JAMA Facial Plastic Surgery Current Issue

About This Journal

Wed, 01 May 2013 00:00:00 GMT

Editor: Wayne F. Larrabee Jr, MD 600 Broadway, Ste 280 Seattle, WA 98122

Acellular Dermal Grafts for Tear Trough Deformity in Revision Lower Blepharoplasty Acellular Dermal Grafts for Tear Trough Deformity

Kridel RH, Sturm-O’Brien AK. — Wed, 01 May 2013 00:00:00 GMT

Despite recommendations in the literature to perform conservative fat resection in lower blepharoplasty, patients are still seen postoperatively with tear trough deformities that can give a “tired” appearance. In these patients, the loss of orbital fat results in loss of support for the globe and a prominent infraorbital rim. Revision blepharoplasty is complex, since autologous fat is not available for repositioning in the lower eyelids.

Combined Rhinoplasty and Genioplasty Long-term Follow-up Combined Rhinoplasty and Genioplasty

Bertossi D, Albanese M, Turra M, et al. — Wed, 01 May 2013 00:00:00 GMT

Importance

Long-term follow-up reference for experienced clinicians dedicated to profileplasty.

Objective

To evaluate the long-term results and complications of combined rhinoplasty and genioplasty.

Design

Retrospective study including objective and subjective evaluation before and after 3 years of undergoing simultaneous open rhinoplasty and genioplasty among a cohort of 90 patients.

Setting

Academic medical center.

Patients

A total of 90 cases of combined rhinoplasty and genioplasty performed from January 2002 through January 2004 were reviewed to evaluate the stability of the esthetic result.

Main Outcome Measure

Long-term stability of the esthetic outcome of the simultaneous open rhinoplasty and genioplasty.

Results

Soft-tissue Pogonion projection to the true vertical line and mandibular height (mandibular incisor tip to menton) were recorded. As far as reduction genioplasty patients are concerned, 45.6% of the patient population had a 100% stability after 3 years (<0.25 mm resorption measured at the menton). On the other hand, if augmentation genioplasty patients are considered, 52.4% (22 patients with a vertical augmentation range from 4-6 mm; mean, 5.3 mm; and 25 patients with a sagittal augmentation from 6-8 mm; mean, 7.2 mm) had 100% stability after 3 years. The chin was stable with no more than 1 mm of recurrence.

Conclusions and Relevance

The results of the study indicate that the combined approach in correcting the facial profile is an effective procedure to achieve a more harmonic and consistent clinical outcome. The recurrence rate of less than 1 mm on the chin bone measurements is relevant to support this statement. An aesthetically proportionate face is strongly determined by the nasal-cervical relationship when observing the patient's profile. Even after a successful rhinoplasty, the patient's face can lack aesthetic attractiveness. Combined rhinoplasty-genioplasty is usually the best solution, particularly for patients with microgenia. It provides optimum patient satisfaction with a low incidence of recurrence.

Level of Evidence

Complications Associated With Injectable Soft-Tissue Fillers A 5-Year Retrospective Review Complications With Injectable Soft-Tissue Fillers

Daines SM, Williams EF. — Wed, 01 May 2013 00:00:00 GMT

Importance

Even when administered by experienced hands, injectable soft-tissue fillers can cause various unintended reactions, ranging from minor and self-limited responses to severe complications requiring prompt treatment and close follow-up.

Objectives

To review the complications associated with injectable soft-tissue filler treatments administered in the Williams Rejuva Center during a 5-year period and to discuss their management.

Design and Setting

Retrospective medical record review in a private practice setting.

Participants

Patients receiving injectable soft-tissue fillers and having a treatment-related complication.

Interventions

Injectable soft-tissue filler treatments.

Main Outcome Measures

A retrospective medical record review was conducted of patients undergoing treatment with injectable soft-tissue fillers between January 1, 2007, and December 31, 2011, and identified as having a treatment-related complication.

Results

A total of 2089 injectable soft-tissue filler treatments were performed during the study period, including 1047 with hyaluronic acid, 811 with poly-L-lactic acid, and 231 with calcium hydroxylapatite. Fourteen complications were identified. The most common complication was nodule or granuloma formation. Treatment with calcium hydroxylapatite had the highest complication rate.

Conclusions and Relevance

Complications are rare following treatment with injectable soft-tissue fillers. Nevertheless, it is important to be aware of the spectrum of potential adverse sequelae and to be comfortable with their proper management.

Level of Evidence

Effects of Salivary Bypass Tubes on Fistula and Stricture Formation Salivary Bypass Tubes

Punthakee X, Zaghi S, Nabili V, et al. — Wed, 01 May 2013 00:00:00 GMT

Importance

Stricture and fistula formation are two of the most common long-term complications of free flap reconstruction of hypopharyngeal defects.

Objective

To examine the effects of salivary bypass tubes (SBTs) on fistula and stricture formation after free flap reconstruction of hypopharyngeal defects.

Design

Retrospective cohort study.

Setting

Academic tertiary care medical center.

Participants

A total of 103 consecutive patients who underwent hypopharyngeal free flap reconstruction.

Intervention

Use of salivary bypass tube.

Main Outcome Measure

Fistula and stricture formation.

Results

The overall fistula and stricture rates were 14.6% and 27.2%, respectively. Subgroup analysis revealed fistula rates of 7.4% in patients who received SBTs and 22.4% in those who did not (P = .048). However, no statistically significant difference between the two groups was shown with multivariate analysis. The unadjusted stricture rate was 30.6% without vs 24.1% with SBT placement (P = .51).

Conclusions and Relevance

Univariate analysis showed that SBT placement significantly reduced the risk of fistula in this population. Larger multicenter studies are needed to further explore the benefits of SBT use in preventing fistula and stricture formation.

Level of Evidence

El Greco's Portrait of a Lady

Collins EB. — Wed, 01 May 2013 00:00:00 GMT

The artist known as El Greco (Domenicos Theotocopulos, 1547-1614) is usually categorized as a Spanish artist even though he was actually born in Crete. It speaks directly to El Greco's fame that during his own lifetime he could be identified as simply “The Greek.” Although travel during his time was dangerous, time consuming, and often uncomfortable, El Greco managed to succeed as an artist in Crete, Italy, and Spain.

Electromyographic Differences Between Normal Upper and Lower Facial Muscles and the Influence of Onabotulinum Toxin A EMG Differences in Onabotulinum Toxin Treatment

Winn BJ, Sires BS. — Wed, 01 May 2013 00:00:00 GMT

Importance

Empirically determined doses of onabotulinum toxin A for aesthetic treatments are as much as 5 times higher for the upper than for the lower facial muscles.

Objective

To use electromyography (EMG) to determine objectively whether the disparity between doses is due to intrinsic differences between the muscle groups' responses to onabotulinum toxin A or to variable amounts of paralysis required to achieve the desired aesthetic outcomes.

Design

We collected EMG data before and at 2 to 4 weeks and 3 months after 8- and 2-U onabotulinum toxin A injections to the corrugator and depressor anguli oris muscles, respectively.

Setting

A private oculofacial plastic surgery practice.

Participants

Twenty-six subjects recruited from February 1 through April 1, 2009.

Interventions

Electromyography recordings and cosmetic onabotulinum toxin A injections.

Main Outcome Measures

Mean motor unit (MU) durations and maximal amplitudes at baseline and 2 to 4 weeks and 3 months after injection.

Results

Baseline mean MU amplitudes were similar for the corrugator and depressor anguli oris muscles. At 2 to 4 weeks after injection, 78% MU and 64% maximal amplitude reduction for the corrugator muscle were detected, but only 54% MU and 18% maximal amplitude reduction for the depressor anguli oris (P = 2.7 × 10⁻⁸ and P = 1.3 × 10⁻¹⁴, respectively). At 3 months, function was partially recovered for both muscle groups.

Conclusions and Relevance

Onabotulinum toxin A causes a similar dose-dependent reduction in MU and maximal voluntary amplitudes for muscles of the upper and lower face. The dose disparity appears to result from differences in the amount of paralysis required to achieve desirable aesthetic results.

Level of Evidence

Facing Levels of Evidence The JAMA Facial Plastic Surgery Initiative Facing Levels of Evidence

Rhee JS, Larrabee WF. — Wed, 01 May 2013 00:00:00 GMT

This year, JAMA Facial Plastic Surgery will inaugurate the official incorporation of a level of evidence (LOE) designation for all original scientific articles that are amenable to this grading process. As outlined in an earlier commentary, developing a sophisticated understanding of the inherent biases and limitations of evidence-based medicine (EBM) is an important initiative for our specialty as we strive to improve the rigor of our studies and produce noteworthy scientific writings that positively affect the health outcomes of our patients.

In This Issue of JAMA Facial Plastic Surgery

Wed, 01 May 2013 00:00:00 GMT

Integrity in Research Publishing and Professional Accountability Integrity & Accountability in Research Publishing

Holt G. — Wed, 01 May 2013 00:00:00 GMT

Research misconduct and misbehavior undermine the integrity of the scientific process. The downstream effect can be deleterious and widespread, threatening the reputations of the investigators, their institutions, and the publishing journal, and diminishing the public's confidence in the scientific process. More important, erroneous or fabricated data and conclusions can lead to clinical recommendations for the practicing physician that may actually be detrimental to the patient's well-being, particularly if adverse events are underreported. If misconduct occurred during the course of a clinical trial, harm might have been done to the research participants in some way—at the minimum subjecting them to unnecessary therapeutic or invasive procedures. Finally, research misconduct and misbehavior threaten the entire fabric of professional integrity in medicine—for what can be more important to our profession than its individual and collective integrity?

Mandibular Osteotomies and Distraction Osteogenesis Evolution and Current Advances Mandibular Osteotomies & Distraction Osteogenesis

Saman M, Abramowitz JM, Buchbinder D. — Wed, 01 May 2013 00:00:00 GMT

Importance

Although a number of mandibular and occlusal problems may be addressed by orthodontic treatment alone, dentofacial osteotomies are often needed to achieve desired functional or cosmetic results. With the increased popularity of mandibular distraction osteogenesis in recent years, the role of the facial plastic and reconstructive surgeon is crucial in the multidisciplinary care of patients with such problems.

Objective

To review the history and evolution of mandibular osteotomies and distraction osteogenesis and to discuss indications, advantages, disadvantages, and recent advances of these techniques.

Evidence Review

MEDLINE and PubMed searches without date limits, confined to publications in English, German, and French languages were used to search for terms mandibular advancement, mandibular osteotomy, orthognathic surgery, mandibular distraction osteogenesis, prognathism, and retrognathism in the respective languages. References not found on the sources noted were found in print form in the New York Medical College Library when needed. Particular techniques, as originally described or relating to mandibular osteotomies and mandibular distraction osteogenesis, were critically reviewed.

Findings

The goal of surgical mandibular modification procedures is to correct a variety of craniofacial abnormalities for both functional and aesthetic purposes. Multiple techniques of both mandibular osteotomy and distraction osteogenesis have been shown to be effective. Their effectiveness and utility is primarily determined by the specific craniofacial defect and desired outcome, as well as surgeon preference and patient compliance.

Conclusions

While mandibular osteotomy has evolved tremendously, distraction osteogenesis continues to grow as a leading method of surgical correction for a variety of craniofacial defects. Current research shows significant strides in making distraction more effective and efficient to use for both the surgeon and the patient. With the growing popularity of these procedures, the up-to-date knowledge of the facial plastic and reconstructive surgeon in these advances is of utmost importance.

Measured Gain in Projection With the Extended Columellar Strut-Tip Graft in Endonasal Rhinoplasty Projection Gain With Columellar Strut-Tip Graft

Carron MA, Zoumalan RA, Pastorek NJ. — Wed, 01 May 2013 00:00:00 GMT

Importance

The extended columellar strut-tip graft was designed to improve nasal tip projection and tip definition in patients undergoing rhinoplasty.

Objective

To determine whether the extended columellar tip graft leads to a true and measurable increase in nasal tip projection or simply gives the illusion of an increase in projection.

Design

Retrospective case review. The mean time of follow-up photographs was 32 months after surgery (range, 8 months to 10 years).

Participants

The study population comprised 15 patients who underwent primary or revision rhinoplasty during the last 10 years.

Intervention

Primary or revision rhinoplasty.

Main Outcome Measure

The outcome measure was the long-term gain in nasal tip projection. Preoperative and postoperative images were cropped and sized equally for accurate comparison. All measurements were made from the alar-facial crease to the tip defining point.

Results

In all 15 patients, an increase in tip projection was obtained. The mean increase in projection was 19% compared with the preoperative projection. After applying a paired t test for analysis, there was a statistically significant increase in nasal projection (P < .05).

Conclusions and Relevance

The extended columellar strut-tip graft effectively corrected poor nasal tip projection. The effect is maintained years later. The extended columellar strut-tip graft is an excellent choice in endonasal rhinoplasty to improve poor tip projection and definition.

Level of Evidence

Open and Closed, or Endoscopic, Brow-lifts Revisited Open and Closed, or Endoscopic, Brow-lifts

LaFerriere KA, Paik YS. — Wed, 01 May 2013 00:00:00 GMT

A Retrospective Comparison of Open and Endoscopic Brow-liftsPuig CM, LaFerriere KAArch Facial Plastic Surg. 2002;4(4):221-225.

Safety of Alloplastic Materials in Rhinoplasty Safety of Alloplastic Materials in Rhinoplasty

Loyo M, Ishii LE. — Wed, 01 May 2013 00:00:00 GMT

Over the past few decades, the use of grafts in rhinoplasty has increased in response to emphasis on the importance of structure and support. Where older techniques emphasized reductive rhinoplasty, long-term complications of nasal collapse, obstruction, and asymmetric healing and nasal deformities were noted. Appreciation of nasal structure and of long-term wound healing has led to modification of surgical techniques to achieve cosmetically pleasing results that maintain respiratory function and heal predictably. Grafting material is often necessary for the techniques that provide such long-lasting results.

The Effects of Alar Batten Grafts on Nasal Airway Obstruction and Nasal Steroid Use in Patients With Nasal Valve Collapse and Nasal Allergic Symptoms A Prospective Study Alar Batten Grafts & Nasal Airway Obstruction

Sufyan AS, Hrisomalos E, Kokoska MS, et al. — Wed, 01 May 2013 00:00:00 GMT

Importance

Clinical management of nasal airway obstruction (NAO) in patients with and without nasal allergic symptoms and nasal valve collapse (NVC).

Objective

To examine the impact that autologous alar batten grafts have on patients with NAO owing to NVC and their affect on nasal steroid use and allergic symptoms.

Design

A prospective study.

Setting

Indiana University Medical Center, Indianapolis.

Participants

Patients with NAO due to NVC with or without symptoms of nasal allergic symptoms.

Interventions

All of the patients had placement of autologous batten grafts during the study period.

Study Selection

Prospective study of patients with dynamic NVC undergoing alar batten graft treatment.

Data Extraction

Nasal Obstruction Symptom Evaluation survey preoperatively and postoperatively, prospective outpatient questionnaire to determine use of nasal steroids and presence of nasal allergic symptoms preoperatively and postoperatively.

Results

A total of 126 patients underwent surgical intervention for the treatment of NAO due to NVC. All of these patients were using nasal steroid sprays, and 78 patients (62%) also reported nasal allergic symptoms at their initial presentation. At 6-month and 1-year postoperative evaluations, 118 (94%) and 122 (97%), respectively, reported significant improvement of their NAO, regardless if they had presented with or without allergic nasal symptoms. Sixty-two of the 78 patients (79%) who initially presented with NAO owing to NVC and nasal allergic symptoms preoperatively reported significant improvement in their NAO and nasal allergic symptoms postoperatively. Eight of 126 (6%) restarted their use of nasal steroids postoperatively. All 8 of these patients reported nasal allergic symptoms preoperatively. No patients in the nonallergic group continued the use of nasal steroids postoperatively. There was no increase in nasal steroid use at the 12-month follow-up visit.

Conclusions and Relevance

Nasal airway obstruction due to NVC in patients can be surgically treated with autologous alar batten grafts. In addition, the use of alar batten grafts may improve NAO in patients with nasal allergic symptoms and reduces their use of nasal steroids. These results support the idea of potential surgical repair of the nasal valve to treat patients with NAO due to nasal allergic symptoms and NVC.

Level of Evidence

The Nasal Keystone Region An Anatomical Study

Simon PE, Lam K, Sidle D, et al. — Wed, 01 May 2013 00:00:00 GMT

The nasal keystone region is an aptly named confluence of bone and cartilage at the junction of the upper and middle thirds of the nose. Its importance to the stability and structure of the nose is exemplified by the number of complications that may arise from poor surgical handling of this area. The keystone region consists of contributions from the paired nasal bones cephalically, paired upper lateral cartilages (ULCs) caudally, quadrangular cartilage anterior-inferiorly, and perpendicular plate of the ethmoid (PPE) posterior-inferiorly.

The Oblique Split Method A Novel Technique for Carving Costal Cartilage Grafts

Taştan E, Yücel Ö, Aydın E, et al. — Wed, 01 May 2013 00:00:00 GMT

Importance

Autogenous rib cartilage is widely used in the septorhinoplasty cases with major structural grafting requirements. However, there is a risk of warping over time.

Objective

To introduce a novel method for carving costal cartilage grafts to obtain straight grafts of varying thicknesses and to eliminate the risk of warping.

Design

Between 2007 and 2011, a total of 43 consecutive patients underwent septorhinoplasty using autogenous costal cartilage grafts carved by the oblique split method (OSM).

Setting

The Ankara Training and Research Referral Hospital, Ankara, Turkey.

Participants

The study included 43 patients with saddle nose deformity and revisional rhinoplasty with a depleted source. All patients were followed-up for a period ranging from 12 to 37 months (mean, 19.2 months) after surgery.

Interventions

All patients underwent open or closed septorhinoplasty. Autogenous costal cartilage was carved with the OSM to obtain grafts suitable for use as columellar strut, dorsal onlay, L-strut, lateral crural strut, caudal extension, and tip or speader grafts in selected cases.

Main Outcome Measures

Patients were evaluated by inspection, palpation, and photographic documentation before surgery. Inspection, palpation, and photographic documentation were carried out every 6 months and 12 months after surgery and once a year thereafter.

Results

Patient satisfaction in terms of form and function was achieved in 41 patients (95%). Two patients required reoperation for further tip projection (n=1) and alar batten graft displacement (n=1). No complication was observed as a result of graft warping, resorption, or fracture.

Conclusions and Relevance

The OSM provides straight costal cartilage grafts of varying thicknesses without the risk of warping. Because they strictly preserve their straight form, the grafts may safely be modified into rectangular shape or carved asymmetrically and/or have their edges beveled. Current data from this study suggest that the OSM offers a flexible and reliable reconstructive option for the rhinoplasty surgeon.

Level of Evidence

Transconjunctival Lower Blepharoplasty With Fat Repositioning A Retrospective Comparison of Transposing Fat to the Subperiosteal vs Supraperiosteal Planes Lower Blepharoplasty With Fat Repositioning

Yoo DB, Peng G, Massry GG. — Wed, 01 May 2013 00:00:00 GMT

Importance

Differences in technique and outcome between fat transposed to the subperiosteal and supraperiosteal planes during transconjunctival lower blepharoplasty remain to be elucidated.

Objective

To provide a single-surgeon comparison of transconjunctival lower blepharoplasty with fat repositioning (TCBFR) to the subperiosteal vs the supraperiosteal plane.

Design

A retrospective medical record review of patients who underwent TCBFR to the subperiosteal or the supraperiosteal plane by a single surgeon from January 1, 2009, through December 31, 2011. Differences in surgical technique, postoperative course, complications, patient satisfaction, and aesthetic results (by blinded assessment of preoperative and postoperative photographs) are reviewed using a 4-point scale.

Setting

An ophthalmic plastic surgical practice.

Participants

The first 20 consecutive patients who underwent TCBFR to the supraperiosteal plane and the previous 20 who underwent TCBFR to the subperiosteal plane.

Intervention

Transconjunctival lower blepharoplasty with fat repositioning.

Main Outcome Measures

Intraoperative findings, postoperative course, complications, and aesthetic results.

Results

We included 40 patients (27 women and 13 men) with a mean age of 57 years and mean follow-up of 10 months. Subperiosteal TCBFR was more meticulous and less disruptive of normal anatomy and resulted in less bleeding. Supraperiosteal surgery was faster yet more traumatic, leading to more bruising, swelling, and with more clinically evident temporary postoperative contour irregularities. All patients expressed a high level of satisfaction (100%). Blinded assessment of results demonstrated no statistically significant difference (P = .45) between the 2 surgical approaches with regard to the final aesthetic result.

Conclusions and Relevance

Transconjunctival lower blepharoplasty with fat repositioning can be performed safely and effectively, whether fat is translocated to the subperiosteal or the supraperiosteal plane. Aesthetic results are comparable between the 2 approaches.

Level of Evidence

Use of Recombinant Human Bone Morphogenetic Protein 2 for Mandible Reconstruction Use of rhBMP-2 for Mandible Reconstruction

Desai SC, Sclaroff A, Nussenbaum B. — Wed, 01 May 2013 00:00:00 GMT

Background

Microvascular osseous free tissue transfer is the standard of care for reconstructing significant mandibulectomy defects; however, this procedure can carry a significant rate of morbidity.

Objectives

To describe the use of recombinant human bone morphogenetic protein 2 (rhBMP-2) as an option for segmental or near-complete rim mandibulectomy defects in a select group of patients, precluding the need for free tissue transfer.

Methods

A retrospective review was performed of 6 patients who had undergone repair of a mandible defect using rhBMP-2 with beta-tricalcium phosphate matrix or a cadaveric bone graft at a single tertiary care institution. The defects resulted from resection of benign neoplasms or from previous trauma. Reconstruction success was defined as no hardware problems, healing without infection, no need for further surgical procedures, and imaging evidence of healing and union without resorption. The median follow-up period was 37.5 months (range, 12-51 months).

Results

Five of 6 patients underwent successful restoration of the mandibulectomy defect. One patient with a compromised immune system developed a significant postoperative wound infection requiring further reconstructive surgery.

Conclusion

The use of an rhBMP-2–based reconstructive approach is a feasible option for segmental or near-complete rim mandibulectomy defects in a select group of patients.

Level of Evidence