Volumetric Changes of the Mid and Lower Face with Animation and the Standardization of Three-Dimensional Facial Imaging.

BACKGROUND: The objective of this study was to quantify volumetric changes of the mid and lower face caused by facial expression to understand how procedural results measured by three-dimensional imaging can be influenced by lack of standardization. Secondarily, the study identified soft-tissue surface landmarks that can be used to ensure the standardization of three-dimensional images. METHODS: Three-dimensional facial images of subjects performing 22 facial expressions or changes in head position were captured. Variable degrees of animation during smiling and frowning were also evaluated. Volumetric changes of the malar and jowl regions were quantified using a three-dimensional superimposed image subtraction technique. The translation of 14 standard soft-tissue surface landmarks was assessed during various facial animations to determine which three-dimensional landmarks can be used to standardize three-dimensional images. RESULTS: Twenty subjects participated in the study. Sixteen of the 22 facial expression studies had a significant effect on malar and/or jowl volume. Significant volume changes were noted with subtle animation during smiling and frowning. A combination of five landmarks (i.e., glabella, bilateral cheilion, pogonion, and laryngeal prominence) can be used to standardize three-dimensional images for evaluation of mid and lower facial volume changes. CONCLUSIONS: Subtle facial expressions may cause significant volumetric changes in the mid and lower face that can mimic the desired outcomes of surgical and nonsurgical facial rejuvenation procedures. The five-point referencing system allows one to identify subtle changes in head position and facial expression and may aid in the standardization of three-dimensional images.

Reducing margins of wide local excision in head and neck melanoma for function and cosmesis: 5-year local recurrence-free survival.

BACKGROUND: The proximity of head and neck (H&N) melanomas to critical anatomical structures requires that surgeons achieve a balance between adequate margins of excision and the functional and cosmetic needs of patients. This study sought to determine the risk associated with reducing margins of wide local excision (WLE) in H&N melanoma and to identify risk factors of recurrence. METHODS: Seventy-nine cases of primary, invasive H&N melanoma were treated by WLE and followed prospectively for local recurrence. Forty-two WLEs were performed according to current practice guidelines (1cm for lesions<1.0 mm thick, 1-2 cm for lesions 1.01-2.0 mm thick, and 2 cm for lesions >2.0 mm thick). Reduced margins (0.5 cm for lesions ≤1.0 mm thick, 0.5-1.0 cm for lesions 1.01-2.0 mm thick, and 1.0 cm for lesion >2.0 mm thick) were utilized in 37 cases to preserve critical anatomical structures such as the eyelid, nose, mouth and auricle. RESULTS: Overall local recurrence rate was 8.9% over a mean follow-up period of 71.3 months and a minimum of 60 months. Reducing margins of WLE did not increase local recurrence rates as demonstrated by local recurrence-free survival (90.4% vs. 91.9%, P = 0.806). CONCLUSION: Margins of WLE may be safely reduced in melanomas in close proximity to structures of the H&N without affecting local recurrence rates.

Effectiveness of conservative therapy and helmet therapy for positional cranial deformation.

BACKGROUND: The authors investigated the effectiveness of conservative (repositioning therapy with or without physical therapy) and helmet therapy, and identified factors associated with treatment failure. METHODS: A total of 4378 patients evaluated for deformational plagiocephaly and/or deformational brachycephaly were assigned to conservative (repositioning therapy, n = 383; repositioning therapy plus physical therapy, n = 2998) or helmet therapy (n = 997). Patients were followed until complete correction (diagonal difference <5 mm and/or cranial ratio <0.85) or 18 months. Rates of correction were calculated, and independent risk factors for failure were identified by multivariate analysis. RESULTS: Complete correction was achieved in 77.1 percent of conservative treatment patients; 15.8 percent required transition to helmet therapy (n = 534), and 7.1 percent ultimately had incomplete correction. Risk factors for failure included poor compliance (relative risk, 2.40; p = 0.009), advanced age (relative risk, 1.20 to 2.08; p = 0.008), prolonged torticollis (relative risk, 1.12 to 1.74; p = 0.002), developmental delay (relative risk, 1.44; p = 0.042), and severity of the initial cranial ratio (relative risk, 1.41 to 1.64; p = 0.044) and diagonal difference (relative risk, 1.31 to 1.48; p = 0.027). Complete correction was achieved in 94.4 percent of patients treated with helmet therapy as first-line therapy and in 96.1 percent of infants who received helmets after failed conservative therapy (p = 0.375). Risk factors for helmet failure included poor compliance (relative risk, 2.42; p = 0.025) and advanced age (relative risk, 1.13 to 3.08; p = 0.011). CONCLUSIONS: Conservative therapy and helmet therapy are effective for positional cranial deformation. Treatment may be guided by patient-specific risk factors. In most infants, delaying helmet therapy for a trial of conservative treatment does not preclude complete correction. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Burnout phenomenon in U.S. plastic surgeons: risk factors and impact on quality of life.

BACKGROUND: Recent studies by the American College of Surgeons reveal that nearly 40 percent of U.S. surgeons exhibit signs of burnout. The authors endeavored to quantify the incidence of burnout among U.S. plastic surgeons, determine identifiable risk factors, and evaluate its impact on quality of life. METHODS: All U.S. residing members of the American Society of Plastic Surgeons were invited to complete an anonymous survey between September of 2010 and August of 2011. The survey contained a validated measure of burnout (Maslach Burnout Inventory) and evaluated surgeon demographics, professional and personal risk factors, career satisfaction, self-perceived medical errors, professional impairment, and family-home conflicts. RESULTS: Of the 5942 surgeons invited, 1691 actively practicing U.S. plastic surgeons (28.5 percent) completed the survey. The validated rate of burnout was 29.7 percent. Significant risk factors for burnout included subspecialty, number of hours worked and night calls per week, annual income, practice setting, and academic rank. Approximately one-fourth of plastic surgeons had significantly lower quality-of-life scores than the U.S. population norm, and this risk increases in burned out surgeons. In addition to having lower career satisfaction and more work-home conflicts, plastic surgeons with burnout also had a nearly two-fold increased risk of self-reported medical errors and self-reported impairment. CONCLUSIONS: Over one-fourth of plastic surgeons in the United States experience validated burnout, with concomitant attenuated career satisfaction and quality of life. Multivariate analysis identified predisposing factors that may aid in better understanding risk profiles that lead to burnout; therefore, efforts to understand and thereby avoid this burnout phenomenon are warranted.