Pub Date : 2019-11-21DOI: 10.1001/jamafacial.2019.0815
Xavier Vega-Córdova, M. Brenner, Harrison C Putman
{"title":"Extended Butterfly Graft for Functional and Cosmetic Correction of Saddle Nose Deformity.","authors":"Xavier Vega-Córdova, M. Brenner, Harrison C Putman","doi":"10.1001/jamafacial.2019.0815","DOIUrl":"https://doi.org/10.1001/jamafacial.2019.0815","url":null,"abstract":"","PeriodicalId":14538,"journal":{"name":"JAMA facial plastic surgery","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2019-11-21","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1001/jamafacial.2019.0815","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"49025310","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2019-11-21DOI: 10.1001/jamafacial.2019.1027
C. Olds, Emily A. Spataro, Kevin Li, Cherian K. Kandathil, Sam P. Most
Importance Best practices for antibiotic use after facial plastic and reconstructive procedures have been the subject of much debate, and there is a need for large-scale data to guide further development of evidence-based guidelines for antibiotic use in this setting. Objective To assess patterns of postoperative antibiotic prescriptions and infection rates after nasal and oculoplastic procedures. Design, Setting, and Participants A retrospective population-based cohort study was conducted using IBM MarketScan Commercial and Medicare Supplemental research databases of 294 039 patients who underwent facial plastic surgery procedures between January 1, 2007, and December 31, 2015. Patients were excluded if they were younger than 18 years, lacked continuous insurance coverage for 1 year before and after the procedure, or underwent additional procedures on the surgery date of interest. Statistical analysis was performed from January 1, 2007, to December 31, 2016. Main Outcomes and Measures Primary outcomes were antibiotic prescription patterns in the immediate postoperative period and rates of postoperative infectious complications. Explanatory variables included patient demographics, procedure type, and relevant comorbidities, which were used in multivariable logistic regression analysis. Results Of the 294 039 patients who met inclusion criteria (55.9% women and 44.1% men; mean [SD] age, 54.0 [18.6 years]), 45.2% filled prescriptions for postoperative antibiotics, including 55.3% of patients undergoing nasal procedures and 14.7% of patients undergoing oculoplastic procedures. Superficial surgical site infections occurred in 1.6% of patients, while deep surgical site infections occurred in 0.3% of patients. On multivariable logistic regression, patients receiving postoperative antibiotics were at significantly decreased risk of postoperative infections (nasal procedures: adjusted odds ratio [aOR], 0.144 [95% CI, 0.102-0.203]; oculoplastic procedures: aOR, 0.254 [95% CI, 0.104-0.622]) compared with those who did not receive postoperative antibiotics. Increased duration of postoperative antibiotics was not associated with reduced rates of infectious complications (nasal procedures: aOR, 1.000 [95% CI, 0.978-1.022]; oculoplastic procedures: aOR, 1.024 [95% CI, 0.959-01.092]). Despite being more likely to experience postoperative infections, patients with a history of tobacco use (aOR, 0.806 [95% CI, 0.747-0.870]), immunodeficiency (aOR, 0.774 [95% CI, 0.737-0.813]), or type 1 or 2 diabetes (aOR, 0.810 [95% CI, 0.772-0.850]) were less likely to be prescribed antibiotics than those without these conditions. Conclusions and Relevance Postoperative antibiotic prescriptions were associated with reduced rates of infections after facial plastic surgery. This study highlights the role of population-level data in the development of best practices for postoperative antibiotic use and identifies the need for additional examination of antibiotic use patt
{"title":"Postoperative Antibiotic Use Among Patients Undergoing Functional Facial Plastic and Reconstructive Surgery.","authors":"C. Olds, Emily A. Spataro, Kevin Li, Cherian K. Kandathil, Sam P. Most","doi":"10.1001/jamafacial.2019.1027","DOIUrl":"https://doi.org/10.1001/jamafacial.2019.1027","url":null,"abstract":"Importance\u0000Best practices for antibiotic use after facial plastic and reconstructive procedures have been the subject of much debate, and there is a need for large-scale data to guide further development of evidence-based guidelines for antibiotic use in this setting.\u0000\u0000\u0000Objective\u0000To assess patterns of postoperative antibiotic prescriptions and infection rates after nasal and oculoplastic procedures.\u0000\u0000\u0000Design, Setting, and Participants\u0000A retrospective population-based cohort study was conducted using IBM MarketScan Commercial and Medicare Supplemental research databases of 294 039 patients who underwent facial plastic surgery procedures between January 1, 2007, and December 31, 2015. Patients were excluded if they were younger than 18 years, lacked continuous insurance coverage for 1 year before and after the procedure, or underwent additional procedures on the surgery date of interest. Statistical analysis was performed from January 1, 2007, to December 31, 2016.\u0000\u0000\u0000Main Outcomes and Measures\u0000Primary outcomes were antibiotic prescription patterns in the immediate postoperative period and rates of postoperative infectious complications. Explanatory variables included patient demographics, procedure type, and relevant comorbidities, which were used in multivariable logistic regression analysis.\u0000\u0000\u0000Results\u0000Of the 294 039 patients who met inclusion criteria (55.9% women and 44.1% men; mean [SD] age, 54.0 [18.6 years]), 45.2% filled prescriptions for postoperative antibiotics, including 55.3% of patients undergoing nasal procedures and 14.7% of patients undergoing oculoplastic procedures. Superficial surgical site infections occurred in 1.6% of patients, while deep surgical site infections occurred in 0.3% of patients. On multivariable logistic regression, patients receiving postoperative antibiotics were at significantly decreased risk of postoperative infections (nasal procedures: adjusted odds ratio [aOR], 0.144 [95% CI, 0.102-0.203]; oculoplastic procedures: aOR, 0.254 [95% CI, 0.104-0.622]) compared with those who did not receive postoperative antibiotics. Increased duration of postoperative antibiotics was not associated with reduced rates of infectious complications (nasal procedures: aOR, 1.000 [95% CI, 0.978-1.022]; oculoplastic procedures: aOR, 1.024 [95% CI, 0.959-01.092]). Despite being more likely to experience postoperative infections, patients with a history of tobacco use (aOR, 0.806 [95% CI, 0.747-0.870]), immunodeficiency (aOR, 0.774 [95% CI, 0.737-0.813]), or type 1 or 2 diabetes (aOR, 0.810 [95% CI, 0.772-0.850]) were less likely to be prescribed antibiotics than those without these conditions.\u0000\u0000\u0000Conclusions and Relevance\u0000Postoperative antibiotic prescriptions were associated with reduced rates of infections after facial plastic surgery. This study highlights the role of population-level data in the development of best practices for postoperative antibiotic use and identifies the need for additional examination of antibiotic use patt","PeriodicalId":14538,"journal":{"name":"JAMA facial plastic surgery","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2019-11-21","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1001/jamafacial.2019.1027","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"47799871","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2019-11-21DOI: 10.1001/jamafacial.2019.0640
D. Sebaratnam, X. L. Wong, L. Kim, K. Cheung
{"title":"Alopecia Following Deoxycholic Acid Treatment for Submental Adiposity.","authors":"D. Sebaratnam, X. L. Wong, L. Kim, K. Cheung","doi":"10.1001/jamafacial.2019.0640","DOIUrl":"https://doi.org/10.1001/jamafacial.2019.0640","url":null,"abstract":"","PeriodicalId":14538,"journal":{"name":"JAMA facial plastic surgery","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2019-11-21","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1001/jamafacial.2019.0640","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"47745539","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2019-11-21DOI: 10.1001/jamafacial.2019.0851
K. Sharaf, A. Kleinsasser, S. Schwenk-Zieger, O. Gires, H. Schinke, V. Kohlbauer, M. Jakob, M. Canis, F. Haubner
Importance Adipose-derived mesenchymal stem cells (ASCs) have been used commonly in regenerative medicine and increasingly for head and neck surgical procedures. Lipoaspiration with centrifugation is purported to be a mild method for the extraction of ASCs used for autologous transplants to restore tissue defects or induce wound healing. The content of ASCs, their paracrine potential, and cellular potential in wound healing have not been explored for this method to our knowledge. Objective To evaluate the characteristics of lipoaspirates used in reconstructive head and neck surgical procedures with respect to wound healing. Design, Setting, and Participants This case series study included 15 patients who received autologous fat injections in the head and neck during surgical procedures at a tertiary referral center. The study was performed from October 2017 to November 2018, and data were analyzed from October 2017 to February 2019. Main Outcomes and Measures Excessive material of lipoaspirates from subcutaneous abdominal fatty tissue was examined. Cellular composition was analyzed using immunohistochemistry (IHC) and flow cytometry, and functionality was assessed through adipose, osteous, and chondral differentiation in vitro. Supernatants were tested for paracrine ASC functions in fibroblast wound-healing assays. Enzyme-linked immunosorbent assay measurement of tumor necrosis factor (TNF), vascular endothelial growth factor (VEGF), stromal-derived factor 1α (SDF-1α), and transforming growth factor β3 (TGF-β3) was performed. Results Among the 15 study patients (8 [53.3%] male; mean [SD] age at the time of surgery, 63.0 [2.8] years), the stromal vascular fraction (mean [SE], 53.3% [4.2%]) represented the largest fraction within the native lipoaspirates. The cultivated cells were positive for CD73 (mean [SE], 99.90% [0.07%]), CD90 (99.40% [0.32%]), and CD105 (88.54% [2.74%]); negative for CD34 (2.70% [0.45%]) and CD45 (1.74% [0.28%]) in flow cytometry; and negative for CD14 (10.56 [2.81] per 300 IHC score) and HLA-DR (6.89 [2.97] per 300 IHC score) in IHC staining; they differentiated into osteoblasts, adipocytes, and chondrocytes. The cultivated cells showed high expression of CD44 (mean [SE], 99.78% [0.08%]) and CD273 (82.56% [5.83%]). The supernatants were negative for TNF (not detectable) and SDF-1α (not detectable) and were positive for VEGF (mean [SE], 526.74 [149.84] pg/mL for explant supernatants; 528.26 [131.79] pg/106 per day for cell culture supernatants) and TGF-β3 (mean [SE], 22.79 [3.49] pg/mL for explant supernatants; 7.97 [3.15] pg/106 per day for cell culture supernatants). Compared with control (25% or 50% mesenchymal stem cell medium), fibroblasts treated with ASC supernatant healed the scratch-induced wound faster (mean [SE]: control, 1.000 [0.160]; explant supernatant, 1.369 [0.070]; and passage 6 supernatant, 1.492 [0.094]). Conclusions and Relevance The cells fulfilled the international accepted criteria for mesenc
{"title":"Molecular Characterization of Lipoaspirates Used in Regenerative Head and Neck Surgery.","authors":"K. Sharaf, A. Kleinsasser, S. Schwenk-Zieger, O. Gires, H. Schinke, V. Kohlbauer, M. Jakob, M. Canis, F. Haubner","doi":"10.1001/jamafacial.2019.0851","DOIUrl":"https://doi.org/10.1001/jamafacial.2019.0851","url":null,"abstract":"Importance\u0000Adipose-derived mesenchymal stem cells (ASCs) have been used commonly in regenerative medicine and increasingly for head and neck surgical procedures. Lipoaspiration with centrifugation is purported to be a mild method for the extraction of ASCs used for autologous transplants to restore tissue defects or induce wound healing. The content of ASCs, their paracrine potential, and cellular potential in wound healing have not been explored for this method to our knowledge.\u0000\u0000\u0000Objective\u0000To evaluate the characteristics of lipoaspirates used in reconstructive head and neck surgical procedures with respect to wound healing.\u0000\u0000\u0000Design, Setting, and Participants\u0000This case series study included 15 patients who received autologous fat injections in the head and neck during surgical procedures at a tertiary referral center. The study was performed from October 2017 to November 2018, and data were analyzed from October 2017 to February 2019.\u0000\u0000\u0000Main Outcomes and Measures\u0000Excessive material of lipoaspirates from subcutaneous abdominal fatty tissue was examined. Cellular composition was analyzed using immunohistochemistry (IHC) and flow cytometry, and functionality was assessed through adipose, osteous, and chondral differentiation in vitro. Supernatants were tested for paracrine ASC functions in fibroblast wound-healing assays. Enzyme-linked immunosorbent assay measurement of tumor necrosis factor (TNF), vascular endothelial growth factor (VEGF), stromal-derived factor 1α (SDF-1α), and transforming growth factor β3 (TGF-β3) was performed.\u0000\u0000\u0000Results\u0000Among the 15 study patients (8 [53.3%] male; mean [SD] age at the time of surgery, 63.0 [2.8] years), the stromal vascular fraction (mean [SE], 53.3% [4.2%]) represented the largest fraction within the native lipoaspirates. The cultivated cells were positive for CD73 (mean [SE], 99.90% [0.07%]), CD90 (99.40% [0.32%]), and CD105 (88.54% [2.74%]); negative for CD34 (2.70% [0.45%]) and CD45 (1.74% [0.28%]) in flow cytometry; and negative for CD14 (10.56 [2.81] per 300 IHC score) and HLA-DR (6.89 [2.97] per 300 IHC score) in IHC staining; they differentiated into osteoblasts, adipocytes, and chondrocytes. The cultivated cells showed high expression of CD44 (mean [SE], 99.78% [0.08%]) and CD273 (82.56% [5.83%]). The supernatants were negative for TNF (not detectable) and SDF-1α (not detectable) and were positive for VEGF (mean [SE], 526.74 [149.84] pg/mL for explant supernatants; 528.26 [131.79] pg/106 per day for cell culture supernatants) and TGF-β3 (mean [SE], 22.79 [3.49] pg/mL for explant supernatants; 7.97 [3.15] pg/106 per day for cell culture supernatants). Compared with control (25% or 50% mesenchymal stem cell medium), fibroblasts treated with ASC supernatant healed the scratch-induced wound faster (mean [SE]: control, 1.000 [0.160]; explant supernatant, 1.369 [0.070]; and passage 6 supernatant, 1.492 [0.094]).\u0000\u0000\u0000Conclusions and Relevance\u0000The cells fulfilled the international accepted criteria for mesenc","PeriodicalId":14538,"journal":{"name":"JAMA facial plastic surgery","volume":"1 1","pages":"1-9"},"PeriodicalIF":0.0,"publicationDate":"2019-11-21","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1001/jamafacial.2019.0851","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"47158581","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2019-11-21DOI: 10.1001/jamafacial.2019.0689
A. Vincent, Scott E. Bevans, J. Robitschek, G. Wind, M. Hohman
Importance Synkinesis is the involuntary movement of 1 area of the face accompanying volitional movement of another; it is commonly encountered in patients affected by facial palsy. Current treatments for synkinesis include biofeedback for muscular retraining and chemodenervation via the injection of botulinum toxin. Chemodenervation is effective in reducing unwanted muscle movement, but it requires a commitment to long-term maintenance injections and may lose effectiveness over time. A permanent solution for synkinesis remains elusive. Objective To evaluate masseteric-to-facial nerve transfer with selective neurectomy in rehabilitation of the synkinetic smile. Design, Setting, and Participants In this case series, 7 patients at a tertiary care teaching hospital underwent masseteric-to-facial nerve transfer with selective neurectomy for synkinesis between September 14, 2015, and April 19, 2018. The medical records of these patients were retrospectively reviewed and demographic characteristics, facial palsy causes, other interventions used, and changes in eFACE scores were identified. Intervention Masseteric-to-facial nerve transfer. Main Outcomes and Measures Changes in eFACE scores (calculated via numeric scoring of many sections of the face, including flaccidity, normal tone, and hypertonicity; higher scores indicate better function and lower scores indicate poorer function) and House-Brackmann Facial Nerve Grading System scores (range, 1-6; a score of 1 indicates normal facial function on the affected side, and a score of 6 indicates absence of any facial function [complete flaccid palsy] on the affected side). Results Among the 7 patients in the study (6 women and 1 man; median age, 49 years [range, 41-63 years]), there were no postoperative complications; patients were followed up for a mean of 12.8 months after surgery (range, 11.0-24.5 months). Patients experienced a significant improvement in mean (SD) eFACE scores in multiple domains, including smile (preoperative, 65.00 [8.64]; postoperative, 76.43 [7.79]; P = .01), dynamic function (preoperative, 62.57 [15.37]; and postoperative, 75.71 [8.48]; P = .03), synkinesis (preoperative, 52.70 [4.96]; and postoperative, 82.00 [6.93]; P < .001), midface and smile function (preoperative, 60.71 [13.52]; and postoperative, 78.86 [14.70]; P = .02), and lower face and neck function (preoperative, 51.14 [16.39]; and postoperative, 66.43 [20.82]; P = .046). Preoperative House-Brackmann Facial Nerve Grading System scores ranged from 3 to 4, and postoperative scores ranged from 2 to 3; this change was not significant. Conclusion and Relevance This study describes the application of masseteric-to-facial nerve transfer with selective neurectomy for smile rehabilitation in patients with synkinesis, with statistically significant improvement in smile symmetry and lower facial synkinesis as measured with the eFACE tool. This technique may allow for long-term improvement of synkinesis and smile. Th
{"title":"Masseteric-to-Facial Nerve Transfer and Selective Neurectomy for Rehabilitation of the Synkinetic Smile.","authors":"A. Vincent, Scott E. Bevans, J. Robitschek, G. Wind, M. Hohman","doi":"10.1001/jamafacial.2019.0689","DOIUrl":"https://doi.org/10.1001/jamafacial.2019.0689","url":null,"abstract":"Importance\u0000Synkinesis is the involuntary movement of 1 area of the face accompanying volitional movement of another; it is commonly encountered in patients affected by facial palsy. Current treatments for synkinesis include biofeedback for muscular retraining and chemodenervation via the injection of botulinum toxin. Chemodenervation is effective in reducing unwanted muscle movement, but it requires a commitment to long-term maintenance injections and may lose effectiveness over time. A permanent solution for synkinesis remains elusive.\u0000\u0000\u0000Objective\u0000To evaluate masseteric-to-facial nerve transfer with selective neurectomy in rehabilitation of the synkinetic smile.\u0000\u0000\u0000Design, Setting, and Participants\u0000In this case series, 7 patients at a tertiary care teaching hospital underwent masseteric-to-facial nerve transfer with selective neurectomy for synkinesis between September 14, 2015, and April 19, 2018. The medical records of these patients were retrospectively reviewed and demographic characteristics, facial palsy causes, other interventions used, and changes in eFACE scores were identified.\u0000\u0000\u0000Intervention\u0000Masseteric-to-facial nerve transfer.\u0000\u0000\u0000Main Outcomes and Measures\u0000Changes in eFACE scores (calculated via numeric scoring of many sections of the face, including flaccidity, normal tone, and hypertonicity; higher scores indicate better function and lower scores indicate poorer function) and House-Brackmann Facial Nerve Grading System scores (range, 1-6; a score of 1 indicates normal facial function on the affected side, and a score of 6 indicates absence of any facial function [complete flaccid palsy] on the affected side).\u0000\u0000\u0000Results\u0000Among the 7 patients in the study (6 women and 1 man; median age, 49 years [range, 41-63 years]), there were no postoperative complications; patients were followed up for a mean of 12.8 months after surgery (range, 11.0-24.5 months). Patients experienced a significant improvement in mean (SD) eFACE scores in multiple domains, including smile (preoperative, 65.00 [8.64]; postoperative, 76.43 [7.79]; P = .01), dynamic function (preoperative, 62.57 [15.37]; and postoperative, 75.71 [8.48]; P = .03), synkinesis (preoperative, 52.70 [4.96]; and postoperative, 82.00 [6.93]; P < .001), midface and smile function (preoperative, 60.71 [13.52]; and postoperative, 78.86 [14.70]; P = .02), and lower face and neck function (preoperative, 51.14 [16.39]; and postoperative, 66.43 [20.82]; P = .046). Preoperative House-Brackmann Facial Nerve Grading System scores ranged from 3 to 4, and postoperative scores ranged from 2 to 3; this change was not significant.\u0000\u0000\u0000Conclusion and Relevance\u0000This study describes the application of masseteric-to-facial nerve transfer with selective neurectomy for smile rehabilitation in patients with synkinesis, with statistically significant improvement in smile symmetry and lower facial synkinesis as measured with the eFACE tool. This technique may allow for long-term improvement of synkinesis and smile. Th","PeriodicalId":14538,"journal":{"name":"JAMA facial plastic surgery","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2019-11-21","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1001/jamafacial.2019.0689","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"42454744","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2019-11-21DOI: 10.1001/jamafacial.2019.1110
Michele Ori, G. Ricci, L. D'Ascanio
{"title":"Clarification of a Suspension Technique for Unstable Nasal Bones.","authors":"Michele Ori, G. Ricci, L. D'Ascanio","doi":"10.1001/jamafacial.2019.1110","DOIUrl":"https://doi.org/10.1001/jamafacial.2019.1110","url":null,"abstract":"","PeriodicalId":14538,"journal":{"name":"JAMA facial plastic surgery","volume":"1 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2019-11-21","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1001/jamafacial.2019.1110","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"41377098","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2019-11-21DOI: 10.1001/jamafacial.2019.0884
Laura E. T. Hetzler, Victoria B Givens, J. Sykes
Importance The tripod theory of the upper nasal third parallels the concept of the well-known nasal tip tripod. We are evaluating the idea that one can simply alter the upper nasal angles reliably without the complex physics associated with the nasal tip to achieve a pleasing cosmetic result. Objective To describe a concept related to the well-known tripod theory with extrapolation to the upper nasal third as it pertains to cosmetic rhinoplasty. Design, Setting, and Participants This is a prospective study in which lateral photographs of 3 women who had not undergone surgery (age range, 20-50 years) were selected for digital manipulation of the nasal radix with subsequent alteration of the nasofrontal and nasofacial angles via imaging software. The altered images were analyzed by 20 blinded individuals between July 2009 and June 2017 to assess how changes in the height of the nasal dorsum and radix alone affect nasal appearance and the perception of ideal nasal angles. The study took place at a tertiary center, and the patients chosen for evaluation had nasal architecture that only required subtle changes rather than structure that demonstrated glaringly obvious overprojection or underprojection and rotation or a large dorsal bony hump. Analysis began June 2018. Main Outcomes and Measures Overall trend in recognition of objective and subjective alterations in projection and rotation for the rhinoplasty- and non-rhinoplasty-trained evaluators. Results Ten medically trained and 10 lay individuals (13 women [65%]; mean [SD] age, 38 [8.6] years) analyzed digitally manipulated photographs of 3 women (age range, 20-50 years) who had not undergone surgery. Lay individuals were more likely to choose an ideal nasal profile based on surrounding facial architecture (28 of 30 [93%]), while individuals with rhinoplasty training tended to separate the ideal nose from the surrounding face (18 of 30 [60%]) (P < .001). Projection was consistently and accurately recognized as being altered by both rhinoplasty-trained and lay individuals (95% CI, -0.18 to 0.38; P = .60 and 95% CI, -0.26 to 0.33; P > .99 for most and least projected), whereas subjective changes in rotation were significantly more elusive to the lay individual (95% CI, -0.04 to 0.52; P = .12 and 95% CI, 0.11 to 0.65; P = .01 for most and least rotated). Conclusions and Relevance Predictable and consistent aesthetic results are the primary aim in rhinoplasty. Alterations in the upper nasal tripod are more reliable with extrapolated healing than with the tripod of the nasal tip. Ultimately, simple alteration of the upper nasal third can result in an improved nasal profile without specific alteration of tip architecture. Level of Evidence NA.
{"title":"The Tripod Concept of the Upper Nasal Third.","authors":"Laura E. T. Hetzler, Victoria B Givens, J. Sykes","doi":"10.1001/jamafacial.2019.0884","DOIUrl":"https://doi.org/10.1001/jamafacial.2019.0884","url":null,"abstract":"Importance\u0000The tripod theory of the upper nasal third parallels the concept of the well-known nasal tip tripod. We are evaluating the idea that one can simply alter the upper nasal angles reliably without the complex physics associated with the nasal tip to achieve a pleasing cosmetic result.\u0000\u0000\u0000Objective\u0000To describe a concept related to the well-known tripod theory with extrapolation to the upper nasal third as it pertains to cosmetic rhinoplasty.\u0000\u0000\u0000Design, Setting, and Participants\u0000This is a prospective study in which lateral photographs of 3 women who had not undergone surgery (age range, 20-50 years) were selected for digital manipulation of the nasal radix with subsequent alteration of the nasofrontal and nasofacial angles via imaging software. The altered images were analyzed by 20 blinded individuals between July 2009 and June 2017 to assess how changes in the height of the nasal dorsum and radix alone affect nasal appearance and the perception of ideal nasal angles. The study took place at a tertiary center, and the patients chosen for evaluation had nasal architecture that only required subtle changes rather than structure that demonstrated glaringly obvious overprojection or underprojection and rotation or a large dorsal bony hump. Analysis began June 2018.\u0000\u0000\u0000Main Outcomes and Measures\u0000Overall trend in recognition of objective and subjective alterations in projection and rotation for the rhinoplasty- and non-rhinoplasty-trained evaluators.\u0000\u0000\u0000Results\u0000Ten medically trained and 10 lay individuals (13 women [65%]; mean [SD] age, 38 [8.6] years) analyzed digitally manipulated photographs of 3 women (age range, 20-50 years) who had not undergone surgery. Lay individuals were more likely to choose an ideal nasal profile based on surrounding facial architecture (28 of 30 [93%]), while individuals with rhinoplasty training tended to separate the ideal nose from the surrounding face (18 of 30 [60%]) (P < .001). Projection was consistently and accurately recognized as being altered by both rhinoplasty-trained and lay individuals (95% CI, -0.18 to 0.38; P = .60 and 95% CI, -0.26 to 0.33; P > .99 for most and least projected), whereas subjective changes in rotation were significantly more elusive to the lay individual (95% CI, -0.04 to 0.52; P = .12 and 95% CI, 0.11 to 0.65; P = .01 for most and least rotated).\u0000\u0000\u0000Conclusions and Relevance\u0000Predictable and consistent aesthetic results are the primary aim in rhinoplasty. Alterations in the upper nasal tripod are more reliable with extrapolated healing than with the tripod of the nasal tip. Ultimately, simple alteration of the upper nasal third can result in an improved nasal profile without specific alteration of tip architecture.\u0000\u0000\u0000Level of Evidence\u0000NA.","PeriodicalId":14538,"journal":{"name":"JAMA facial plastic surgery","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2019-11-21","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1001/jamafacial.2019.0884","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"43817952","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2019-11-21DOI: 10.1001/jamafacial.2019.0733
P. Govas, R. Kazi, Rachel M Slaugenhaupt, B. Carroll
Importance Vibration has been shown to decrease injection site pain in patients; however, to date, this effect has not been assessed for patients who catastrophize pain (ie, patients who anticipate a higher pain level). The anticipation of a pain score greater than 4 on the 11-point Numeric Rating Scale (NRS) has been associated with an increase in a patient's perception of procedural pain. Objective To assess the efficacy of vibration during cutaneous anesthetic injection for dermatologic surgery for patients who catastrophize pain (NRS score >4) and patients who do not (NRS score ≤4). Design, Setting, and Participants Randomized, parallel-group clinical trial from June 19 to September 4, 2018, at a tertiary dermatologic surgery clinic among 87 adults undergoing cutaneous cancer removal surgery. Patients completed a preprocedural questionnaire detailing their baseline pain, anticipated pain, and drug use. Analysis was performed on an intent-to-treat basis. Interventions Use of a vibratory anesthetic device (VAD) on the treatment site prior to anesthetic injection in the on (VAD ON) or off (VAD OFF) mode. Main Outcomes and Measures Pain was reported using the 11-point NRS (where 0 indicates no pain and 11 indicates the worst pain imaginable). A minimum clinically important difference of 22% or more and a substantial clinically important difference of 57% or more were used to assess the efficacy of vibration in patient-reported NRS score during anesthetic injection (iNRS score). Results A total of 87 patients were included, with 101 unique events reported (among the unique events, 37 were reported in women and 64 were reported in men; mean [SD] age, 66.0 [11.3] years). The mean (confidence level [CL]) iNRS score for patients who catastrophized pain was 2.27 (0.66) compared with 1.44 (0.39) for patients who did not (P = .03). A 38.9% decrease in mean (CL) iNRS score was reported with VAD ON compared with VAD OFF in all participants (1.24 [0.38] vs 2.04 [0.54]). Patients who catastrophized pain reported a 25.5% decrease in mean (CL) iNRS score with VAD ON vs VAD OFF (1.91 [0.99] vs 2.57 [0.98]), and patients who did not reported a 79.4% decrease (1.02 [0.40] vs 1.84 [0.66]). VAD ON was the only statistically significant variable to affect iNRS score (F statistic, 2.741; P = .03). Conclusions and Relevance This trial demonstrates that those who catastrophize pain prior to a procedure report a higher perceived level of pain. The application of vibration during local anesthetic injection resulted in a minimum clinically important difference in pain level for patients who catastrophize pain and a substantial clinically important difference in pain level for patients who do not. Level of Evidence 2. Trial Registration ClinicalTrials.gov identifier: NCT03467685.
{"title":"Effect of a Vibratory Anesthetic Device on Pain Anticipation and Subsequent Pain Perception Among Patients Undergoing Cutaneous Cancer Removal Surgery: A Randomized Clinical Trial.","authors":"P. Govas, R. Kazi, Rachel M Slaugenhaupt, B. Carroll","doi":"10.1001/jamafacial.2019.0733","DOIUrl":"https://doi.org/10.1001/jamafacial.2019.0733","url":null,"abstract":"Importance\u0000Vibration has been shown to decrease injection site pain in patients; however, to date, this effect has not been assessed for patients who catastrophize pain (ie, patients who anticipate a higher pain level). The anticipation of a pain score greater than 4 on the 11-point Numeric Rating Scale (NRS) has been associated with an increase in a patient's perception of procedural pain.\u0000\u0000\u0000Objective\u0000To assess the efficacy of vibration during cutaneous anesthetic injection for dermatologic surgery for patients who catastrophize pain (NRS score >4) and patients who do not (NRS score ≤4).\u0000\u0000\u0000Design, Setting, and Participants\u0000Randomized, parallel-group clinical trial from June 19 to September 4, 2018, at a tertiary dermatologic surgery clinic among 87 adults undergoing cutaneous cancer removal surgery. Patients completed a preprocedural questionnaire detailing their baseline pain, anticipated pain, and drug use. Analysis was performed on an intent-to-treat basis.\u0000\u0000\u0000Interventions\u0000Use of a vibratory anesthetic device (VAD) on the treatment site prior to anesthetic injection in the on (VAD ON) or off (VAD OFF) mode.\u0000\u0000\u0000Main Outcomes and Measures\u0000Pain was reported using the 11-point NRS (where 0 indicates no pain and 11 indicates the worst pain imaginable). A minimum clinically important difference of 22% or more and a substantial clinically important difference of 57% or more were used to assess the efficacy of vibration in patient-reported NRS score during anesthetic injection (iNRS score).\u0000\u0000\u0000Results\u0000A total of 87 patients were included, with 101 unique events reported (among the unique events, 37 were reported in women and 64 were reported in men; mean [SD] age, 66.0 [11.3] years). The mean (confidence level [CL]) iNRS score for patients who catastrophized pain was 2.27 (0.66) compared with 1.44 (0.39) for patients who did not (P = .03). A 38.9% decrease in mean (CL) iNRS score was reported with VAD ON compared with VAD OFF in all participants (1.24 [0.38] vs 2.04 [0.54]). Patients who catastrophized pain reported a 25.5% decrease in mean (CL) iNRS score with VAD ON vs VAD OFF (1.91 [0.99] vs 2.57 [0.98]), and patients who did not reported a 79.4% decrease (1.02 [0.40] vs 1.84 [0.66]). VAD ON was the only statistically significant variable to affect iNRS score (F statistic, 2.741; P = .03).\u0000\u0000\u0000Conclusions and Relevance\u0000This trial demonstrates that those who catastrophize pain prior to a procedure report a higher perceived level of pain. The application of vibration during local anesthetic injection resulted in a minimum clinically important difference in pain level for patients who catastrophize pain and a substantial clinically important difference in pain level for patients who do not.\u0000\u0000\u0000Level of Evidence\u00002.\u0000\u0000\u0000Trial Registration\u0000ClinicalTrials.gov identifier: NCT03467685.","PeriodicalId":14538,"journal":{"name":"JAMA facial plastic surgery","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2019-11-21","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1001/jamafacial.2019.0733","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"42519524","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2019-11-21DOI: 10.1001/jamafacial.2019.1020
Emily A. Spataro, M. Saltychev, Cherian K. Kandathil, Sam P. Most
Importance While extracorporeal septoplasty (ECS) and its modifications have been previously studied, to our knowledge, no systematic review of surgical outcomes and complications of this technique has been performed. Objective To evaluate the evidence of surgical outcomes and complications of ECS (including modified techniques) to treat severe L-strut septal deviation defined as deviation within 1.0 cm of the caudal or dorsal septum. Data Sources MEDLINE, Embase, CINAHL, CENTRAL, Scopus, and Web of Science databases and reference lists were searched from inception to April 2018 for clinical and observational studies. Search terms included extracorporeal, septoplasty, and septum. Study Selection Selection criteria were defined according to the population, intervention, comparison, and outcome framework. Relevant studies were selected by 2 independent reviewers based on abstracts and full texts. Data Extraction and Synthesis Data were extracted using standardized lists chosen by the authors according to Cochrane Collaboration guidelines. Data were collected and synthesized with ranges reported, as well as assessment of bias and heterogeneity when applicable. Analysis started in February 2019. Main Outcomes and Measures Outcomes assessed included functional nasal airway improvement by objective measurements and subjective measurements (Nasal Obstruction Symptom Evaluation [NOSE] and visual analog scale scores); complications including bleeding, infection, dorsal irregularities, and other functional or cosmetic deficits; and as revision surgery rates. Results Of 291 records initially obtained, 31 were considered relevant after review according to PRISMA guidelines. All studies except 1 randomized clinical trial (3.2%) were observational in nature, with 21 retrospective studies (67.7%) and 9 prospective studies (29.0%). Conventional ECS was performed in 16 studies (51.6%), and modified ECS was performed in 15 studies (48.4%). The sample size varied from 10 to 567, and the mean age varied from 22.5 to 46 years. Of 31 studies, 14 (45%) were of good methodology. Meta-analysis was performed on 5 studies reporting change in NOSE scores, with pooled effect of -60.0 (95% CI, -67.8 to -52.2) points, but heterogeneity was high, with I2 = 96%. When comparing complications between modified and conventional ECS, the relative risk for infections was 0.95 (95% CI, 0.34-2.7); for bleeding, 0; for nasal dorsal irregularities, 0.29 (95% CI, 0.16-0.53); for other cosmetic complications, 4.3 (95% CI, 0.87-21.1); for other functional complications, 0.47 (95% CI, 0.20-1.1); and for revision operations, 1.4 (95% CI, 0.83-2.3). Conclusions and Relevance Of the 31 studies included in this systematic review, less than half were of good methodology, and a significant level of heterogeneity was found regarding type of outcome measure used and reporting of complications. To improve the level of evidence, better study methodology, standardization of surgical outcom
重要性虽然体外隔膜成形术（ECS）及其改良术之前已经进行了研究，但据我们所知，尚未对该技术的手术结果和并发症进行系统审查。目的评估ECS（包括改良技术）治疗严重L型鼻中隔偏曲（定义为尾中隔或背中隔1.0 cm以内的偏曲）的手术结果和并发症的证据。数据来源MEDLINE、Embase、CINAHL、CENTRAL、Scopus和Web of Science数据库和参考文献列表从开始到2018年4月进行了临床和观察性研究搜索。搜索词包括体外，隔膜成形术和隔膜。研究选择根据人群、干预、比较和结果框架确定选择标准。相关研究由2名独立评审员根据摘要和全文进行选择。数据提取和合成使用作者根据Cochrane协作指南选择的标准化列表提取数据。收集数据并将其与报告的范围进行综合，并在适用时评估偏差和异质性。分析始于2019年2月。主要结果和测量结果评估结果包括通过客观测量和主观测量（鼻阻塞症状评估[NOSE]和视觉模拟量表评分）改善鼻气道功能；并发症，包括出血、感染、背部不规则和其他功能或美容缺陷；以及作为翻修手术率。结果根据PRISMA指南，在最初获得的291份记录中，31份在审查后被认为是相关的。除1项随机临床试验（3.2%）外，所有研究均为观察性研究，其中21项为回顾性研究（67.7%），9项为前瞻性研究（29.0%）。16项研究（51.6%）采用常规ECS，15项研究（48.4%）采用改良ECS。样本量从10到567不等，平均年龄从22.5到46岁不等。在31项研究中，有14项（45%）采用了良好的方法。对5项报告NOSE评分变化的研究进行了荟萃分析，综合效应为-60.0（95%CI，-67.8至-52.2）分，但异质性很高，I2 = 96%。当比较改良ECS和传统ECS的并发症时，感染的相对风险为0.95（95%CI，0.34-2.7）；出血，0；对于鼻背不规则性，0.29（95%CI，0.16-0.53）；对于其他美容并发症，4.3（95%CI，0.87-21.1）；对于其他功能性并发症，0.47（95%CI，0.20-1.1）；对于翻修手术，为1.4（95%CI，0.83-2.3）。结论和相关性在本系统综述中纳入的31项研究中，只有不到一半的研究具有良好的方法学，并且在使用的结果测量类型和并发症报告方面发现了显著的异质性。为了提高证据水平，需要更好的研究方法、手术结果测量的标准化和并发症的报告。
{"title":"Outcomes of Extracorporeal Septoplasty and Its Modifications in Treatment of Severe L-Strut Septal Deviation: A Systematic Review and Meta-analysis.","authors":"Emily A. Spataro, M. Saltychev, Cherian K. Kandathil, Sam P. Most","doi":"10.1001/jamafacial.2019.1020","DOIUrl":"https://doi.org/10.1001/jamafacial.2019.1020","url":null,"abstract":"Importance\u0000While extracorporeal septoplasty (ECS) and its modifications have been previously studied, to our knowledge, no systematic review of surgical outcomes and complications of this technique has been performed.\u0000\u0000\u0000Objective\u0000To evaluate the evidence of surgical outcomes and complications of ECS (including modified techniques) to treat severe L-strut septal deviation defined as deviation within 1.0 cm of the caudal or dorsal septum.\u0000\u0000\u0000Data Sources\u0000MEDLINE, Embase, CINAHL, CENTRAL, Scopus, and Web of Science databases and reference lists were searched from inception to April 2018 for clinical and observational studies. Search terms included extracorporeal, septoplasty, and septum.\u0000\u0000\u0000Study Selection\u0000Selection criteria were defined according to the population, intervention, comparison, and outcome framework. Relevant studies were selected by 2 independent reviewers based on abstracts and full texts.\u0000\u0000\u0000Data Extraction and Synthesis\u0000Data were extracted using standardized lists chosen by the authors according to Cochrane Collaboration guidelines. Data were collected and synthesized with ranges reported, as well as assessment of bias and heterogeneity when applicable. Analysis started in February 2019.\u0000\u0000\u0000Main Outcomes and Measures\u0000Outcomes assessed included functional nasal airway improvement by objective measurements and subjective measurements (Nasal Obstruction Symptom Evaluation [NOSE] and visual analog scale scores); complications including bleeding, infection, dorsal irregularities, and other functional or cosmetic deficits; and as revision surgery rates.\u0000\u0000\u0000Results\u0000Of 291 records initially obtained, 31 were considered relevant after review according to PRISMA guidelines. All studies except 1 randomized clinical trial (3.2%) were observational in nature, with 21 retrospective studies (67.7%) and 9 prospective studies (29.0%). Conventional ECS was performed in 16 studies (51.6%), and modified ECS was performed in 15 studies (48.4%). The sample size varied from 10 to 567, and the mean age varied from 22.5 to 46 years. Of 31 studies, 14 (45%) were of good methodology. Meta-analysis was performed on 5 studies reporting change in NOSE scores, with pooled effect of -60.0 (95% CI, -67.8 to -52.2) points, but heterogeneity was high, with I2 = 96%. When comparing complications between modified and conventional ECS, the relative risk for infections was 0.95 (95% CI, 0.34-2.7); for bleeding, 0; for nasal dorsal irregularities, 0.29 (95% CI, 0.16-0.53); for other cosmetic complications, 4.3 (95% CI, 0.87-21.1); for other functional complications, 0.47 (95% CI, 0.20-1.1); and for revision operations, 1.4 (95% CI, 0.83-2.3).\u0000\u0000\u0000Conclusions and Relevance\u0000Of the 31 studies included in this systematic review, less than half were of good methodology, and a significant level of heterogeneity was found regarding type of outcome measure used and reporting of complications. To improve the level of evidence, better study methodology, standardization of surgical outcom","PeriodicalId":14538,"journal":{"name":"JAMA facial plastic surgery","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2019-11-21","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1001/jamafacial.2019.1020","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"47015965","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
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