcome (rs = 0.05, P = .64).
Conclusions and Relevance To our knowledge, this is the first study to prospectively evaluate the association between opioid use, patient-reported pain, and perceived surgical success. These data may help guide preoperative counseling because patients who are interested purely in breathing improvement (without cosmetic change) may warrant additional pain-specific counseling to optimize patient satisfaction.
Level of Evidence 3.
Question What is the composition of lipoaspirates used for lipotransfer in the head and neck, and what is their potential for wound healing in vitro?
Findings In this case series study of lipoaspirate samples obtained from 15 patients, adipose-derived mesenchymal stem cells were found in high purity and were able to multidifferentiate. The adipose-derived stem/stromal cells and their supernatants had proliferation- and immune-modulating properties in vitro.
Meaning The findings suggest that lipoaspirates contain a concentration of adipose-derived stem/stromal cells that can be used for regenerative head and neck surgical procedures.
Importance Adipose-derived mesenchymal stem cells (ASCs) have been used commonly in regenerative medicine and increasingly for head and neck surgical procedures. Lipoaspiration with centrifugation is purported to be a mild method for the extraction of ASCs used for autologous transplants to restore tissue defects or induce wound healing. The content of ASCs, their paracrine potential, and cellular potential in wound healing have not been explored for this method to our knowledge.
Objective To evaluate the characteristics of lipoaspirates used in reconstructive head and neck surgical procedures with respect to wound healing.
Design, Setting, and Participants This case series study included 15 patients who received autologous fat injections in the head and neck during surgical procedures at a tertiary referral center. The study was performed from October 2017 to November 2018, and data were analyzed from October 2017 to February 2019.
Main Outcomes and Measures Excessive material of lipoaspirates from subcutaneous abdominal fatty tissue was examined. Cellular composition was analyzed using immunohistochemistry (IHC) and flow cytometry, and functionality was assessed through adipose, osteous, and chondral differentiation in vitro. Supernatants were tested for paracrine ASC functions in fibroblast wound-healing assays. Enzyme-linked immunosorbent assay measurement of tumor necrosis factor (TNF), vascular endothelial growth factor (VEGF), stromal-derived factor 1α (SDF-1α), and transforming growth factor β3 (TGF-β3) was performed.
Results Among the 15 study patients (8 [53.3%] male; mean [SD] age at the time of surgery, 63.0 [2.8] years), the stromal vascular fraction (mean [SE], 53.3% [4.2%]) represented the largest fraction within the native lipoaspirates. The cultivated cells were positive for CD73 (mean [SE], 99.90% [0.07%]), CD90 (99.40% [0.32%]), and CD105 (88.54% [2.74%]); negative for CD34 (2.70% [0.45%]) and CD45 (1.74% [0.28%]) in flow cytometry; and negative for CD14 (10.56 [2.81] per 300 IHC score) and HLA-DR (6.89 [2.97] per 300 IHC score) in IHC staining; they differentiated into osteoblasts, adipocytes, and chondrocytes. The cultivated cells showed high expression of CD44 (mean [SE], 99.78% [0.08%]) and CD273 (82.56% [5.83%]). The supernatants were negative for TNF (not detectable) and SDF-1α (not detectable) and were positive for VEGF (mean [SE], 526.74 [149.84] pg/mL for explant supernatants; 528.26 [131.79] pg/106 per day for cell culture supernatants) and TGF-β3 (mean [SE], 22.79 [3.49] pg/mL for explant supernatants; 7.97 [3.15] pg/106 per day for cell culture supernatants). Compared with control (25% or 50% mesenchymal stem cell medium), fibroblasts treated with ASC supernatant healed the scratch-induced wound faster (mean [SE]: control, 1.000 [0.160]; explant supernatant, 1.369 [0.070]; and passage 6 supernatant, 1.492 [0.094]).
Conclusions and Relevance The cells fulfilled the international accepted criteria for mesenchymal stem cells. The lipoaspirates contained ASCs that had the potential to multidifferentiate with proliferative and immune-modulating properties. The cytokine profile of the isolated ASCs had wound healing–promoting features. Lipoaspirates may have a regenerative potential and an application in head and neck surgery.
Level of Evidence NA.
A middle-aged woman presented with saddle nose deformity after prior rhinoplasty. The patient related concerns of chronic nasal obstruction, which had worsened in the years since her procedure. She was also concerned about the appearance of her nose. She wished to have the deformity corrected and to have normal breathing restored.
Examination demonstrated severe nasal saddling with collapse of the cartilaginous dorsum and a deficient bony dorsum due to prior overresection. In addition, the upper lateral cartilages demonstrated an inverted-V deformity. Her nasal tip was overrotated, and the lower lateral cartilages (LLCs) were weakened, producing a pinched nasal deformity (Figure 1). Findings of the Cottle maneuver were positive. Marked internal nasal valve collapse was present, causing substantial functional deficit. Much of the septal cartilage had been resected.
There are no better authors to write about the advances in any field than those who are actively shaping it. The editors of this text combine nearly 8 decades of clinical experience to provide the most current and comprehensive approach to evaluating and managing facial trauma. True to its subtitle, this book covers everything from the first encounter with the patient with facial trauma in the emergency department all the way through final reconstruction.
The authors include increasingly relevant topics in the field, such as intraoperative imaging, virtual surgical planning, and vascularized composite allotransplantation, that previously may have been considered tangential but are now integral to modern facial trauma surgery. In our increasingly digital world, the book appropriately includes an easy-to-use electronic book, which includes a collection of high-quality videos that walk the viewer through many of the evaluation methods, clinical examination findings, and surgical techniques that are described in the text.
Question Has there been a decrease in the amount of opioids prescribed to patients following rhinoplasty and/or septoplasty since the Vermont opioid prescribing legislation took effect on July 1, 2017, and if so, are patients experiencing more postoperative pain?
Findings In this case-control study of 80 adults, the mean number of opioid pills prescribed to patients after the Vermont opioid prescribing legislation decreased from 17.5 to 9.7, which was associated with a statistically significant decrease in the mean morphine milligram equivalents that were prescribed (130.9 to 73.2). There was no statistically significant difference in the number of postoperative telephone calls for pain, second prescriptions, or increased complaints of pain at the postoperative visit.
Meaning Since there was no increase in patients’ complaints about postoperative pain or a need for a second prescription after surgery, the decreased amount of opioids prescribed seems sufficient for pain control.
Importance Opioid prescriptions have increased substantially over the last 2 decades, contributing to the opioid epidemic. Physician practices and legislative changes play a key role in decreasing prescription opioid use.
Objective To evaluate changes in opioid prescribing habits for patients undergoing rhinoplasty and/or septoplasty before and after the adoption of new opioid legislation.
Design, Setting, and Participants This single-institution case-control study examined opioid prescribing habits for 80 patients who were undergoing rhinoplasty and septoplasty with or without turbinate reduction at the University of Vermont between March 2016 and May 2018. Patients were excluded if they underwent concomitant endoscopic sinus surgery or were younger than 14 years. Patients were divided by surgery date before or after legislative changes on July 1, 2017.
Exposures Rhinoplasty and septoplasty with or without turbinate reduction.
Main Outcomes and Measures Patient demographics and opioid prescriptions were recorded. Patients were evaluated if they reported pain during follow-up, called the office, or received a second prescription. The Vermont Prescription Monitoring System was queried to determine if opioid prescriptions were filled within 30 days of the procedure. The 2 groups were compared to test the hypothesis that opioid prescriptions had decreased after legislative changes.
Results Of a total of 80 participants, the mean (SD) age in the before (15 women [37.5%]) and after (16 women [40.0%]) groups were 41.4 years and 40.6 years, respectively. There was a statistically significant decrease in the number of pills prescribed to the after group (17.5 to 9.7; P < .001) as well as a decrease in the morphine milligram equivalents that were prescribed (130.9 to 73.2; P < .001). There was no statistical difference in the number of postoperative telephone calls for pain, second prescriptions, or increased complaints of pain at the postoperative visit.
Conclusions and Relevance Recent laws in Vermont regarding opioid prescribing were implemented in 2017 to curb the ongoing opioid epidemic. Our observations of patients undergoing septoplasties and rhinoplasties found a significant reduction in opioid prescriptions. This was not associated with an increase in patient complaints about postoperative pain or the need for a second prescription after surgery. This shows that we may safely be able to decrease the number of narcotic medications that we prescribe.
Level of Evidence 3.