Injectable Fillers for Lower Face Rejuvenation.

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

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

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

New Concepts in Dorsal Hump Reduction.

Dorsal hump modification is a commonly performed procedure in most rhinoplasties. Specifically, hump reductions play a significant role in aesthetic rhinoplasty when the surgeon and patient wish to have a "smaller" and less projected nasal complex. There are several techniques available in order to perform a hump reduction. The purpose of this article is to review some of the surgical options available for dorsal hump reduction and management of the dorsum following this procedure.

Impact of 2 Lateral Nasal Osteotomy Techniques on the Periorbital Subunits.

PURPOSE: The periorbital area undergoes a series of postoperative sequelae after rhinoplasty. PATIENTS AND METHODS: Between January 2015 and January 2016, 50 patients aged between 19 and 46 years who underwent rhinoplasty qualified for the study. Of these patients, 25 were chosen for each group: One group underwent a low-to-low lateral nasal osteotomy, and the other group underwent a low-to-high lateral nasal osteotomy. Six specific periocular findings were designated and recorded to measure differences in the outcomes of the 2 osteotomy techniques. Specific periocular findings included the amount of scleral show as measured through the marginal reflex distance; lateral and medial scleral surface area; and palpebral fissure height, width, and inclination. RESULTS: There were no significant differences in any of the outcome variables at different intervals between the 2 groups (P > .05) except for palpebral fissure inclination after 3 months (P = .02). CONCLUSIONS: According to the results and considering the inherent limitations of the study, it can be concluded that both low-to-low and low-to-high techniques are similar and have no considerable permanent effects on the periorbital region.

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

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

Obese Tracheostomy: A Challenging Path From Surgery to Decannulation.

PURPOSE: Well-defined or standardized tracheostomy decannulation guidelines are not available, and the long-term data on the outcomes in the obese are limited. The purpose of the present study was to determine the outcomes associated with tracheostomy for obese patients from surgery to decannulation. The specific aims were to measure 1) the rate of successful tracheostomy downsize; 2) the rate of successful tracheostomy decannulation; and 3) the associated pre-, intra-, and postoperative subject variables with tracheostomy downsizing and decannulation success. PATIENTS AND METHODS: A retrospective cohort study was implemented to determine the outcomes associated with downsizing and decannulation after obese tracheostomy. The predictive value of the independent variables from the subjects' pre-, intra-, and postoperative periods were evaluated as they related to successful downsizing and decannulation. The included subjects had undergone tracheostomy from April 2016 to December 2018. The primary outcomes were successful downsizing and successful decannulation. A downsize checklist was created with the following yes/no criteria that should reasonably be met before downsizing a tracheostomy in an obese subject. The secondary analysis was the association between the checklist criteria and successful downsize and decannulation. The data were analyzed using the χ2 test, analysis of variance, t test, likelihood ratio, Kaplan-Meier analysis with Cox regression, and logistic binary regression, with statistical significance set at P < .05. RESULTS: The study sample included 82 obese subjects (body mass index [BMI] >30 kg/m2), with a mean age of 55.7 ± 15.0 years; 56% were men. Only 62 of the subjects could be downsized (75.6%) and 39 (47.6%) could be decannulated. The general trend showed that an increased BMI resulted in an increased time to decannulation, long-term tracheostomy dependence, and less successful downsize and decannulation. For patients with a BMI of 30 kg/m2 or more, the downsize success rate was 93.5% and the decannulation success rate was 89.7%. CONCLUSIONS: Obese patients have a greater likelihood of complications and an increased risk of remaining tracheostomy dependent. Consideration of the patient's BMI is crucial when initiating the decannulation progression.

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

BACKGROUND: To introduce a novel technique for advancement genioplasty helping surgeons to avoid soft tissue difficulties especially in short-faced patients with deep mentolabial fold and everted lower lip. CASE PRESENTATION: In a trapezius-shaped, osteotomy was performed in the chin region. The mobilized segment was advanced, and the existing gap was grafted using interpositional allograft materials. Each side had been fixated by three-hole plates and two screws. The outcomes revealed no change in lower anterior teeth vitality. The patients did not report any changes of sensation in lower lip and chin either. The measurements indicated no increase in depth of mentolabial fold in patients undergoing this surgical technique. The postoperative evaluation showed a successful esthetic outcome for the patient and the surgeon concurrently. CONCLUSION: Based on our experience, the authors concluded that the Balcony technique is a simple and reliable procedure for patients with a deep mentolabial fold.

Comparison of Piezosurgery and Conventional Osteotomy Post Rhinoplasty Morbidities: A Double-Blind Randomized Controlled Trial.

PURPOSE: Several approaches have been introduced to decrease soft tissue injury during rhinoplasty. The piezoelectric ultrasonic device can be used to perform more precise bone surgeries and avoid soft tissue perforation. This study compared postoperative pain, edema, and ecchymosis in internal lateral osteotomies performed by the piezosurgery device with the conventional method. MATERIALS AND METHODS: In this double-blind randomized controlled trial, patients who underwent an osteotomy of the lateral nasal walls were randomly assigned to a conventional intranasal lateral osteotomy method using an osteotome (group A) or an internal lateral osteotomy using the piezosurgery device (group B). Postoperative pain was assessed 1, 2, and 3 days after surgery using the visual analog scale, edema was graded based on a 4-grade visual scale, and ecchymosis was assessed by a 3-grade visual scale 2 and 7 days after surgery. Data were analyzed by the Mann-Whitney U test with a significance level of .05. RESULTS: Overall, 20 patients (10 per group) were included in this study. Postoperative pain and ecchymosis were significantly decreased in group B at all time points (P < .05). Edema was significantly decreased in group B after 2 days (P = .043), although the difference was not significant after 7 days (P = .280). CONCLUSIONS: Performing an internal lateral osteotomy using the piezosurgery device is associated with decreased postoperative pain, edema, and ecchymosis compared with a conventional osteotomy.

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

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

Tracheostomy in the Morbidly Obese: Difficulties and Challenges.

PURPOSE: This study evaluated the difficulties and challenges associated with open tracheostomy in the morbidly obese patient (body mass index [BMI] ≥30 kg/m2). PATIENTS AND METHODS: Forty patients met all the inclusion criteria. A retrospective chart review was performed to evaluate indications for tracheostomy, duration of intubation before tracheostomy, history of tracheostomy, duration of operative procedure, duration in the operating room, and all perioperative complications. RESULTS: Complications were classified as intraoperative (5%) and postoperative (17.5%). The average BMI was 46 kg/m2 (range, 31.1 to 75.3 kg/m2). The average duration of intubation before tracheostomy was 11 days. Ten patients (25%) previously underwent tracheostomy. The average operating time was 60 minutes (range, 20 to 95 minutes). The average total time in the operating room was 100 minutes (range, 45 to 146 minutes). CONCLUSION: This study shows that although open tracheostomy in the morbidly obese patient is increasing in demand, the procedure can be predictably performed albeit at a much longer duration and a higher perioperative complication rate compared with the traditional tracheostomy.

Incidence of retrobulbar hemorrhage in the emergency department.

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

Value of microvascular surgery in academic oral and maxillofacial surgery.

PURPOSE: The specialty of oral and maxillofacial surgery has witnessed a large trend of inclusion of maxillofacial oncology and microvascular reconstructive surgery within its scope of practice in recent years. The purpose of this report is to describe the authors' experience with a very active oncologic and microvascular reconstructive surgical service within an academic oral and maxillofacial surgical program at a large university teaching hospital. MATERIALS AND METHODS: The operative log from July 1, 2010, to June 30, 2011, of 325 operations devoted to head and neck oncology and reconstruction was examined. Thirty-nine patients (group A) received a pedicled flap for head and neck reconstruction. Sixty-three patients (group B) received a microvascular free tissue transfer for head and neck reconstruction. Financial records of 20 consecutive patients who underwent simultaneous ablative and reconstructive procedures in each group were then reviewed for total hospital charges, including direct (surgical fees) and indirect (hospital stay, operating room expenses, and ancillary services) charges, and length of stay. RESULTS: Total hospital charges and direct surgical fees, were higher for the microvascular reconstruction group (group B). Length of hospital stay was not statistically different between the two groups. CONCLUSIONS: Microvascular reconstructive surgery performed within an academic oral and maxillofacial surgical program has many financial and intangible benefits within a medical center.

Submental liposuction versus formal cervicoplasty: which one to choose?

PURPOSE: Esthetic rejuvenation of the submental area is a fairly common concern of patients seeking cosmetic surgery. There are several techniques used to obtain esthetic results. A common dilemma is the proper determination as to which procedure, liposuction versus formal cervicoplasty, is more appropriate. This manuscript describes the factors involved in the aging process of the submental area, as well as the inherent advantages of formal cervicoplasty over liposuction. MATERIALS AND METHODS: A comprehensive review of the intrinsic and extrinsic aging process is described, and advantages and disadvantages of liposuction as well as cervicoplasty are detailed. RESULTS: On the basis of the specific factors leading to the fullness of the anterior neck/submental area, proper rejuvenation technique must include platysmaplasty, in addition to liposuction. Isolated liposuction is only beneficial in an isolated group of cosmetic patients. CONCLUSIONS: Formal cervicoplasty, including open liposuction and platysmaplasty, is a superior operation compared with isolated liposuction of the submental area. Whereas liposuction does have a role in cosmetic surgery of the submental area, it is not a comprehensive procedure and does not address all of the anatomic components leading to submental fullness.

Our experience with 171 open tracheostomies.

PURPOSE: Tracheotomy is one of the oldest surgical procedures known. There are multiple indications for tracheostomies. Operative complications have ranged between 5-40%. This manuscript describes our experience with 171 open tracheostomies at a major academic medical center. METHODS: A retrospective review of all patients' records who underwent an open tracheostomy by the Division of OMS between July 1, 2007 to December 31, 2010 was performed. Specific information including indication for procedure, age of patient, type and size of tracheostomy tube, and any post-operative complications were compiled. Based on the data gathered, statistical analysis was performed to establish incidence of complications and its correlation to the specific indication for the tracheostomy. Trends and outcome assessments were then determined. RESULTS: Median age for tracheostomy in the group was 36 (17-89). Majority of tracheostomies were performed in conjunction with head and neck oncologic procedures (51%). Complication rate was 4.1% (7 patients out of 171). CONCLUSION: Open tracheostomy is an extremely useful surgical procedure. If performed appropriately, it is associated with a low complication rate.

Septoplasty: thoughts and considerations.

PURPOSE: Septoplasty has been around for thousands of years. It is considered an extremely valuable procedure to address multiple issues and patient complaints. The purpose of this manuscript is to detail exact surgical procedure, as well as different variations available to the practitioner. Terminology and nomenclature used in this procedure will also be highlighted. METHODS: Various types of septoplasty including access and incision variations were discussed and evaluated in this manuscript. Benefits of each method as well as specific surgical approach were described. RESULTS: Each specific method of performing a septoplasty has its own benefits and advantages. Irrespective of the method, septoplasty is a valuable procedure in nasal surgery. CONCLUSION: Septoplasty is an extremely useful surgical procedure. There are multiple different methods of performing this operation.