Direct Neck Lift for Men.

Direct neck lift offers an excellent surgical technique for men seeking to rejuvenate the neck and avoid a full rhytidectomy. In this chapter, we provide an overview of direct submentoplasty techniques, as well as clinical pearls to consider in the preoperative, intraoperative, and postoperative periods. Different surgical incisions and resultant scars in the anterior neck are discussed and illustrated with figures. Given the degree of variation of submental fullness with which patients present, it is beneficial to be familiar with several different techniques to address the submental and submandibular areas.

Complications in Rhinoplasty.

Rhinoplasty is widely regarded as one of the more technically challenging surgeries, owing in part to the many possible short- and long-term complications that can arise. Although severe complications are uncommon, unforeseen complications can lead to esthetic and functional compromise, patient dissatisfaction, and need for revision surgery. The rhinoplasty surgeon must be prepared to counsel patients and identify and manage the range of complications that may result from this procedure. This article reviews some of the most frequently encountered complications related to rhinoplasty and their management approaches.

Management of Dorsal Graft and Implant Infections.

Deficiency of the nasal dorsum can result from several etiologies, most commonly congenital, traumatic, or iatrogenic. The use of dorsal grafts or implants for augmentation of the dorsum is a mainstay of both functional and cosmetic rhinoplasty. Due to the cosmetically sensitive nature of the dorsum, and the relatively large amount of graft or implant material that is typically used, infections in this area can be particularly difficulty to manage. Here, we review the current literature on dorsal graft and implant infections, along with options for management.

Nasal obstruction symptom evaluation (NOSE) score outcomes after septorhinoplasty.

OBJECTIVES/HYPOTHESIS: The time interval at which Nasal Obstruction Symptom Evaluation (NOSE) scores stabilize after functional septorhinoplasty has not been determined. Our goal was to characterize longitudinal trends of patient-reported outcomes of nasal obstruction using the NOSE survey instrument following functional septorhinoplasty. STUDY DESIGN: Prospective longitudinal cohort study. METHODS: Adult patients (≥18 years) with nasal obstruction who underwent functional septorhinoplasty by three different surgeons at a single academic, tertiary referral center were identified. NOSE scores were obtained preoperatively and prospectively during three postoperative intervals defined as early (1-3 months), middle (4-6 months), and late (≥10 months.) Longitudinal analysis included repeated measures analysis of variance and adjustments for multiple comparisons. RESULTS: A total of 49 patients met inclusion criteria. For the total cohort, mean NOSE scores significantly improved between preoperative and early postoperative evaluations (71.4, standard deviation [SD] ± 17.0 vs. 24.2, SD ± 19.5; P < .001) but did not significantly change between early and middle (20.6, SD ± 19.1; P = .543) or middle and late (23.1, SD ± 24.9; P > .999) time intervals. CONCLUSIONS: Patients with nasal obstruction who undergo functional septorhinoplasty can be expected to have significant improvement in self -reported nasal obstruction as early as 1 to 3 months postoperatively with a continued, durable, long-standing benefit lasting at least 10 months after surgery. Future studies can consider the 3-month time frame as a proxy for 1 year outcomes to help reduce survey burden. LEVEL OF EVIDENCE: 2c Laryngoscope, 129:841-846, 2019.

Technical Refinements and Outcomes of the Modified Anterior Septal Transplant.

IMPORTANCE: Severe anterior septal deviation and resultant nasal obstruction represent a difficult surgical task to correct. The goal of surgery is to straighten the anterior dorsal and caudal struts, while maintaining nasal tip and midvault support. This study presents a novel extracorporeal septoplasty technique to straighten the crooked anterior septum. OBJECTIVE: To describe the novel anterior septal transplant technique, which consists of complete resection of the caudal septum and reconstruction with extended spreader grafts and a columellar strut, without a separate caudal septal replacement graft. DESIGN, SETTING, AND PARTICIPANTS: This study was a retrospective case series at a tertiary academic referral center. Participants were sequential adult patients undergoing anterior septal transplant from January 1, 2008, to December 31, 2015. MAIN OUTCOMES AND MEASURES: Patient-reported nasal obstruction using Nasal Obstruction Symptom Evaluation (NOSE) scores and objective photographic analysis. Nasal tip deviation, projection, and rotation were measured. Preoperative and postoperative outcomes were compared. Complications are reported. RESULTS: Seventy-one patients (mean age, 46 years [age range, 16-72 years]; 48 [67.6%] female and 23 [32.4%] male) were included in the case series. Postoperative NOSE scores (mean [SD], 24.00 [24.58]) were significantly better than preoperative NOSE scores (mean [SD], 72.25 [14.55]) (P < .001). A separate cohort of 32 patients (mean age, 42 years [age range, 13-72 years]; 23 [71.9%] female and 9 [28.1%] male) had photographs available for analysis. In the frontal view, nasal deviation improved from a mean (SD) of 2.9 (2.0) degrees before surgery to a mean (SD) of 1.4 (1.7) degrees after surgery (P = .004). In the base view, the deviation was corrected from a mean (SD) of 4.9 (2.8) degrees to a mean (SD) of 1.7 (1.2) degrees (P < .001). Tip rotation and projection were unchanged after surgery. Four patients had mild dorsal irregularities after surgery. CONCLUSIONS AND RELEVANCE: Anterior septal transplant by the described technique is a safe and effective treatment option for severe anterior septal deviation. LEVEL OF EVIDENCE: 4.

Hybrid Cartilage-Modifying Otoplasty Technique and Outcomes.

IMPORTANCE: Otoplasty is performed to correct prominauris, one of the most common head and neck congenital deformities. Advances in combination hybrid approaches enable surgeons to achieve greater precision and accuracy. OBJECTIVE: To describe a hybrid cartilage-modifying approach and evaluate the procedure's effectiveness and safety. DESIGN, SETTING, AND PARTICIPANTS: Medical record review including patients undergoing otoplasty by the present technique from January 2006 to December 2016 as performed by the senior author at a tertiary academic referral center. Twenty-three patients underwent 24 total procedures including both bilateral (n = 17) and unilateral (n = 7) procedures. Two procedures were revisions. INTERVENTIONS: Hybrid cartilage-modifying otoplasty procedure. MAIN OUTCOMES AND MEASURES: Preoperative and postoperative measurements were recorded. Paired sample t testing was performed to assess changes between preoperative superior, middle, and inferior helical measurements and corresponding postoperative measurements for all operated ears. Two-tailed, independent sample t testing was performed to compare postoperative differences between right and left ears within separate superior, middle, and inferior measurements in patients undergoing bilateral otoplasty. RESULTS: Twenty-four surgeries were performed on 23 patients. The mean (SD) age at surgery was 16.3 (13.6) years with 13 patients (58%) between the ages of 4 and 10 years. Preoperatively, the mean (SD) superior, middle, and inferior helical rim-to-mastoid distance of the 41 discrete ears measured 16.5 (3.1) mm, 24.1 (3.8) mm, and 19.3 (4.4) mm, respectively. Mean (SD) postoperative measurements were 12.1 (2.4) mm, 14.7 (2.5) mm, and 14.0 (2.8) mm, respectively, for mean (SD) decreases of 4.4 (2.7) mm, 9.4 (3.4) mm, and 5.3 (3.6) mm. For the 17 bilateral procedures, the mean (standard error) postoperative scores between ears measured 0.7 (0.9) mm for the superior, 0.5 (0.9) mm for the middle, and 0.2 (1.0) mm for the inferior. The unaffected ear was measured in 4 of 7 (57%) of patients undergoing unilateral otoplasty, and the mean (SD) postoperative differences between left and right ears were 1.3 (0.8) mm, 3.0 (1.2) mm, and 1.0 (0.7) mm for the superior, middle, and inferior, respectively. Preoperative-to-postoperative differences for all ears (n = 41) were significant (P < .001 for all) for superior, middle, and inferior measurements. There were no significant absolute differences identified for superior (P = .41), middle (P = .58), and inferior (P = .88) measurements regarding left vs right postoperative comparisons for bilateral otoplasties. One patient undergoing bilateral repair required subsequent revision surgery of 1 ear. Two patients developed chronic suture site irritation, and 1 patient developed a hematoma. CONCLUSIONS AND RELEVANCE: The present technique allows multiple opportunities to adjust the auricular parameters. The results indicate a low revision rate and high degree of symmetry. LEVEL OF EVIDENCE: 4.

Modifications to the Butterfly Graft Used to Treat Nasal Obstruction and Assessment of Visibility.

IMPORTANCE: Graft visibility in the supratip region has been the main criticism of the butterfly graft. Because of the graft location, slightly unfavorable supratip fullness can occur, resulting in patient dissatisfaction with the cosmetic result. OBJECTIVE: To describe the clinical outcomes and visibility of the butterfly graft after technique modifications. DESIGN, SETTING, AND PARTICIPANTS: In this retrospective review of adults who had undergone primary or secondary rhinoplasty with butterfly grafting from July 1, 2013, through July 31, 2014, at a tertiary care center at an academic institution, an operative log and photographs were reviewed in an effort to analyze outcomes of butterfly graft use in rhinoplasty. MAIN OUTCOMES AND MEASURES: Nasal obstruction and visibility of the butterfly graft. RESULTS: Thirty-four patients were included in the case series (mean [SD] age, 46 [19.4] years; 23 women and 11 men). The mean (SD) length of the graft was 3.4 (0.5) cm, and the mean (SD) width was 0.9 (0.2) cm. A significant decrease was found in the Nasal Obstruction Symptoms Evaluation score after surgery (mean [SD] preoperative score, 69 [17]; mean [SD] postoperative score, 23 [24]; P < .001). In regard to appearance, 25 patients (74%) rated their appearance as improved or no changes, 6 (18%) as minimally worse, and 1 (3%) as much worse. Fifty-nine observers participated in the masked survey for the study. When the graft was present, observers detected it 59.7% (282 of 472 answers) of the time. When the graft was not present, its presence was suspected 36.5% (237 of 649 answers) of the time. CONCLUSIONS AND RELEVANCE: The modified butterfly graft is a longer and thinner graft than the originally described butterfly graft. It is still an effective tool in the treatment of nasal obstruction with acceptable visibility. In most cases, it is difficult for health care professionals to identify the presence of the graft. LEVEL OF EVIDENCE: 4.

Facelift Controversies.

The primary purpose of the facelift is to restore the shape, volume, and contours of the youthful face. Facelift surgery has evolved over the years into multiple techniques to accomplish the same results. This article discusses the common controversies in facelift surgery and evaluates the best available evidence to guide surgical decision-making. In regard to the salient question of whether there is a "best" technique, the literature suggests that the options are generally equal in efficacy. This highlights the need for high-quality research with standardized preoperative assessment and evaluation of postoperative results to better assess outcomes.

Revision Rhinoplasty.

Revision rhinoplasty is one of the most challenging operations the facial plastic surgeon performs given the complex 3-dimensional anatomy of the nose and the psychological impact it has on patients. The intricate interplay of cartilages, bone, and soft tissue in the nose gives it its aesthetic and function. Facial harmony and attractiveness depends greatly on the nose given its central position in the face. In the following article, the authors review common motivations and anatomic findings for patients seeking revision rhinoplasty based on the senior author's 30-year experience with rhinoplasty and a review of the literature.

Evolution of the rhytidectomy.

Since the advent of facelift surgery, there has been a progressive evolution in technique. Methods of dissection trended towards progressively aggressive surgery with deeper dissection for repositioning of ptotic facial tissues. In recent decades, the pendulum has swung towards more minimally invasive options. Likewise, there has been a shift in focus from repositioning alone to the addition of volumization for facial rejuvenation. The techniques in this article are reviewed in a chronologic fashion with a focus on historical development as well as brief discussion on efficacy in relation to the other existing options. There is currently no gold standard technique with a plethora of options with comparable efficacy. There is controversy over which approach is optimal and future research is needed to better delineate optimal treatment options, which may vary based on the patient.

Management of the Deviated Nasal Dorsum.

The deviated nasal dorsum veers off the ideal straight vertical orientation at midline. Deviations in the dorsum lead to functional and aesthetic consequences that frequently prompt the patient to seek consultation with a rhinoplasty surgeon. Inability to breathe through the nose and self-image perception significantly detracts from the patient's quality of life. Correction of the deviated nasal dorsum represents a challenge for the rhinoplasty surgeon. Anatomic correction of deviations is the goal. Straightening a deviated nasal dorsum will require maneuvers to realign the nose distinct from traditional aesthetic rhinoplasty techniques. The nasal dorsum is formed by the three-dimensional structures of the septum, the bony nasal pyramid, and the cartilaginous nasal midvault. Restoring the position of the septum at midline is the first step in providing adequate support to the nasal architecture. Extracorporeal septoplasty and anterior septal transplant are often necessary techniques to correct the septum and achieve dorsal correction. Subsequently, asymmetric maneuvers to bony dorsum and midvault are performed to restore symmetry. Asymmetric hump reduction and nasal osteotomies are often necessary. Supporting the midvault to avoid nasal collapse often requires asymmetric maneuvers to the upper lateral cartilages and asymmetric spreader grafts. Finally, camouflaging grafts to the nasal dorsum may be necessary. Significant rigidity and memory of the native tissues must be overcome to successfully straighten a nose. The surgeon who can master the deviated dorsum will significantly improve the appearance and quality of life of the patients he or she treats.

Secondary cleft rhinoplasty.

The cleft nasal deformity seen in patients with unilateral and bilateral cleft lip presents a formidable challenge for the facial plastic surgeon. The underlying anatomic deformities combined with scarring from previous procedures make secondary cleft rhinoplasty a difficult procedure for even the most experienced surgeons. Numerous techniques for secondary cleft rhinoplasty have been described in the literature over the past several decades, yet the lack of wide adoption of any given technique highlights the great variability seen with this problem. Regardless, the fundamental goals of achieving nasal symmetry with definition of the nasal base and tip, correction of nasal airway obstruction, and repair of nasal scarring or webbing have driven the progressive evolution of techniques developed to correct various aspects of the cleft nasal deformity. Despite the number of techniques that have been published, very few studies have looked specifically at outcomes in secondary cleft rhinoplasty, and further work is needed in this area. In this article, we will review anatomy of the cleft nasal deformity, repair strategies and timing, surgical techniques for both unilateral and bilateral cleft nasal deformity, and outcomes for secondary cleft rhinoplasty.

Complications of forehead lift.

Complications and prevention of complications in brow lift are presented. A discussion of anatomic features of the brow introduces the article in keeping with the focus that a thorough understanding of the anatomy, patient variations, and potential complications is requisite for surgeons performing forehead rejuvenation. The varying approaches to brow lift are discussed. Complications reviewed are bleeding, nerve injury, scarring, alopecia, brow asymmetry, and brow elevation overcorrection or undercorrection.

Complications in periorbital surgery.

Comprehensive rejuvenation of the periorbital region commonly involves management of the brow, as well as the upper and lower eyelids. Browlifting, upper and lower blepharoplasty, fat transfer, and neuromodulators are frequently utilized with excellent results. However, surgery in this region can be fraught with potential complications ranging from a poor cosmetic outcome to orbital hematoma and vision loss. Although avoidance of complications is preferred, it is incumbent on the surgeon to have a detailed understanding of the pathophysiology, prevention, and management of these complications. The authors examine the more common complications of periorbital surgery.

Technical considerations in endoscopic brow lift.

The authors discuss how, in performing an endoscopic brow lift, meticulous surgical technique, adherence to anatomic dissection planes, and direct visualization used at key points in the procedure enable a safer, more-complete dissection and a better outcome. Anatomy as it relates to the procedure is discussed. Patient evaluation and patient expectations are reviewed with a discussion of the points to present to patients about outcomes of this surgery. Detailed steps of the endoscopic brow-lift technique are presented. Complications are discussed and the authors conclude with a summarization of what the ideal brow-lift procedure would accomplish.