JAMA facial plastic surgery最新文献

Importance: Rhytidectomy, or face-lift surgery, is the mainstay of facial rejuvenation and is constantly evolving. There is continuous research to improve outcomes and minimize complications of this surgery.

Objective: To synthesize the updated techniques in rhytidectomy published during the past 5 years, including surgical technique, advances in anesthetic technique, minimally invasive techniques, and adjunctive procedures performed at the time of rhytidectomy.

Evidence review: On February 8, 2018, a literature search was performed of the PubMed and Cochrane databases using the search terms, face-lift or rhytidectomy and techniques. Articles published from February 8, 2013, to February 8, 2018, that related to techniques of facial rejuvenation in the lower one-third of the face by lifting and supporting tissue with 5 or more patients were included. Systematic reviews and primary literature were considered; narrative reviews, validation studies, and anatomic studies were eliminated. The initial search resulted in 604 articles after duplicates were removed. This was reduced to 84 articles after dual independent review screening.

Findings: Of the 84 articles included, 51 (61%) regarding techniques of face-lifting in the past 5 years pertained to soft-tissue techniques; 14 (17%) pertained to implants or adjunctive medications, such as tissue sealants; and 12 (14%) related to adjunctive techniques performed in addition to face-lifting, such as fat grafting, resurfacing, and liposuction. All studies found the techniques reported therein to be effective, with similar or fewer complications compared with the literature. However, according to the Oxford Centre for Evidence-Based Medicine criteria, the level of evidence of the studies was generally poor, because 45 of the studies (54%) were case series (level 4 of evidence).

Conclusions and relevance: Several new techniques have been explored for rhytidectomy or face-lift in the past 5 years, including soft-tissue techniques, introduction of implants or topical medications such as tissue sealants, and concomitant adjunctive techniques to enhance results. The overall quality of the evidence is poor, with most articles using case series with nonvalidated measures to evaluate outcomes. There is considerable room for improvement in the literature if additional studies using cohort designs and validated outcomes are performed to validate the quality of the techniques introduced during the past 5 years.

Importance: There is no imaging standard to model nasal cartilage for the planning of rhinoplasty procedures. Preoperative visualization of cartilage may improve objective evaluation of nasal deformities, surgical planning, and surgical reconstruction.

Objectives: To evaluate the feasibility of visualizing nasal cartilage using high resolution micro-computed tomography (CT) compared with the criterion standard of pathologic findings in a cadaveric specimen and to evaluate its accuracy compared with various clinical CT protocols.

Design, setting, and participants: Anatomic study at the University of Washington using single human cadaveric nasal specimens performed from July 10, 2017, to March 30, 2018.

Interventions: A micro-CT acquisition with 60-micron resolution was obtained of a nasal specimen. The specimen was then scanned with 5 different clinical CT protocols to span both clinical care and machine limits. The specimen was then sectioned in 5-mm axial slices for pathologic analysis.

Main outcomes and measures: Micro-CT images were registered to pathologic specimen cross-sections using a graphite fiducial system. Cartilage substructures were manually segmented and analyzed. A library of matched images across the micro-CT and various clinical CT protocols was then developed. Region of interest analysis was performed for each of the cartilage structures and their boundaries on clinical CT protocols and micro-CT, with the outcome of mean (SD) density using Hounsfield units.

Results: A single human cadaveric nasal specimen was used to obtain the following results. Lower lateral cartilage, upper lateral cartilage, and septal cartilage were accurately delineated on the micro-CT images compared with pathologic findings. The mean absolute deviation from pathologic findings was 0.30 mm for septal cartilage thickness, 0.98 mm for maximal upper lateral cartilage length, and 1.40 mm for maximal lower lateral cartilage length. On clinical CT protocols, only septal cartilage was well discriminated from boundary. Higher radiation dose resulted in more accurate density measurements of cartilage, but it did not ultimately improve ability to discriminate cartilage.

Conclusions and relevance: The results of this anatomic study may represent a notable step toward advancing knowledge of the capabilities and pitfalls of nasal cartilage visualization on CT. Nasal cartilage visualization was feasible on the micro-CT compared with pathologic findings. Future research may further examine the barriers to accurately visualizing upper lateral cartilage and lower lateral cartilage, a prerequisite for clinical application.

Level of evidence: NA.

Importance: Blood loss from surgical procedures is a major issue worldwide as the demand for blood products is increasing. Tranexamic acid is an antifibrinolytic agent commonly used to reduce intraoperative blood loss.

Objective: To systematically examine the role of tranexamic acid in reducing intraoperative blood loss and postoperative edema and ecchymosis among patients undergoing primary elective rhinoplasty.

Data sources: A systematic review and meta-analysis was undertaken in an academic medical setting using Medline, Embase, and Google Scholar from inception to June 30, 2018. All references of included articles were screened for potential inclusion. The search was mapped to Medical Subject Headings, and the following terms were used to identify potential articles: reconstruction or rhinoplasty and tranexamic acid or anti-fibrinolysis or antifibrinolysis and bleeding or ecchymosis or bruising or edema or complications.

Study selection: The population of interest consisted of adult patients undergoing primary elective rhinoplasty. The intervention was the use of tranexamic acid. The control group was composed of patients receiving a placebo. Primary outcomes were intraoperative blood loss and postoperative edema and ecchymosis. In vitro or animal studies were excluded, and only English-language articles were included.

Data extraction and synthesis: The PRISMA guidelines were followed, and articles were assessed using the Cochrane Collaboration's tool for assessing risk of bias and the Grading of Recommendations Assessment, Development and Evaluation (GRADE) guidelines. Random-effects meta-analysis was performed to determine the overall effect size.

Main outcomes and measures: The primary outcomes were intraoperative blood loss and postoperative edema and ecchymosis.

Results: Five studies (comprising 332 patients) were included in the qualitative analysis, all of which were randomized clinical trials published within the past 5 years. The mean (SD) patient age was 27 (7) years (age range, 16-42 years), while the mean (SD) sample size was 66 (19) (range, 50-96). Meta-analysis of 4 studies (271 patients) indicated that tranexamic acid treatment resulted in a mean reduction in intraoperative blood loss of -41.6 mL (95% CI, -69.8 to -13.4 mL) compared with controls (P = .004). Three studies indicated that postoperative edema and ecchymosis were reduced with tranexamic acid treatment compared with controls; however, there was no significant difference compared with corticosteroid use. Four studies were considered of high methodological quality, with a low risk of bias. The overall quality of evidence was high.

Conclusions and relevance: Tranexamic acid has the ability to significantly reduce intraoperative blood loss and postoperative edema and ecchymosis among patients

Importance: In the last decade, there has been a significant increase in the number of practitioners administering botulinum toxin for facial synkinesis. However, there are few resources available to guide treatment patterns, and little is known about how these patterns are associated with functional outcomes and quality of life.

Objective: To evaluate botulinum treatment patterns, including the dosing and frequency of muscle targeting, for treatment of facial synkinesis and to quantify patient outcomes.

Design, setting, and participants: This prospective cohort study of 99 patients treated for facial synkinesis was conducted from January 2016 through December 2018 at the Vanderbilt Bill Wilkerson Center in Nashville, Tennessee, a tertiary referral center.

Intervention: Onabotulinum toxin A treatment of facial synkinesis.

Main outcomes and measures: Patient-reported outcomes on the Synkinesis Assessment Questionnaire and botulinum treatment patterns, including the dosages and frequency of injection for each facial muscle, were compared at the initiation of treatment and at the end of recorded treatment.

Results: In total, 99 patients (80 female patients [81%]) underwent botulinum injections for treatment of facial synkinesis. The median (interquartile range) age was 54.0 (43.5-61.5) years, and the median (interquartile range) follow-up was 27.1 (8.9-59.7) months. Most patients underwent injections after receiving a diagnosis of Bell palsy (41 patients, 41%) or after resection of vestibular schwannoma (36 patients [36%]). The patients received a total of 441 treatment injections, and 369 pretreatment and posttreatment Synkinesis Assessment Questionnaire scores were analyzed. The mean botulinum dose was 2 to 3 U for each facial muscle and 9 to 10 U for the platysma muscle. The dose increased over time for the majority of all muscles, with steady state achieved after a median of 3 treatments (interquartile range, 2-3). Linear regression analysis for cluster data of the mean total questionnaire score difference was -14.2 (95% CI, -17.0 to -11.5; P < .001). There was a significant association of postinjection questionnaire score with younger patients, female sex, total dose, and synkinesis severity. Oculo-oral synkinesis may respond more to treatment compared with oro-ocular synkinesis.

Conclusion and relevance: Patients with facial synkinesis responded significantly to botulinum treatment. Treatment began with 6 core facial muscles that were injected during most treatment sessions, and dosages increased after the first injection until steady state was achieved. Those with a greater degree of morbidity, younger patients, and females showed significant improvement, and the larger the dose administered, the greater the response. Oculo-oral synkinesis may be more responsive than oro-ocular synkinesi

Importance: Assessment of melolabial flap perfusion using indocyanine green (ICG) angiography for nasal reconstruction has not been previously described.

Objective: To assess melolabial flap relative perfusion using ICG angiography in nasal reconstruction and highlight its clinical relevance.

Design, setting, and participants: In this retrospective case series at a tertiary referral center, 10 patients undergoing melolabial flap reconstruction of nasal defects between January 2015 to April 2018 with flap perfusion were assessed by ICG angiography.

Exposures: Indocyanine green angiography was performed to assess melolabial flap perfusion at second stage surgery after temporary clamping of the pedicle and after pedicle division and flap inset.

Main outcomes and measures: Flap perfusion in relation to a reference point on the cheek was calculated after both pedicle clamping and division by 2 methods: (1) ingress (arterial inflow) and egress (venous outflow) flap-to-cheek ratio; (2) flap-to-cheek perfusion (fluorescence) ratio at 3 time points (midpoint of ICG flap inflow, maximum [peak] fluorescence, and midpoint of ICG outflow), and their calculated mean. Correlations of perfusion with time between stages, and patient factors were performed; perfusion parameters after temporary pedicle clamping and after division and flap inset were compared.

Results: Ten patients (mean [SD] age, 66 [7.5] years) were enrolled with a mean (SD) interval of 23 (4) days between first and second surgery. No correlation existed between perfusion parameters and time interval between first and second stage, or any other patient factors. Of the different perfusion parameters, a statistically significant difference was observed when comparing temporary clamping and postdivision mean (SD) flap-to-cheek perfusion ratio (0.89 [0.22] and 0.80 [0.19]; 95% CI, 4.1-12.6; P = .001), as well as mean (SD) peak perfusion ratio (0.81 [0.2] and 0.77 [0.2]; 95% CI, 0.005-0.080; P = .02) only. No partial or complete flap necrosis was reported after pedicle division.

Conclusions and relevance: Indocyanine green angiography is an effective method to determine neovascularization perfusion of melolabial flaps, with a mean perfusion of 89% after pedicle clamping. Future applications of this technology include use in patients at high risk for flap necrosis, or those who may benefit from early flap division to ensure adequate perfusion and minimize the time interval between staged procedures.

Level of evidence: NA.

Importance: Complications that arise after treatment of mandible fractures can result in significant morbidity. Identifying modifiable risk factors associated with these complications is valuable in guiding clinical practice for improved patient outcomes.

Objective: To describe the risk factors associated with complications in patients undergoing treatment for mandible fracture.

Design, setting, and participants: A retrospective review was conducted of 137 patients presenting to a tertiary care, level 1 trauma center with mandible fractures between January 1, 2014, and January 1, 2017. Outcomes and demographic characteristics for patients with at least 3 weeks of follow-up were compared using multivariate logistic regression analysis.

Results: Of the 137 patients meeting inclusion criteria, there were 113 males (82.5%) and 24 females (17.5%), with a mean (SD) age at presentation of 32.3 (15.7) years. Median follow-up was 71 days (range, 22-1189 days). Postoperative complications were identified in 29 patients (21.2%); complications included wound dehiscence or surgical site infection (n = 17), bony nonunion (n = 5), and hardware exposure (n = 13). Complications were managed surgically in 19 patients and nonsurgically in 10 patients. On univariate analysis, the initial surgery was completed later (mean [SD], 5.9 [6.6] days after injury) in patients who developed complications than in those who did not (mean [SD], 3.8 [4.0] days). On multivariate analysis, complications were associated with increased time from injury to treatment (odds ratio [OR], 1.60; 95% CI, 1.02-2.53; P = .04), tobacco use (OR, 8.10; 95% CI, 1.26-52.00; P = .03), and dental extraction (OR, 93.00; 95% CI, 1.19 to >999.00; P = .04). Residence in the same city as the medical center was associated with fewer complications (OR, 0.08; 95% CI, 0.01-0.69; P = .02).

Conclusions and relevance: In a 3-year review of mandible fractures managed at a single academic center, complications were associated with an increased time to treatment, tobacco use, dental extraction, and living farther from the treatment facility. On a systems level, the results of this study suggest that expediting intervention for mandible fractures may improve outcomes.

Level of evidence: 3.