JAMA facial plastic surgery最新文献

Importance: Quantitative assessment of facial function is difficult, and historic grading scales such as House-Brackmann have well-recognized limitations. The electronic, clinician-graded facial function scale (eFACE) allows rapid regional analysis of static, dynamic, and synkinetic facial function in patients with unilateral facial palsy within the course of a clinical encounter, but it relies on clinician assessment. A newly developed, machine-learning algorithm (Emotrics) provides automated, objective facial measurements but lacks clinical input (ie, recognizing laterality of facial palsy or synkinesis).

Objectives: To compare the sensitivity of a clinician-based tool (eFACE) to a well-established intervention for facial palsy (eyelid weight placement) with an automated facial-measurement algorithm (Emotrics).

Design, setting, and participants: A retrospective review was conducted of the most recent 53 patients with unilateral facial palsy who received an eyelid weight at the Massachusetts Eye and Ear Infirmary Facial Nerve Center from 2014 to 2017. Preoperative and postoperative photographs were deidentified and randomized. The entire cohort was analyzed by 3 clinicians, as well as by the Emotrics program.

Main outcomes and measures: eFACE scores of the palpebral fissure at rest (0, wide; 100, balanced; 200, narrow), with gentle eyelid closure (0, incomplete; 100, complete), and with forceful eyelid closure (0, incomplete; 100, complete) before and after eyelid weight placement were compared with palpebral fissure measurements by Emotrics.

Results: Of the 53 participants, 33 were women, and mean (SD) age was 44.7 (18) years. The mean (SD) eFACE scores and Emotrics measurements (in millimeters) before vs after eyelid weight placement of the palpebral fissure at rest (eFACE, 84.3 [15.9] vs 109.7 [21.4]; Emotrics, 10.3 [2.2] vs 9.1 [1.8]), with gentle eyelid closure (eFACE, 65.9 [28.0] vs 92.1 [15.4]; Emotrics, 4.4 [2.7] vs 1.3 [2.0]), and with forceful eyelid closure (eFACE, 75.1 [28.6] vs 97.0 [10.7]; Emotrics, 3.0 [3.1] vs 0.5 [1.3]) all significantly improved. Subgroup analysis of patients with expected recovery (eg, Bell palsy) (n = 40) demonstrated significant development of ocular synkinesis on eFACE (83.9 [22.7] vs 98.9 [4.4]) after weight placement, which could also explain the improvement in eyelid function. The scores of patients with no expected recovery (n = 13) improved in both eFACE and Emotrics analysis following eyelid weight placement, though results did not reach significance, likely limited by the small subgroup size.

Conclusions and relevance: The eFACE tool agrees well with automated, objective facial measurements using a machine-learning based algorithm such as Emotrics. The eFACE tool is sensitive to spontaneous recovery and surgical intervention, and may be used for rapid regional facial

Importance: This study characterizes and compares common surgical manipulations' effects on septal cartilage to understand their implications for rhinoplasty outcomes based on cell viability and cartilage health.

Objective: To illustrate distinct differences in the impact of various surgical manipulations on septal cartilage in an in vitro septal cartilage model. A secondary objective is to better understand the chondrocyte's response to injury as well as how alterations in the extracellular matrix correspond to chondrocyte viability.

Design, setting, and participants: In this bench-top in vitro porcine model using juvenile bovine septal cartilage from bovine snouts, easily obtainable septal cartilage was used to generate large numbers of homogenous cartilage specimens. Quantitative outcomes at early and late time points were cell viability, cell stress, matrix loss, and qualitative assessment through histologic examination. The study was performed at a single academic tertiary care research hospital.

Interventions: Four common surgical manipulations were contrasted with a control group: crushed cartilage, scored cartilage, diced cartilage, and shaved cartilage.

Main outcomes and measures: Following the manipulation of the cartilage, the quantitative outcomes were glycosaminoglycan release to the media, lactate dehydrogenase release to the media, and cell death analysis through apoptosis staining. The qualitative outcomes were histologic staining of the manipulated cartilage with safranin-O/fast green stain to identify proteoglycan loss.

Results: The crushing followed by shaving manipulations were the most damaging as indicated by increased levels of lactate dehydrogenase release, glycosaminoglycans loss, and cell death. Matrix loss did not increase until after 48 hours postinjury. Furthermore, chondrocyte death was seen early after injury and accelerated to the late time point, day 9, in all manipulations. Conversely, cell stress was found to be greater at 48 hours postinjury, which then declined to the late time point, day 9.

Conclusions and relevance: The crushing manipulation followed by shaving and then dicing were the most destructive methods of cartilage manipulation relative to control specimens. Collectively, these outcomes demonstrate the range of injury which occurs with all septal cartilage manipulations and can inform rhinoplasty practice to use the least damaging effective surgical manipulation to obtain the desired outcome.

Level of evidence: NA.

Importance: Aberrant synkinetic movement after facial nerve injury can lead to prominent facial asymmetry and resultant psychological distress. The current practices of neuroinhibition to promote greater facial symmetry are often temporary in nature and require repeated procedures.

Objective: To determine whether myelin-associated glycoprotein (MAG), a specific neuroinhibitor, can prevent neuroregeneration with efficacy comparable with that of vincristine, a well-established neurotoxin.

Design, setting, and participants: Rats transgenic for Thy-1 cell surface antigen-green fluorescent protein (Thy1-Gfp) were randomized into 3 groups. Each rat received bilateral crush axotomy injuries to the buccal and marginal mandibular branches of the facial nerves. The animals received intraneural injection of saline, MAG, or vincristine.

Main outcomes and measures: The animals were imaged via fluorescent microscopy at weeks 1, 3, 4, and 5 after surgery. Quantitative fluorescent data were generated as mean intensities of nerve segments proximal and distal to the axotomy site. Electrophysiological analysis, via measurement of compound muscle action potentials, was performed at weeks 0, 3, 4, and 5 after surgery.

Results: A total of 12 rats were included in the study. Administration of MAG significantly reduced fluorescent intensity of the distal nerve in comparison with the control group at week 3 (mean [SD], MAG group: 94 [11] intensity units vs control group: 130 [11] intensity units; P < .001), week 4 (MAG group: 81 [19] intensity units vs control group: 103 [9] intensity units; P = .004), and week 5 (MAG group: 76 [10] intensity units vs control group: 94 [10] intensity units; P < .001). In addition, rats treated with MAG had greater fluorescent intensity than those treated with vincristine at week 3 (mean [SD], MAG group: 94 [11] intensity units vs vincristine group: 76 [6] intensity units; P = .03), although there was no significant difference for weeks 4 and 5. At week 5, both MAG and vincristine demonstrated lower distal nerve to proximal nerve intensity ratios than the control group (control group, 0.94; vs MAG group, 0.82; P = .01; vs vincristine group; 0.77; P < .001). There was no significant difference in amplitude between the experimental groups at week 5 of electrophysiological testing.

Conclusions and relevance: Lower facial asymmetry and synkinesis are common persistent concerns to patients after facial nerve injury. Using the Thy1-Gfp rat, this study demonstrates effective inhibition of neuroregeneration via intraneural application of MAG in a crush axotomy model, comparable with results with vincristine. By potentially avoiding systemic toxic effects of vincristine, MAG demonstrates potential as an inhibitor of neural regeneration for patients with synkinesis.

Level of evidence: NA.

Importance: Using health utility values (HUVs) as an outcome measure for surgical procedures, including rhinoplasty, allows for a standardized measurement of the qualitative and financial benefit of that procedure on overall health.

Objective: To use Euroqol 5-Dimension (EQ-5D)-derived HUVs to evaluate nasal obstruction outcomes following surgery between primary rhinoplasty (PSRP) and rhinoplasty with previous nasal surgery (RNS) in a prospective cohort study.

Design, setting, and participants: A single-institution prospective cohort study between 2013 and 2017 was carried out including 185 patients who underwent RNS before functional rhinoplasty and 278 patients who underwent PSRP for nasal obstruction. The analysis was carried out between December 2018 and February 2019.

Main outcomes and measures: Patients in the RNS cohort and PSRP cohort who completed the EQ-5D questionnaire immediately prior to surgery and postoperatively at 2, 4, 6, and 12 months were included in the study. The EQ-5D scores were converted to HUV scores and compared to evaluate for improvement in health status following surgery.

Results: Of the 185 patients in the RNS cohort, 97 (52%) were women and the mean (SD) age was 42.6 (13.4) years. Of the 278 in the PSRP cohort, 156 (55%) were women and the mean (SD) age was 36.0 (15.8) years. Both cohorts experienced significant improvement in HUV postoperatively. The mean (SD) HUV values were decreased in the RNS cohort versus the PSRP cohort both preoperatively (0.85 [0.16] versus 0.89 [0.14]) and postoperatively at 1 year (0.92 [0.14] versus 0.94 [0.11]); however, the difference in HUV was not statistically significant after 6 months postoperatively. Patients in the RNS cohort were typically older (76 [41%] older than 40 years vs 84 [31%], P = .02) and more likely to have sleep apnea (31 [19%] vs 24 [10%], P = .01) than in the PSRP cohort. On multivariable analysis, the use of spreader grafts and alar rim grafts in the PSRP cohort was significantly associated with improved HUV at 12 months. (r = -0.06; 95% CI, -0.11 to -0.01, P = .03).

Conclusions and relevance: Patients with a history of prior nasal surgery may represent a unique cohort when assessing health utility outcomes. Euroqol 5-dimension questionnaire-derived HUVs are a valid predictor of outcomes in all patients who undergo septorhinoplasty. Although outcomes were significantly improved for both cohorts, previous surgical history should be considered when performing cost utility analysis on the benefits of functional rhinoplasty.

Level of evidence: 3.

Importance: Social media platforms and photograph (photo) editing applications are increasingly popular sources of inspiration for individuals interested in cosmetic surgery. However, the specific associations between social media and photo editing application use and perceptions of cosmetic surgery remain unknown.

Objective: To assess whether self-esteem and the use of social media and photo editing applications are associated with cosmetic surgery attitudes.

Design, setting, and participants: A population-based survey study was conducted from July 1 to September 19, 2018. The web-based survey was administered through online platforms to 252 participants.

Main outcomes and measures: Each participant's self-esteem was measured using the Rosenberg Self-esteem Scale (scores range from 0-30; higher scores indicate higher self-esteem) and the Contingencies of Self-worth Scale (scores range from 1-7; higher scores indicate higher self-worth). Cosmetic surgery attitude was measured using the Acceptance of Cosmetic Surgery Scale (scores range from 1-7; higher scores indicate higher acceptance of cosmetic surgery). Unpaired, 2-tailed t tests were used to assess the significance of self-esteem and cosmetic surgery attitude score differences among users of various social media and photo editing applications. Structural equation modeling was used to assess the association between social media investment and cosmetic surgery attitudes.

Results: Of the 252 participants, 184 (73.0%) were women, 134 (53.2%) reported themselves to be white, and the mean age was 24.7 (range, 18-55) years. Scores on the Rosenberg Self-esteem Scale from users and nonusers across applications were compared, with lower self-esteem scores noted in participants who reported using YouTube (difference in scores, -1.56; 95% CI, -3.01 to -0.10), WhatsApp (difference in scores, -1.47; 95% CI, -2.78 to -0.17), VSCO (difference in scores, -3.20; 95% CI, -4.98 to -1.42), and Photoshop (difference in scores, -2.92; 95% CI, -5.65 to -0.19). Comparison of self-esteem scores for participants who reported using other social media and photo editing applications yielded no significant differences. Social media investment had a positive association with consideration of cosmetic surgery (R, 0.35; 95% CI, 0.04-0.66). A higher overall score on the Acceptance of Cosmetic Surgery Scale was noted in users of Tinder (difference in means, 0.79; 95% CI, 0.34-1.23), Snapchat (difference in means, 0.39; 95% CI, 0.07 to 0.71), and/or Snapchat photo filters (difference in means, 0.44; 95% CI, 0.16-0.72). Increased consideration of cosmetic surgery but not overall acceptance of surgery was noted in users of VSCO (difference in means, 0.84; 95% CI, 0.32-1.35) and Instagram photo filters (difference in means, 0.38; 95% CI, 0.01-0.76) compared with nonusers.

Conclusions and relevance: