Objective To explore the complications and associated risks factors after orbital exenteration and lateral skull base defect repair.

Methods Patients who had undergone a reconstruction of their orbital cavity and lateral skull base defects were selected from our departmental database. The outcome of interest was postoperative complications. The risks factors were defined as age, sex, history of radiation therapy, and intracranial involvement (with and without dural involvement). Information was collected on the type of reconstruction used after the orbital cavity repair. The ² test and logistic regression were used to analyze associations between postoperative complications and the various risks factors.

Results Of the 32 identified patients, 19 had intracranial involvement (9 with dural involvement). Twenty-four patients underwent reconstruction with free tissue transfer in the same setting. Reconstruction with free tissue transfer was significantly associated with fewer major postoperative complications (P < .053). There was a trend toward more complications with a history of radiation therapy or intracranial involvement.

Conclusions Reconstruction of the orbital cavity and lateral skull base can be challenging, especially if there is a history of radiation therapy and intracranial involvement. Free tissue transfer is a safe and effective method for reconstruction of such defects.

Objective It is well known that gradual loss of elastic fibers and skin relaxation cause the aging process, but whether changes in the orbicularis oculi muscle may contribute to the aging of the upper eyelid is not known. The aim of the present study was to use histopathologic examination to investigate whether the orbicularis oculi contributes to upper eyelid aging.

Methods Full-thickness upper eyelids, which were removed during blepharoplasty using en bloc resection, were stained with hematoxylin-eosin and examined. Eleven patients with oriental eyelid, 14 patients with bilateral dermatochalasia, and 2 patients with facial nerve palsy and contralateral dermatochalasia were included in this study.

Results Patients ranged in age from 21 to 73 years (median age, 55.8 years). Histologic results revealed that changes in the aging upper eyelid were mainly in the skin and subcutaneous layers with large masses of deranged elastic fibers in the papillary dermis, which was characterized as solar elastosis.

Conclusions Our study revealed that the entire orbicularis oculi muscle layer remained morphologically intact with aging. Moreover, our findings suggests that a minimally invasive surgical approach with muscle sparing in upper blepharoplasty in selected patients could yield good results in terms of cosmetic outcomes and upper eyelid function while minimizing postoperative complications.

Objective To report and discuss the outcome of a prospective, internally controlled, randomized, double-blind, split-face study comparing the onset of action of 2 commercially available botulinum neuromodulators.

Methods Ninety individuals with moderate-to-severe lateral orbital rhytids were treated with onabotulinumtoxinA, 10 U, and abobotulinumtoxinA, 30 U, for the treatment of lateral orbital rhytids. Participants were assessed live with a validated 5-point photographic scale before treatment and on days 2, 4, and 6 after treatment. Photographs were taken at each encounter. Statistical analysis was applied to evaluate for any significant difference in onset of action between the 2 products.

Results AbobotulinumtoxinA and onabotulinumtoxinA demonstrated statistically significant change from baseline at day 2 in the treatment of lateral orbital rhytids at maximal contraction and rest when evaluated independently by investigator and participant (P < .001). Also at day 2, the improvement with abobotulinumtoxinA was better than that with onabotulinumtoxinA for the primary end point of maximal contraction graded by the investigator, although this did not reach statistical significance (P = .21); by day 4, the greater improvement achieved with abobotulinumtoxinA reached statistical significance (P = .02) and remained superior at day 6 (P = .02). The primary findings were strengthened by similar results in the secondary end points of patient self-grade at maximal contraction and at rest and of investigator grade at rest.

Conclusions In conclusion, both abobotulinumtoxinA and onabotulinumtoxinA achieved statistically significant onset of action at day 2. This improvement was seen in all end points, with abobotulinumtoxinA demonstrating a trend toward greater improvement than onabotulinumtoxinA at day 2 and a statistically significant greater improvement at days 4 and 6 when looking at maximal contraction.

Evidence-based medicine (EBM) aims to apply the best available evidence gained from the scientific method to clinical decision making. The notion seems noble in its purpose, yet there are some apprehensions and misconceptions among physicians, especially those in a predominantly surgical field such as facial plastic surgery. Developing a sophisticated understanding of the inherent biases and limitations of EBM will become increasingly important for the researcher and practicing surgeon as we strive to improve the rigor of our studies and produce noteworthy scientific evidence that improves the health outcomes for our patients.

Objective To use the trimmed cartilage as a support material for both internal and external valves.

Methods The lateral crural turn-in flap (LCTF) technique is simply to make cephalic trimming of the lateral crura and turn it into a pocket created under the remaining lateral crus. Twenty-four patients with lateral crura wider than 12 mm and in whom this technique was applied took part in this study. The trimmed cartilage was used to reshape and/or support the lateral crus and the internal valve by keeping the scroll intact. The support and suspension of the lateral crura "sandwich" helped not only to prevent stenosis of the internal valve angle but also to widen it in some cases.

Results The LCTF has been used in 24 patients to reshape and/or add structure to the lateral crus with great success. The internal valve was also kept open by keeping the scroll area intact, especially in 1 patient with concave lateral crura in whom this technique helped to widen the internal valve angle.

Conclusions This study shows that the LCTF can be used to reshape and add structure to the lateral crus and to suspend the internal valve. Although it is a powerful technique by itself in functional rhinoplasty, it should be combined with other methods, such as spreader flaps/grafts or alar battens, to obtain the maximum functional result.

Objective To evaluate the histological changes induced in human skin by injection of autologous platelet-rich fibrin matrix (PRFM).

Methods Four healthy adult volunteers were included in the study. Platelet-rich fibrin matrix was prepared from 9 mL of autologous blood using a proprietary system (Selphyl; Aesthetic Factors, Wayne, New Jersey) and injected into the deep dermis and immediate subdermis of the upper arms of subjects. Full-thickness skin biopsy specimens were taken from the treated areas over a 10-week period, and the specimens were processed for histological evaluation.

Results Findings from histological examination supported the clinical observation of soft-tissue augmentation. As early as 7 days after treatment, activated fibroblasts and new collagen deposition were noted and continued to be evident throughout the course of the study. Development of new blood vessels was noted by 19 days; also at this time, intradermal collections of adipocytes and stimulation of subdermal adipocytes were noted. These findings became more pronounced over the duration of the study, although the fibroblastic response became much less pronounced. No abnormal mitotic figures were observed at any point, and a very mild chronic inflammatory response was noted only at the earliest time points of the study.

Conclusions Injection of PRFM into the deep dermis and subdermis of the skin stimulates a number of cellular changes that can be harnessed for use. Coupled with prior in vitro and in vivo studies, we now have a much clearer picture of the cellular effects of PRFM and its potential uses in facial plastic surgery. Further work is planned to more clearly elucidate the potential role of PRFM in aesthetic and reconstructive surgery.

Trial Registration clinicaltrials.gov Identifier: NCT00956020

Objective To evaluate possible botulinum toxin A effects in a cell culture model.

Methods In a cell culture model with dermal fibroblasts and microvascular endothelial cells, possible botulinum toxin A effects were evaluated. Cell proliferation and cytokine expression were analyzed using viability assays and enzyme-linked immunosorbent assay techniques.

Results Neither cell proliferation nor cytokines and growth factors (interleukin 6, monocyte chemoattractant protein 2, fibroblast growth factor, macrophage colony-stimulating factor, and vascular endothelial growth factor) were affected by botulinum toxin A incubation.

Conclusions The present data do not add evidence to suggest a significant therapeutic role of botulinum toxin A injections for cutaneous wound healing beyond chemoimmobilization. Further studies that include patient-specific cells of hypertrophic scars are required to better understand what role botulinum toxin A can play in the treatment of mature scar tissue.

Objective To evaluate whether final ostium size is determined by the osteotomy created during dacryocystorhinostomy (DCR).

Design Prospective nonrandomized study. Intraoperative measurements of bony osteotomy were taken during external DCR. Endonasal endoscopy with functional endoscopic dye testing and internal ostium photography were performed 3 months after surgery.

Results Fifty patients (mean age, 63 years) underwent 55 DCRs. Postoperative nasal endoscopy with functional endoscopic dye testing was performed in 27 cases (49%), and measurements of intranasal ostia were feasible in 24 of them (86%). The mean follow-up time was 7 months (range, 3-12 months). Surgical success was achieved in 25 of 27 patients (93%) who underwent postoperative nasal endoscopy. There was no difference in either the intraoperative osteotomy size or the postoperative ostium size between failed and successful cases. The mean (SD) intraoperative osteotomy size was 256.3 (89.0) mm², and the mean (SD) postoperative ostium size was 9.6 (6.7) mm². The intraoperative osteotomy size correlated positively with the postoperative intranasal ostium size (r = 0.45; P = .03, Pearson bivariate correlation).

Conclusions Larger osteotomies created during external DCR are correlated with larger postoperative ostia as measured by endonasal endoscopy and image analysis software. There is a trend toward greater success with larger osteotomies; however, failed cases in this series were not associated with smaller-sized intraoperative osteotomies.

Objectives To learn how nasal batten grafts affect patients' assessment of their nasal airway patency and to determine the extent to which patients believe batten grafts altered their appearance.

Methods A prospective survey study of 18 patients in a tertiary veterans hospital who had nasal airway obstruction (NAO) due to nasal valve collapse was completed. Patients had placement of bilateral polyethylene batten grafts during a 36-month study period. The Nasal Obstruction Symptom Evaluation (NOSE) validated survey was used to measure a patient's subjective postoperative change in nasal airway obstruction. In addition, the patients were asked to rate the extent their appearance had changed.

Results All patients presented with complaints of NAO due to nasal valve collapse either in isolation or in combination with another anatomical source of obstruction. The nasal valve collapse was identified by clinical examination. All patients had preoperative photographs. Most patients had a trial with an intranasal stent before opting for surgical implantation of the batten grafts. The results of the NOSE survey demonstrate significant improvement in nasal obstruction. Patients also reported only a minimal change in appearance. There was 1 patient with implant extrusions and only a few implants were removed.

Conclusions Nasal airway obstruction due to nasal valve collapse can be effectively treated with polyethylene batten grafts. The implants are well tolerated, and patients report a significant improvement in NAO. There is little risk of implant extrusion, exposure, or intolerance. In addition, patients did not note a significant change to their appearance.

Objective To develop a new, custom-made pressure device that can be used with established designs as an adjuvant therapy for optimized treatment of auricular keloids.

Methods Seven patients (4 males, 3 females; mean [SD] age, 22.6 [8.3] years) were treated with surgical excision and corticosteroid injection followed by application of our new auricular pressure device.

Results All patients tolerated the adjuvant therapy and wore the device overnight for 5 nights per week. Usage was not interrupted or cancelled. No recurrence was observed during the follow-up period (mean [SD] duration of follow-up, 24 [6] months). All patients were satisfied with the results; none described pruritus, pain, or dysesthesia.

Conclusion Overnight usage of the new pressure device seems to be a safe and effective extension of established auricular keloid therapy with the potential for prophylaxis of recurrence.

Objective To determine how mechanical stability changes in the lower lateral cartilage (LLC) after varying degrees of cephalic resection in a porcine cartilage nasal tip model.

Methods Alar cartilage was harvested from fresh porcine crania (n = 14) and sectioned to precisely emulate a human LLC in size and dimension. Flexural mechanical analysis was performed both before and after cephalic trims of 0 (control), 4, and 6 mm. Cantilever deformation tests were performed on the LLC models at 3 locations (4, 6, and 8 mm from the midline), and the integrated reaction force was measured. An equivalent elastic modulus of the crura was calculated assuming that the geometry of the LLC model approximated a modified single cantilever beam. A 3-dimensional finite element model was used to model the stress distribution of the prescribed loading conditions for each of the 3 types of LLC widths.

Results A statistically significant decrease (P = .02) in the equivalent elastic modulus of the LLC model was noted at the most lateral point at 8 mm and only when 4 mm of the strut remained (P = .05). The finite element model revealed that the greatest internal stresses was at the tip of the nose when tissue was flexed 8 mm from the midline.

Conclusion Our results provide the mechanical basis for suggested clinical guidelines stating that a residual strut of less than 6 mm can lead to suboptimal cosmetic results owing to poor structural support of the overlying skin soft-tissue envelope by an overly resected LLC.

Objectives To define variations of the depressor septi muscle in Iranians; to provide guidance for modification of this muscle during rhinoplasty in patients with an active muscle and short upper lip; and to correlate our findings with our clinical experience to develop the applied algorithms.

Methods This study was conducted by dissecting 82 depressor septi nasi muscles in 41 Iranian cadavers. Origin and insertion points of each muscle were studied.

Results Three variations were found in muscle insertion points: periosteal, orbicularis oris, and floating. Forty-four percent of the muscles were inserted into the periosteum of the maxilla (n = 36); 39% of muscles were inserted into the orbicularis oris muscle (n = 32); and 17% were diminutive or floating (n = 14). Periosteal insertion was thicker and stronger than the other variations. In all cadavers, the origin of the muscle was medial crus of alar cartilage and caudal of the nasal septum.

Conclusions This cadaveric dissection showed that the percentage of depressor septi muscle insertions is not similar to that found in other surveys. In this study, periosteal insertion of the depressor septi muscle was the most common variation.

Objective To introduce and analyze suction-assisted analysis of nasal valve strength in functional septorhinoplasty. This is a novel method for helping the surgeon analyze the integrity of a patient's airway during surgery.

Methods In this prospective study, 20 patients who underwent functional septorhinoplasty were analyzed. Negative pressure using suction tubing was placed at the nasal sill, and measurements of the amount of maximal depression of the nasal valve were performed in the operating room immediately before incision and immediately after closure of the incisions.

Results All 20 patients had an immediate decrease in the deviation of the weakest point of the valve, with a mean change of 2.14 mm. The change on both sides was statistically significant (paired t test, P < .001). This novel method helped the surgeons decide which grafts provided the most immediate structural benefit.

Conclusions Structure-based septorhinoplasty can immediately improve the strength of the nasal valve. Suction-assisted analysis of the nasal valve can be a useful "real-time" tool for determining which maneuvers improve the strength of the nasal valve.

Objectives To define (1) at-risk structures during the orthodromic temporalis tendon transfer and (2) achievable tendon length without temporal releasing incisions or perioral lengthening materials.

Methods Ten fresh cadavers provided 20 hemifaces for dissection. Measurements and photographic documentation were used to examine the parotid duct, masseteric artery, inferior alveolar nerve, internal maxillary artery, and mobilized tendon relative to adjacent landmarks.

Results The parotid duct was found in a reproducible region posterior to the melolabial crease and inferior to a parotid duct reference line. The masseteric artery was found posterior to the posterior-most attachment of the tendon at its exit from the sigmoid notch (mean, 14.5 mm). The inferior alveolar nerve was found posterior to the anterior edge of the ascending ramus (mean, 18.3 mm). The internal maxillary artery coursed superiorly from posterior to anterior along the medial mandible near the coronoidectomy site. The tendon reached beyond the melolabial crease in 17 of 20 hemifaces (85%).

Conclusions The parotid duct reference line and the melolabial crease allow estimation of the parotid duct location. Anatomical relationships between the tendon, parotid duct, neurovasculature, and anatomical landmarks underscore the importance of deliberate soft-tissue retraction and subperiostial elevation to minimize injury. The tendon alone usually provides adequate length for orthodromic suspension.

Objective To determine the effectiveness of treating scars with microporous paper tape or silicone gel sheeting (SGS) in preventing hypertrophic scarring

Methods Forty hypertrophic scars were induced in a validated rabbit ear model. Wounds were randomized and bandaged for 30 days with either SGS (20 wounds), paper tape (20 wounds), or untreated controls (40 wounds). Two outcome measures of hypertrophic scarring included (1) histologic measurement of scar elevation index (SEI) and (2) blinded photograph analysis using a visual analog scale.

Results In histologic comparison, no difference in mean (SE) SEI between treatment groups was seen (paper tape group, 1.32 [0.2]; SGS group, 1.41 [0.18]; control, 1.35 [0.23]; P = .51). In photographic analysis, both treatment groups were superior to the control group (P < .01), whereas no difference was seen between the SGS and paper tape groups (P = .88).

Conclusions Paper tape and SGS demonstrated equal effectiveness in the prevention of hypertrophic scarring on visual analysis, whereas histologic analysis demonstrated no difference in treatment groups from controls. The effectiveness of paper tape in preventing hypertrophic scarring in humans will require further laboratory and clinical investigation.

Objective To assess the feasibility of laser tissue welding for repair of facial nerve injury.

Methods In a prospective in vivo animal survival surgery model, rabbit facial nerve injury was followed by either standard suture neurorrhaphy or laser tissue welding using a diode laser (808 ± 1 nm) to weld biological solder. Rabbits were evaluated at 4, 8, 12, and 16 weeks by facial videography and electromyography. Histopathological analysis of the repair was performed at 4 and 16 weeks.

Results Videographic analysis demonstrated the laser tissue welding repair trended toward superior outcomes compared with suture neurorrhaphy at all 4 time points. Electrophysiological analysis demonstrated similar or better results, with statistically significant improvement at week 16 (P < .05). Histologic analysis demonstrated no difference in axon organization or extravasation between groups; however, the laser nerve repair created a greater initial inflammatory reaction. An analysis of operative time demonstrated significantly decreased time and ease of use for laser tissue welding.

Conclusions This pilot study demonstrates that laser nerve welding may be an expedient, feasible, and safe method for facial nerve repair in a rabbit model. Further experiments with larger numbers are needed to provide additional evidence that laser tissue welding produces a neurorrhaphy that has functional, electrophysiological, and histological results that could rival traditional suture neurorrhaphy.

Telecanthus, which is the lateral displacement of the medial canthus, can be a congenital deformity or can occur after facial trauma. Several epicanthoplasty methods have been described, but the orbitonasal angle and appropriate shape cannot be reconstructed in Asians. We solved this problem by using a dog-ear effect. This article describes a new design for epicanthoplasty and its results.