Techniques for Creating Inconspicuous Facelift Scars: An Update.

Importance: Patients seeking rhytidectomy desire an improved neckline, jawline, and midface, but rarely at the cost of visible incision lines that divulge a facelift. Objective: To describe an update to our facelift incision planning and specific surgical maneuvers to create inconspicuous scars. Design: Surgical pearls-description of novel surgical technique. Setting: A private practice. Participants: Patients who underwent cervicofacial rhytidectomy.

The Use of Acellular Human Dermis as a Dorsal Camouflaging Graft in Rhinoplasty.

Background: Acellular human dermis (AHD) has many uses in rhinoplasty, but its long-term use as a camouflaging graft has not been adequately described. Objective: To measure the long-term outcomes (infections/contour irregularities) of AHD used as a camouflage graft in rhinoplasty. Methods: A retrospective study of 91 patients who underwent rhinoplasty requiring AHD as a camouflage graft for a 20-year time period (2000-2020) was performed. Complications, revisions, and long-term outcomes were assessed. Surgical technique for AHD use as a dorsal and tip camouflage graft was described in detail and illustrated using intraoperative photography. Results: Of the 91 patients who required AHD in their rhinoplasties, 70 (77%) were performed in revision cases to thicken thinned and scarred skin envelopes. Only 1% had postoperative contour problems that were attributable to AHD, and only 3% had resorption of the AHD. Four percent had postoperative infections, all of which resolved with a single course of oral antibiotics. Patients were followed a mean of 3.8 years. Conclusions: AHD can be a safe, effective, and readily available option for use in thickening the nasal skin envelope in rhinoplasty.

Reducing the Alar Base While Minimizing Visible Sequalae: A Review of Three Alar Base Reduction Techniques over 35 Years.

Importance: Although classically described and routinely performed, alar base reduction remains nuanced without consensus as to the gold standard. Objective: To compare the measurement of alar base reduction among three techniques and the incidence of postoperative dermabrasion in rhinoplasties performed for 35 years. Methods: A retrospective cohort study of patients who underwent rhinoplasty with alar base reduction between 1983 and 2020 by one surgeon. Dermabrasion rates for visible incisions were evaluated based on patient demographics and surgical technique. Results: Of 312 patients, 82% (258) were women. The mean age was 33 years (SD 11.9). Patients self-identified as White (54.5%), Hispanic (22.4%), African American (8.3%), Middle Eastern, (5.2%), Asian (4.8%), Indian (2.2%), Mediterranean (1.3%), or unspecified (1.3%). Alar flare reduction was used alone in 202 (64.7%) patients. Eighty-two (26.3%) patients underwent postoperative dermabrasion to visible incisions. Patients self-reporting Middle Eastern race were offered dermabrasion at a rate 3.7 × higher than other race groups (OR = 3.73, CI 1.23-11.194, p = 0.02). Conclusion and Relevance: Alar flare reduction, sill reduction, and V-to-Y advancement are techniques that can be used to narrow the alar base. Visible incisions are the most common downside but can be addressed with postoperative interventions including dermabrasion.

Concomitant Rhinoplasty and Septal Perforation Repair.

The rhinoplasty surgeon may encounter nasal septal perforations (NSPs) during the examination of the prospective rhinoplasty candidate, many of whom have had prior septal surgery. While small NSPs may be asymptomatic, larger NSPs may cause nasal obstruction, crusting, bleeding, or external nasal deformities. Septal perforation repair and rhinoplasty can be safely and effectively performed simultaneously for the appropriate surgical candidate. In this article, we review the important considerations when determining the surgical candidacy for concomitant rhinoplasty and septal perforation repair.

Approach to Correction of Septal Perforation.

Iatrogenic septal perforation is a complication of nasal surgery. Small or posterior perforations cause few symptoms, and need only conservative treatment. Larger and anterior perforations contribute to nasal airflow disturbances and external nasal deformities. When considering surgical candidacy, one should consider the severity of symptoms, location and size of the perforation, and need for revsional rhinoplasty. We repair perforations using intranasal mucosal advancement flaps augmented by an interposition connective tissue graft. Septal perforation repairs are tedious and technically challenging. We review key points to minimize unintended perforation formation following nasal surgery.

Enhancing Facelift With Simultaneous Submalar Implant Augmentation.

BACKGROUND: The midface is particularly prone to the senescent changes of soft tissue ptosis and volume loss, which in individuals with aging or low adiposity can manifest as submalar hollowing. Facelift alone in those with submalar hollowing inadequately addresses the volume loss and may result in a gaunt appearance postoperatively. Submalar implant augmentation is a powerful tool for permanent midface volume restoration for a more youthful and natural contour, as opposed to soft tissue fillers that diminish over time. When performed together, submalar augmentation and facelift synergistically enhance facial rejuvenation results. OBJECTIVES: Determine the long-term safety and efficacy of submalar implant augmentation as an adjunct to facelift. METHODS: Retrospective review evaluating results and complications in all consecutive patients who had submalar implant augmentation with SMAS-plication facelift in a single surgeon private practice setting from January 1, 1991, to December 31, 2017. RESULTS: Forty-eight patients underwent submalar augmentation with simultaneous facelift with an overall satisfaction rate of 95.7%. Complications included 2.1%transient infraorbital hypoesthesia, 1.1% prolonged swelling, and 1.1% capsular contraction that required a minor adjustment under local anesthesia. No infection, implant migration, or extrusion or facial nerve injury occurred. CONCLUSIONS: Submalar implant augmentation is a safe and effective means of enhancing facelift results through midface volume restoration, subperiosteal release, and improved soft tissue suspension in a more favorable vector. Submalar implant augmentation performed simultaneously with facelift may be an attractive alternative to repeated soft tissue filler or fat injections for patients with submalar hollowing who are interested in facial rejuvenation surgery.

Contemporary Trends in the Surgical Management of Nasal Septal Perforations: A Community Survey.

There currently exists an overabundance of publications advocating different septal perforation repair methods. The objective of this article was to examine the preponderance of techniques and trends in the surgical management of septal perforations in the practices of otolaryngologists, rhinologists, and facial plastic surgeons. The study was designed as a multicenter cross-sectional survey. The participants were members of the American Academy of Facial Plastic and Reconstructive Surgery and the American Rhinologic Society. Septal perforation closure rates and perforation repair approach, technique, and interposition graft material preferences were the main outcomes. A total of 320 respondents completed the survey, of whom 75% performed perforation repairs. The success rates in closing perforations < 1 cm, 1-2 cm, and > 2 cm were 84%, 64%, and 31%, respectively. The respondents had a similar preference for the endoscopic (52%) and external rhinoplasty (49%) approaches, followed by the endonasal approach (43%). Bilateral intranasal mucosal advancement flaps (79%) and unilateral intranasal mucosal rotational or advancement flaps (60%) were the favored repair techniques. Most respondents (84%) incorporated an interposition graft and intranasal splints (89%) for the repair, and the most popular interposition graft material was acellular dermis (63%). The self-reported perforation closure success rates in this survey were lower than those published in the literature, a phenomenon possibly explained by the premise that surgeons with favorable outcomes are more apt to share their results. The preferred surgical approach was evenly distributed between the external rhinoplasty and endoscopic approaches and influenced by a surgeon's training, perforation size and location, and the need for concomitant rhinoplasty. This study is the first to characterize contemporary community trends in the surgical closure of septal perforations and demonstrates that while preference for perforation repair approach among the respondents varied, surgeons favored septal perforation repair using bilateral intranasal mucosal advancement flaps with an interposition graft.

Simultaneous Septal Perforation Repair with Septorhinoplasty: A 31-Year Experience.

Septal perforation repair and septorhinoplasty (SRP) each present unique surgical challenges. However, in many instances, these procedures may be performed together successfully. In this study, the authors aim to determine the safety and effectiveness of combining primary or revision SRP and septal perforation repair via an open approach. A retrospective review was carried out of all consecutive patients who had SRP and septal perforation repair via an open approach between 1986 and 2017 in the senior author's practice. Perforation closure in surgery and at the patient's last follow-up, resolution of presenting symptoms, cosmetic results, and complications were analyzed. Records for 141 patients who had simultaneous septal perforation repair and SRP via an open approach, with a mean follow-up of 3.24 years, were reviewed. The mean anterior-posterior perforation dimension was 1.41 ± 0.89 cm, and the mean vertical perforation dimension was 1.16 ± 0.59 cm. The most common etiologies for septal perforation were previous SRP (35.4%) and septoplasty (24.1%). An overall 93.6%, perforation closure, 91.1% symptom relief, and 91.2% patient satisfaction with cosmetic results were achieved. Septal perforations under 1.5 cm in height were closed in 96.7% of patients as opposed to 71.4% of patients with perforations 1.5 cm or taller. Minor revision rhinoplasties were performed in 7.0% of patients. Postoperative infections were rare and noted in only two (1.4%) patients. In the largest study of its kind to date, the authors have shown that in experienced hands septal perforation repair may be performed simultaneously with primary or revision SRP via an open approach without compromising the perforation repair outcome. The vertical dimension of a septal perforation and presence of mucosa above and below a perforation are important considerations for the difficulty of a perforation closure, as septal mucosa is recruited from these locations in our technique of four-quadrant intranasal bipedicled mucosal advancement flap closure.

Opioid Use by Patients After Rhinoplasty.

IMPORTANCE: Given the increase in opioid addiction and overdose in the United States, reasoned opioid use after outpatient surgery may affect prescription medication abuse. OBJECTIVES: To examine patient use of opioids after rhinoplasty and establish an optimal postrhinoplasty pain management regimen. DESIGN, SETTING, AND PARTICIPANTS: In this case series, opioid use was evaluated in 62 patients who underwent rhinoplasty performed by 3 fellowship-trained facial plastic surgeons, 2 in private practice in Texas and 1 in an academic setting in Michigan, from February 2016 to September 2016. MAIN OUTCOMES AND MEASURES: Opioid use, pain control, and adverse effects were examined and opioid use was compared across patient demographic and surgical procedure characteristics, including rhinoplasty and septoplasty, open vs closed techniques, revision vs primary operations, reduction of turbinates, and use of osteotomies. Opioid use was self-reported as the number of prescribed tablets containing a combination of hydrocodone bitartrate (5 mg) and acetaminophen (325 mg) that were consumed. RESULTS: The mean (SEM) age of the patients was 38.7 (16.4) years and included 50 female patients (81%). Of the initially prescribed 20 to 30 hydrocodone-acetaminophen combination tablets, the 62 patients included in this study used a mean (SEM) of 8.7 (0.9) tablets, only 40% of those prescribed after rhinoplasty. In addition, 46 patients (74%) consumed 15 or fewer tablets, whereas only 3 patients (5%) required refills of pain medication. Sex, age, concurrent septoplasty or turbinate reduction, use of osteotomy, and history of a rhinoplasty were not associated with the number of tablets used. The most common adverse effects included drowsiness in 22 patients (35%), nausea in 7 (11%), light-headedness in 3 (5%), and constipation in 3 (5%). CONCLUSIONS AND RELEVANCE: To mitigate the misuse or diversion of physician-prescribed opioid medications, surgeons must be steadfast in prescribing an appropriate amount of pain medication after surgery. A multifaceted pain control program is proposed to manage postoperative pain and ascertain the balance between controlling pain and avoiding overprescribing narcotics. LEVEL OF EVIDENCE: NA.

Current Trends in Management of Submental Liposis: A Pooled Analysis and Survey.

IMPORTANCE: Since its approval by the US Food and Drug Administration for treatment of moderate to severe submental liposis in April 2015, deoxycholic acid (Kybella) has received significant media attention as a novel aesthetic treatment. Four phase 3 clinical trials have published data demonstrating the safety and efficacy of the drug compared with placebo; however, no study has juxtaposed the product with submental liposuction. OBJECTIVE: To evaluate the efficacy of injectable deoxycholic acid in the treatment of isolated submental liposis. EVIDENCE REVIEW: A pooled analysis of the data from the 2 European and 2 North American phase 3 clinical trials was performed by grouping the study participants by treatment arm to analyze efficacy, adverse effects, and treatment variables. Members of the American Academy of Facial Plastic and Reconstructive Surgery (AAFPRS) were also surveyed regarding their clinical use of deoxycholic acid, fees, and adverse events. FINDINGS: The pooled analysis included 1738 unique patients (348 men [20.0%] and 1390 women [80.0%]; mean [SD] age, 47.7 [1.6] years) and revealed that all studies demonstrated efficacy compared with placebo. However, a significant number of patients experienced pain, edema, and numbness after injection. The clinical trial population was injected with a mean (SD) of 186.0 (106.6) mg of drug per patient during the course of treatment. A total of 102 members responded to the survey, representing 4% of AAFPRS membership. Based on the results of the survey, clinicians reported charging a mean (SD) of $691.04 ($168.68) per 20-mg vial of deoxycholic acid, resulting in a cost of $6426.35 per study participant. The survey revealed a mean (SD) total cost to the patient for submental liposuction to be $2976.56 ($1041.62). CONCLUSIONS AND RELEVANCE: Although the clinical trials demonstrated functional drug efficacy, the large volume of drug used precluded cost-effectiveness. The survey found clinical practice to differ from the protocols used in the trials. Deoxycholic acid may be only fiscally efficacious for patients with mild to moderate submental liposis who require only 20 to 30 mg of drug per treatment for 3 treatment sessions. LEVEL OF EVIDENCE: 1.

Cheek and Chin Implants to Enhance Facelift Results.

The traditional rhytidectomy addresses facial and neck aging as it relates to soft tissue laxity. The modern volumetric facelift provides optimal results by addressing not only skin laxity but also the loss of volume secondary to tissue atrophy and bony resorption. While multiple techniques including fat grafting, dermal fillers, and tissue resuspension are used to correct the tissue loss, alloplastic midface augmentation remains the most permanent method. In our practice we often address midface cheek hollowness or atrophy with the placement of submalar implants at the time of rhytidectomy. In addition to midface volumetric rejuvenation, alloplastic chin implantation can help strengthen and further define a retrusive chin and weak jawline. In this article we discuss technique, indications, and benefits of performing alloplastic augmentation as an adjunct to rhytidectomy.

Dorsal Augmentation with Homologous Rib.

Dorsal augmentation grafts are used to reconstruct and raise the nasal dorsum in patients with dorsal saddling due to trauma, infection, or previous nasal surgery, as well as in patients with a narrow, congenitally low, and/or wide dorsum. Alloplastic implants and various biomaterials are available for grafting, each with advantages and disadvantages. Although autologous septal cartilage is a preferable and often convenient source of cartilage, it is frequently not sufficient for large volume dorsal augmentation, nor is it available in patients who have had septoplasty, infection, previous rhinoplasty with grafting, or significant trauma. Ear cartilage may be used but it is difficult to make homogenous and smooth, and dorsal irregularities can be seen in the long term especially in thin-skinned patients. For these reasons, we frequently use irradiated costal cartilage from tissue banks as our grafting source, thereby eliminating the morbidity of harvesting the patient's own rib. Proper surgical techniques, the use of antibiotics, and proper sculpting and placement of the cartilage limits complications such as warping, resorption, infection, and extrusion. Irradiated homograft costal cartilage grafts have been used successfully in large numbers of patients with long-term follow-up with low complication rates and serve as a welcome alternative to harvesting a patient's rib cartilage.

Columellar Aesthetics in Open Rhinoplasty.

Detailed descriptions of the ideals of columellar aesthetics and nostril shape are conspicuously lacking from the medical literature. Achieving an aesthetic nasal base is critical to an optimal rhinoplasty result. Deviations in the columella and variations in its width and height lead to distortion of nostril shape and frequently compromise function. Six types of columellar disproportion are presented with detailed explanations of how to treat each. By properly recognizing and addressing columellar deformities, the surgeon can optimize both the aesthetic and functional results that are achieved.

A Staging System for Revision Rhinoplasty: A Review.

IMPORTANCE: Rhinoplasty is known to be one of the more technically challenging cosmetic procedures, with a revision rate of 5% to 15%. Reasons for revisions may range from minor deformities that can be treated in the office to major cosmetic and functional defects that require multiple surgical procedures to correct. The literature lacks a uniform scale that systematically evaluates the patient presenting for revision rhinoplasty. The TNM staging system for classifying malignant tumors was developed to aid the physician in planning treatment, providing some information about prognosis, assisting in evaluating the results of treatment, and facilitating the exchange of information. Although the patient presenting for a revision rhinoplasty does not have a potentially lethal disease, a classification system for such patients resembling that used for malignant tumors may provide similar benefits. OBSERVATIONS: As in TNM staging, we describe 3 major components that determine the overall difficulty of surgery for revision rhinoplasty. In our PGS system, "P" represents "problem," consisting of the specific anatomic anomaly with which the patient presents. The second component in our system is "G" for "graft," based on the number of grafts required. The third component of this system is "S," for "number of previous surgical procedures." In addition, we have included a category "E," for "patient expectations," which is added after the stage of the patient's condition has been determined through the PGS classification. CONCLUSIONS AND RELEVANCE: Rather than being measured in terms of survival, as with the TNM system for malignant tumors, the prognosis in revision rhinoplasty is measured in terms of what can be achieved with surgery as opposed to what cannot. This preoperative staging system may help the patient understand the complexity of the repair required and help manage expectations. The PGS system will facilitate exchange of information between surgeons who perform revision rhinoplasty. A standardized evaluation system will allow meaningful comparisons of surgical techniques and evaluations of outcomes of rhinoplasty procedures.