Investigation of the Longevity of the Endoscopic Midface Lift

Key Points

Question  Is the endoscopic preperiosteal midface lift an effective technique, and do the results last?

Findings  In this retrospective review, there was a significant, objective improvement (decrease) in midfacial height after the endoscopic preperiosteal midface lift that persisted for at least 5 years and up to 15 years. Validated regional and global aesthetic scales demonstrated lasting improvement in midface appearance over time.

Meaning  There is a persistent improvement in midfacial height after the endoscopic preperiosteal midface lift that is achieved without complete disruption of the midfacial ligaments.

Importance  To our knowledge, until now, the efficacy and durability of the transtemporal endoscopic preperiosteal midface lift has not been reported in the literature.

Objective  To determine the efficacy and longevity of the endoscopic preperiosteal midface lift using objective measurements and validated aesthetic scales.

Design, Setting, and Participants  This retrospective review included patients 18 years or older who were treated for aging midface by endoscopic midface lift by the senior author (A.E.W.) between June 2000 and August 2016. Patients were categorized based on length of follow-up into 3 groups: (1) short-term (1-3 years), (2) intermediate-term (3-5 years), and (3) long-term (>5 years).

Interventions or Exposures  Endoscopic preperiosteal midface lift.

Main Outcomes and Measures  (1) Objective measurements of midfacial height (the width of the interzygomatic distance of the midface to the medial canthus [WIZDOM-MC]), (2) validated regional aesthetic scales, and (3) global aesthetic scoring systems measured preoperatively, 3 to 6 months postoperatively, and at the most recent follow-up visit.

Results  Adult patients 18 years or older (median [range] age, 59 [31-79] years) who were treated for aging midface by undergoing an endoscopic midface lift were included in this study. The medical records of 143 patients were reviewed (135 women and 8 men). The endoscopic midface lift resulted in objective improvement in midfacial height. The median WIZDOM-MC decreased by 3.4 mm after the endoscopic midface lift (interquartile range [IQR], 2.3-4.4 mm; P < .001), thus shortening the elongated lower eyelid. At 5 to 15 years after surgery, there was a sustained decrease in median WIZDOM-MC of 2.1 mm (IQR, 0.8-3.1 mm; P < .001). Improvement in the infraorbital hollow was also sustained in patients at more than 5 years’ follow-up (IQR, 0-1.0; P < .001). Improvements in upper cheek fullness and lower cheek fullness were maintained at 3 to 5 years and tended to be at baseline at more than 5 years. Global aesthetic improvement scores remained significantly improved at 5 to 15 years’ follow-up.

Conclusions and Relevance  There is a significant, objective improvement in midfacial height after the endoscopic midface lift that persists for up to 15 years. Validated midfacial scales and global aesthetic scoring systems demonstrate sustained improvement in midface appearance over time. Surgery that minimally disrupts the zygomatic and orbicularis retaining ligaments can provide long-lasting aesthetic improvements.

Level of Evidence  4.

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Outcomes of Extracorporeal Septoplasty and Its Modifications for L-Strut Septal Deviation

Key Points

Question  Is extracorporeal septoplasty (including modified techniques) effective in the treatment of severe L-strut septal deviation?

Findings  In this meta-analysis of 31 studies, 5 reporting change in Nasal Obstruction Symptom Evaluation scores indicate both a clinical and statistically significant improvement of nasal obstruction, but heterogeneity was high.

Meaning  Although extracorporeal septoplasty and its modifications may be effective methods to reduce nasal airway obstruction for deviations of the septal L-strut, standardized reporting of outcomes and sound methodology of study design is needed.

Importance  While extracorporeal septoplasty (ECS) and its modifications have been previously studied, to our knowledge, no systematic review of surgical outcomes and complications of this technique has been performed.

Objective  To evaluate the evidence of surgical outcomes and complications of ECS (including modified techniques) to treat severe L-strut septal deviation defined as deviation within 1.0 cm of the caudal or dorsal septum.

Data Sources  MEDLINE, Embase, CINAHL, CENTRAL, Scopus, and Web of Science databases and reference lists were searched from inception to April 2018 for clinical and observational studies. Search terms included extracorporeal, septoplasty, and septum.

Study Selection  Selection criteria were defined according to the population, intervention, comparison, and outcome framework. Relevant studies were selected by 2 independent reviewers based on abstracts and full texts.

Data Extraction and Synthesis  Data were extracted using standardized lists chosen by the authors according to Cochrane Collaboration guidelines. Data were collected and synthesized with ranges reported, as well as assessment of bias and heterogeneity when applicable. Analysis started in February 2019.

Main Outcomes and Measures  Outcomes assessed included functional nasal airway improvement by objective measurements and subjective measurements (Nasal Obstruction Symptom Evaluation [NOSE] and visual analog scale scores); complications including bleeding, infection, dorsal irregularities, and other functional or cosmetic deficits; and as revision surgery rates.

Results  Of 291 records initially obtained, 31 were considered relevant after review according to PRISMA guidelines. All studies except 1 randomized clinical trial (3.2%) were observational in nature, with 21 retrospective studies (67.7%) and 9 prospective studies (29.0%). Conventional ECS was performed in 16 studies (51.6%), and modified ECS was performed in 15 studies (48.4%). The sample size varied from 10 to 567, and the mean age varied from 22.5 to 46 years. Of 31 studies, 14 (45%) were of good methodology. Meta-analysis was performed on 5 studies reporting change in NOSE scores, with pooled effect of −60.0 (95% CI, −67.8 to −52.2) points, but heterogeneity was high, with I2 = 96%. When comparing complications between modified and conventional ECS, the relative risk for infections was 0.95 (95% CI, 0.34-2.7); for bleeding, 0; for nasal dorsal irregularities, 0.29 (95% CI, 0.16-0.53); for other cosmetic complications, 4.3 (95% CI, 0.87-21.1); for other functional complications, 0.47 (95% CI, 0.20-1.1); and for revision operations, 1.4 (95% CI, 0.83-2.3).

Conclusions and Relevance  Of the 31 studies included in this systematic review, less than half were of good methodology, and a significant level of heterogeneity was found regarding type of outcome measure used and reporting of complications. To improve the level of evidence, better study methodology, standardization of surgical outcomes measures, and reporting of complications are needed.

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A Practical Precaution Relevant to Facial Injections

To the Editor We read with interest the case report by Sebaratnam et al.1 Recently a new type of white adipose tissue (WAT), dermal WAT (dWAT), has been identified and is recognized as playing a role in skin processes such as hair follicle growth, thermoregulation, wound healing, and signal transmission.2 This layer lies in the reticular dermis encasing mature hair follicles.3 In addition this fat compartment is associated with specific adipose stem cell phenotypes (CD24+), distinctly different from subcutaneous WAT, suggesting unique functions of this fat depot.2 Dermal WAT is organized in cone-like structures (often identified in deeper skin graft donor areas) and is particularly associated with scarring when exposed at that depth.4 Importantly, dWAT appears to have a unique relationship with the hair follicle and dynamic reciprocity is seen between these 2 anatomic regions through WNT signaling pathway and its major mediator cadherin-associated protein β 1 (CTNNB1 or β-catenin).5 Research of this signaling has revealed that dWAT is directly stimulated in unison with anagen and regresses through telogen.5 This is a logical relationship when one considers the evolutionary function both regions serve in relation to thermoregulation.

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A Practical Precaution Relevant to Facial Injections—Reply

In Reply We greatly appreciate the insights provided by Widgerow regarding a potential mechanism through which deoxycholic acid treatment could lead to a telogen effluvium.1 The hair follicle unit intimately interacts with dermal white adipose tissue (dWAT). As the hair follicle moves through the anagen, catagen, and telogen phases, there is progressive rearrangement of dermal adipocytes as well as variation in the thickness of the dWAT.2 The expansion of the dWAT follows the burgeoning of anagen hair follicles mediated by multiple signaling pathways including hedgehog, Shh, bone morphogenetic proteins, and WNT. Similarly, catagen causes regression of the dWAT, in part through lipolysis.3 Defects in the generation of immature adipocytes in the dWAT have previously been proposed to block follicle stem cell activation.4 The inflammatory response induced by deoxycholic acid may cause such a defect, with the panniculitis at the injection site leading to a reduction in the availability of immature adipocytes. This, in turn, could potentially deplete the signals propelling hair follicle units into the anagen phase, with a relative preponderance of follicles in catagen and telogen. Arresting this transition through the hair follicle cycle could lead to the telogen effluvium observed clinically. As the panniculitis abates over a period of weeks, adipocytes may be able to regain their physiological functioning, which would account for the reversal of the telogen effluvium that is observed in most patients. Our hypothesis is speculative, but offers a biologically plausible mechanism to account for the clinical changes observed in this emerging therapy.

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The Tripod Concept of the Upper Nasal Third

Key Points

Question  Can we describe a concept related to the well-known tripod theory with extrapolation to the upper nasal third as it pertains to cosmetic rhinoplasty?

Findings  In this study of 10 lay individuals and 10 rhinoplasty-trained individuals who evaluated manipulated photographs of 3 women who had not had surgery, lay individuals were more likely to choose an ideal nasal profile based on surrounding facial architecture, while individuals with rhinoplasty training tended to separate the ideal nose from the surrounding face (statistically significant). Projection was recognized as being altered by both rhinoplasty-trained and lay individuals (although not statistically significant), whereas subjective changes in rotation were significantly more elusive to the lay individual (statistically significant).

Meaning  Simple alteration of the upper nasal third can result in an improved nasal profile without specific alteration of tip architecture.

Importance  The tripod theory of the upper nasal third parallels the concept of the well-known nasal tip tripod. We are evaluating the idea that one can simply alter the upper nasal angles reliably without the complex physics associated with the nasal tip to achieve a pleasing cosmetic result.

Objective  To describe a concept related to the well-known tripod theory with extrapolation to the upper nasal third as it pertains to cosmetic rhinoplasty.

Design, Setting, and Participants  This is a prospective study in which lateral photographs of 3 women who had not undergone surgery (age range, 20-50 years) were selected for digital manipulation of the nasal radix with subsequent alteration of the nasofrontal and nasofacial angles via imaging software. The altered images were analyzed by 20 blinded individuals between July 2009 and June 2017 to assess how changes in the height of the nasal dorsum and radix alone affect nasal appearance and the perception of ideal nasal angles. The study took place at a tertiary center, and the patients chosen for evaluation had nasal architecture that only required subtle changes rather than structure that demonstrated glaringly obvious overprojection or underprojection and rotation or a large dorsal bony hump. Analysis began June 2018.

Main Outcomes and Measures  Overall trend in recognition of objective and subjective alterations in projection and rotation for the rhinoplasty- and non–rhinoplasty-trained evaluators.

Results  Ten medically trained and 10 lay individuals (13 women [65%]; mean [SD] age, 38 [8.6] years) analyzed digitally manipulated photographs of 3 women (age range, 20-50 years) who had not undergone surgery. Lay individuals were more likely to choose an ideal nasal profile based on surrounding facial architecture (28 of 30 [93%]), while individuals with rhinoplasty training tended to separate the ideal nose from the surrounding face (18 of 30 [60%]) (P < .001). Projection was consistently and accurately recognized as being altered by both rhinoplasty-trained and lay individuals (95% CI, −0.18 to 0.38; P = .60 and 95% CI, −0.26 to 0.33; P > .99 for most and least projected), whereas subjective changes in rotation were significantly more elusive to the lay individual (95% CI, −0.04 to 0.52; P = .12 and 95% CI, 0.11 to 0.65; P = .01 for most and least rotated).

Conclusions and Relevance  Predictable and consistent aesthetic results are the primary aim in rhinoplasty. Alterations in the upper nasal tripod are more reliable with extrapolated healing than with the tripod of the nasal tip. Ultimately, simple alteration of the upper nasal third can result in an improved nasal profile without specific alteration of tip architecture.

Level of Evidence  NA.

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Postoperative Antibiotic Use Among Patients Undergoing Functional Facial Plastic and Reconstructive Surgery

Key Points

Question  How frequently are antibiotics prescribed after nasal and oculoplastic procedures, and is antibiotic use associated with reduced postoperative infection rates?

Findings  Of 294 039 adult patients in this population-based cohort study, 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. Increased duration of postoperative antibiotics was not associated with reduced infection rates.

Meaning  Antibiotic use after facial plastic and reconstructive procedures is associated with decreased rates of postoperative infections.

Importance  Best practices for antibiotic use after facial plastic and reconstructive procedures have been the subject of much debate, and there is a need for large-scale data to guide further development of evidence-based guidelines for antibiotic use in this setting.

Objective  To assess patterns of postoperative antibiotic prescriptions and infection rates after nasal and oculoplastic procedures.

Design, Setting, and Participants  A retrospective population-based cohort study was conducted using IBM MarketScan Commercial and Medicare Supplemental research databases of 294 039 patients who underwent facial plastic surgery procedures between January 1, 2007, and December 31, 2015. Patients were excluded if they were younger than 18 years, lacked continuous insurance coverage for 1 year before and after the procedure, or underwent additional procedures on the surgery date of interest. Statistical analysis was performed from January 1, 2007, to December 31, 2016.

Main Outcomes and Measures  Primary outcomes were antibiotic prescription patterns in the immediate postoperative period and rates of postoperative infectious complications. Explanatory variables included patient demographics, procedure type, and relevant comorbidities, which were used in multivariable logistic regression analysis.

Results  Of the 294 039 patients who met inclusion criteria (55.9% women and 44.1% men; mean [SD] age, 54.0 [18.6 years]), 45.2% filled prescriptions for postoperative antibiotics, including 55.3% of patients undergoing nasal procedures and 14.7% of patients undergoing oculoplastic procedures. Superficial surgical site infections occurred in 1.6% of patients, while deep surgical site infections occurred in 0.3% of patients. On multivariable logistic regression, patients receiving postoperative antibiotics were at significantly decreased risk of postoperative infections (nasal procedures: adjusted odds ratio [aOR], 0.144 [95% CI, 0.102-0.203]; oculoplastic procedures: aOR, 0.254 [95% CI, 0.104-0.622]) compared with those who did not receive postoperative antibiotics. Increased duration of postoperative antibiotics was not associated with reduced rates of infectious complications (nasal procedures: aOR, 1.000 [95% CI, 0.978-1.022]; oculoplastic procedures: aOR, 1.024 [95% CI, 0.959-01.092]). Despite being more likely to experience postoperative infections, patients with a history of tobacco use (aOR, 0.806 [95% CI, 0.747-0.870]), immunodeficiency (aOR, 0.774 [95% CI, 0.737-0.813]), or type 1 or 2 diabetes (aOR, 0.810 [95% CI, 0.772-0.850]) were less likely to be prescribed antibiotics than those without these conditions.

Conclusions and Relevance  Postoperative antibiotic prescriptions were associated with reduced rates of infections after facial plastic surgery. This study highlights the role of population-level data in the development of best practices for postoperative antibiotic use and identifies the need for additional examination of antibiotic use patterns and recommendations for populations at increased risk for postoperative wound infection.

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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.

Original Article

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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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