Highlights
The Efficacy of Oral Celecoxib for Acute Postoperative Pain in Face-lift Surgery
Importance
Exploring methods of potentially improving patient comfort and pain control in cosmetic facial surgery.
Objective
To examine the effects of celecoxib in reducing pain and possible opioid consumption following face-lift surgery.
Design, Setting, and Participants
We reviewed the medical records of 100 patients: 50 consecutive patients who underwent a face-lift without receiving perioperative celecoxib and 50 patients who underwent face-lift and received immediate preoperative and standing postoperative celecoxib.
Main Outcomes and Measures
In addition to demographic information, the following outcome measures were recorded for each group: visual analog scale patient-reported pain, acetaminophen and/or opioid consumption rates, and related analgesic adverse effects.
Results
The participants in the noncelecoxib vs celecoxib groups had similar demographic characteristics: mean age, 59.6 vs 57.9 years; mean BMI, 23.3 vs 22.3; history of chronic pain or opioid use, 7 (14%) vs 6 (12%); and 94% of both groups were women. Postoperative pain scores were higher in the noncelecoxib vs celecoxib groups; mean (SD) overall pain score was 3.88 (2.20) vs 2.31 (2.36) (P < .001). The noncelecoxib group had a higher number of postoperative opioid doses than did the celecoxib group: 9.40 (4.30) vs 5.18 (4.58) (P < .05). The noncelecoxib group had a higher incidence of postoperative nausea and vomiting: 12 (24%) vs 0 in the celecoxib group.
Conclusions and Relevance
Preemptive treatment with oral celecoxib appears to be effective in decreasing acute postoperative pain and opioid consumption in patients undergoing face-lift. Given the well-documented adverse effects of opioids, celecoxib is a desirable alternative.
Level of Evidence
3.
Population-Based Assessment of Currently Proposed Ideals of Nasal Tip Projection and Rotation in Young Women
Importance
There is no universally accepted quantitative metric that defines the ideal nasal tip rotation and projection.
Objective
To identify the ideal nasal tip projection (NTP) and rotation by using 3 classic NTP methods (Crumley 1, Crumley 2, and Goode).
Design, Setting, and Participants
Lateral facial portraits of normal-appearing white women aged 18 to 25 years were selected from a previously validated and attractiveness-scored database of images. Each image was digitally modified to fit the NTP ideals outlined by the Crumley 1, Crumley 2, and Goode methods with columellar facial angles (rotation metric) of 96°, 101°, 106°, 111°, and 116° (15 modified images per portrait). These variants were incorporated into electronic surveys that were distributed to traditional focus-group and online social-network participants. Analysis was performed using paired comparison analysis, a consumer preference research analytic. The traditional focus-group participants were undergraduate students at the University of California, Irvine, whose online social-network contacts were also used.
Main Outcomes and Measures
Mean ranks.
Results
There were no significant differences in preference between the traditional focus-group (n = 106) and online participants (n = 3872) (P > .05). The most preferred rotation variant for all 3 NTP methods was 106° (Crumley 1: mean rank, 2.11 [95% CI, 2.07-2.16]; Crumley 2: mean rank, 2.07 [95% CI, 2.02-2.12]; and Goode: mean rank, 2.05 [95% CI, 1.99-2.11]; P < .001). Crumley 1 was considered to be the most attractive NTP method (mean rank, 1.84 [95% CI, 1.82-1.85]; P < .001) overall and was the most preferred NTP method for faces of above-average attractiveness (mean rank, 1.78 [95% CI, 1.76-1.80]; P < .001). No significantly preferred NTP method was found for faces of average attractiveness (P > .05). The most aesthetic combination of tip rotation and projection was a columellar facial angle of 106° with the Crumley 1 tip projection.
Conclusions and Relevance
To our knowledge, this is the first population-based study to attempt to simultaneously determine the ideal NTP and rotation. Each classic NTP method uses measurements dependent on both projection and rotation; thus, ideal rotation for each NTP method must be determined before comparison of the ideals. A rotation of 106° (columellar facial angle) was found to be the most aesthetic. The Crumley 1 method was determined to be the most attractive nasal tip variant overall.
Level of Evidence
NA.
Characterization of Postoperative Changes in Nasal Airflow Using a Cadaveric Computational Fluid Dynamics Model Supporting the Internal Nasal Valve
Importance
Collapse or compromise of the internal nasal valve (INV) results in symptomatic nasal obstruction; thus, various surgical maneuvers are designed to support the INV.
Objective
To determine the effect on nasal airflow after various surgical techniques focused at the level of the INV and lateral nasal sidewall.
Design and Setting
A fresh cadaver head was obtained and underwent suture and cartilage graft techniques directed at the level of the INV using an external approach. Preoperative and postoperative digital nasal models were created from the high-resolution, fine-cut, computed tomographic imaging after each intervention. Isolating the interventions to the level of the INV, we used computational fluid dynamic techniques to calculate nasal resistance, nasal airflow, and nasal airflow partitioning for each intervention.
Intervention
Suture and cartilage graft techniques.
Main Outcomes and Measures
Nasal airflow, nasal resistance, and partitioning of airflow.
Results
Using the soft-tissue elevation model as baseline, computational fluid dynamic analysis predicted that most of the suture and cartilage graft techniques directed toward the nasal valve improved nasal airflow and partitioning while reducing nasal resistance. Specifically, medial and modified flare suture techniques alone improved nasal airflow by 16.9% and 15.1%, respectively. The combination of spreader grafts and modified flare suture improved nasal airflow by 13.2%, whereas spreader grafts alone only improved airflow by 5.9%. The largest improvements in bilateral nasal resistance were achieved using the medial and modified flare sutures, outperforming the combination of spreader grafts and modified flare suture.
Conclusions and Relevance
Techniques directed at supporting the INV have tremendous value in the treatment of nasal obstruction. The use of flare sutures alone can address dynamic valve collapse or upper lateral cartilage incompetence without gross disruption of the nasal architecture. Using computational fluid dynamic techniques, this study suggests that flare sutures alone may improve flow and reduce resistance when placed medially, surpassing spreader grafts alone or in combination with flare sutures. The longevity of these maneuvers can only be assessed in the clinical setting. Studies in additional specimens and clinical correlation in human subjects deserve further attention and investigation.
Level of Evidence
NA.
Treatment Outcomes of Extracorporeal Septoplasty Compared With In Situ Septal Correction in Rhinoplasty
Importance
Extracorporeal septoplasty (ECS) in rhinoplasty is a useful surgical procedure that can achieve considerable functional and aesthetic improvements in the treatment of a deviated nose. However, to our knowledge, no study has compared the treatment outcomes of ECS with those of in situ septal correction (ISSC) in rhinoplasty.
Objective
To compare the surgical outcomes of ECS with those of conventional ISSC in the treatment of a deviated nose.
Design, Setting, and Participants
We retrospectively reviewed the medical records of 169 patients who underwent rhinoplasty from July 1, 2006, through December 31, 2012. For ECS, we used a modified technique. For ISSC, several techniques, including batten and spreader grafting and caudal cutting and suture, were used alone or in combination. Eighty-four patients underwent ECS. The remaining 85 patients, who were age- and sex-matched controls who were operated on at a similar time point, were treated by ISSC for the correction of a deviated nose.
Main Outcomes and Measures
Surgical outcomes were assessed and compared using the anthropometric measurement of photographs and by reviewing medical records to evaluate functional outcomes and complications after surgery.
Results
There were 52 I-shape (61.9%) and 32 C-shape (38.1%) types of external nose deviations in the ECS group. There were 59 I-shape (69.4%) and 26 C-shape (30.6%) types of external nose deviations in the ISSC group. Postoperative deviation angle (P < .001), nasofrontal (P < .05) and nasolabial (P < .001) angles, and nasal tip projection (P < .001) values were significantly improved from the preoperative values in both groups. The mean operating times of ECS and ISSC were 135 and 128 minutes, respectively. The rates of complications, such as an irregular contour of the dorsum, saddling, and postoperative infection, were similar between the 2 groups. However, no patients in the ECS group experienced postoperative nasal obstruction, whereas 5 of 78 patients (6.4%) in the ISSC group experienced persistent or unresolved nasal obstruction that required revision septoplasty.
Conclusions and Relevance
We found that ECS is a useful technique for markedly deviated noses that can achieve a comparable aesthetic success but better functional outcome than ISSC in rhinoplasty.
Level of Evidence
3.
Surface Electromyographic Mapping of the Orbicularis Oculi Muscle for Real-Time Blink Detection
Importance
Facial paralysis is a life-altering condition that significantly impairs function, appearance, and communication. Facial rehabilitation via closed-loop pacing represents a potential but as yet theoretical approach to reanimation. A first critical step toward closed-loop facial pacing in cases of unilateral paralysis is the detection of healthy movements to use as a trigger to prosthetically elicit automatic artificial movements on the contralateral side of the face.
Objectives
To test and to maximize the performance of an electromyography (EMG)-based blink detection system for applications in closed-loop facial pacing.
Design, Setting, and Participants
Blinking was detected across the periocular region by means of multichannel surface EMG at an academic neuroengineering and medical robotics laboratory among 15 healthy volunteers.
Main Outcomes and Measures
Real-time blink detection was accomplished by mapping the surface of the orbicularis oculi muscle on one side of the face with a multichannel surface EMG. The biosignal from each channel was independently processed; custom software registered a blink when an amplitude-based or slope-based suprathreshold activity was detected. The experiments were performed when participants were relaxed and during the production of particular orofacial movements. An F1 score metric was used to analyze software performance in detecting blinks.
Results
The maximal software performance was achieved when a blink was recorded from the superomedial orbit quadrant. At this recording location, the median F1 scores were 0.89 during spontaneous blinking, 0.82 when chewing gum, 0.80 when raising the eyebrows, and 0.70 when smiling. The overall performance of blink detection was significantly better at the superomedial quadrant (F1 score, 0.75) than at the traditionally used inferolateral quadrant (F1 score, 0.40) (P < .05).
Conclusions and Relevance
Electromyographic recording represents an accurate tool to detect spontaneous blinks as part of closed-loop facial pacing systems. The early detection of blink activity may allow real-time pacing via rapid triggering of contralateral muscles. Moreover, an EMG detection system can be integrated in external devices and in implanted neuroprostheses. A potential downside to this approach involves cross talk from adjacent muscles, which can be notably reduced by recording from the superomedial quadrant of the orbicularis oculi muscle and by applying proper signal processing.
Level of Evidence
NA.
Intraoperative Laser-Assisted Indocyanine Green Imaging for Objective Measurement of the Vascular Delay Technique in Locoregional Head and Neck Flaps
Importance
Reconstruction of oncologic or traumatic head and neck defects often requires complex planning of locoregional, pedicled, or interpolated flaps. In cases with a higher risk of flap failure, vascular delay with staged reconstruction can help improve tissue perfusion and increase chances of flap survival. An objective tool is needed to help guide reconstructive surgeons with the intraoperative decision to pursue vascular delay.
Objectives
To describe a pilot study using a novel application of a technique that quantifies and validates the benefit of the vascular delay procedure in locoregional flaps and to demonstrate a practical and broadly applicable technology that can be easily incorporated into intraoperative decision making and improve outcomes for high-risk flaps.
Design, Setting, and Participants
A pilot study using intraoperative laser-assisted indocyanine green imaging measurements and fluorescence videos to objectively measure the benefit of vascular delay procedures in patients with head and neck defects and wound healing risk factors requiring locoregional flap reconstruction at an academic tertiary care center.
Main Outcomes and Measures
Intraoperative laser-assisted indocyanine green imaging with video documentation and quantitative measurements was used to evaluate flap perfusion before a vascular delay procedure. Measurements were repeated after a 3-week vascular delay procedure.
Results
Two patients were identified based on comorbid conditions that resulted in a higher risk of flap failure, as well as the need for a locoregional flap for reconstruction. At the initial elevation of the flap, quantitative results from flap imaging demonstrated low perfusion numbers and minimal fluorescence, suggesting poor tissue perfusion and increased likelihood of postoperative flap compromise or failure. Following a vascular delay of 3 weeks, repeat measurements were substantially improved. No wound healing issues were observed.
Conclusions and Relevance
This is the first study to date to quantitatively demonstrate the benefit of the vascular delay technique in patients with potential vascular compromise in locoregional head and neck flap reconstruction. Data obtained suggest that this technology can be used to guide intraoperative decision making in complicated reconstructions and help optimize patient outcomes.
Level of Evidence
NA.
Use of Angular Vessels in Head and Neck Free-Tissue Transfer A Comprehensive Preclinical Evaluation
Importance
The angular artery, its perforating branches, and their zones of tissue perfusion have been described extensively for facial reconstruction. Various cutaneous and mucosal flaps with either anterograde or retrograde perfusion play an important role in facial and oral reconstruction. However, these flaps share the limitations of pedicled nature and donor-site intolerance. Free-tissue transfer (FTT) has transformed capabilities and outcomes in head and neck reconstruction. While less constrained by tissue volume and subtype, FTT has its own limitations, including pedicle reach for anastomosis to inflow and outflow vasculature in upper face reconstruction. The angular vessels, owing to their relatively high central location and accessibility via a camouflaged nasolabial fold incision, may have value in midface and nasal reconstruction.
Objectives
To detail a technique for consistently locating the angular vessels while preserving the integrity of adjacent neuromuscular structures and to evaluate the caliber and consistency of the angular artery and vein for their usability in microvascular anastomosis.
Design and Setting
We conducted a PubMed literature search for the terms angular artery, melolabial flap, nasolabial flap, retroangular flap, and any associations with FTT. We also performed 26 anatomic cadaveric dissections on 13 fresh cadavers to evaluate the angular arteries and veins.
Main Outcomes and Measures
Vessel caliber, length, and variability were analyzed and utility for use in FTT was assessed. A total of 26 angular arteries and 26 angular veins were included in the analysis. Anatomic relationships were used to develop a surgical schema for dissection and isolation of the angular vessels specifically for FTT.
Results
The angular vessels have consistent anatomic relationships facilitating localization and have a consistent caliber amenable to use in microvascular FTT. The mean (SD) artery diameter was 2.34 (0.67) mm prior to dilation and 3.21 (0.87) mm after dilation. The diameters of the vein before and after dilation were 3.57 (0.53) mm and 6.40 (0.81) mm, respectively. There was no statistical difference between the vessels on the right and left sides.
Conclusions and Relevance
We describe for the first time the anatomic cadaveric dissection and analysis of the angular arteries and veins specifically to determine compatibility with regard to FTT. We found good FTT compatibility.
Level of Evidence
NA.
Endoscopic Forehead Approach for Minimally Invasive Benign Tumor Excisions
Importance
Direct transcutaneous resection has been a widely accepted standard for the removal of benign forehead lesions. In recent years, the endoscopic approach has become more prevalent because of its noninvasiveness. To date, only a few studies with limited case numbers have reported on this technique. We report our findings from one of the largest cohorts of patients undergoing tumor resection of the forehead via the endoscopic approach.
Objectives
To evaluate results of the endoscopic forehead approach for benign tumor excisions, to give a more nuanced insight into this procedure, and to discuss technical pearls and potential pitfalls from our experience.
Design, Setting, and Participants
Multicenter, retrospective case study at 2 university centers and 1 private practice among 36 patients aged 18 to 72 years (mean age, 44 years) who underwent the endoscopic forehead approach for benign tumor resections.
Main Outcomes and Measures
Symptoms at presentation, surgical procedure and duration, type of lesions, intraoperative and postoperative complications, recurrences, and patient satisfaction.
Results
In total, 34 patients had an asymptomatic forehead mass, while 2 patients reported discomfort and headache. Among all patients, complete tumor excision was achieved endoscopically. The mean operative time was 36 minutes. Histopathological examination revealed 18 lipomas, 13 osteomas, 2 dermoid cysts, and 1 bone fragment after previous rhinoplasty. In 2 patients, no specimen was submitted. No hematomas, infections, scalp numbness, contour irregularities, temporal branch paralysis, or tumor recurrences occurred. One patient had a prolonged area of alopecia, which resolved on its own. All patients attested to a high satisfaction rate.
Conclusions and Relevance
The endoscopic approach offers excellent aesthetic results and allows for safe tumor removal. It has proven to be an effective and minimally invasive alternative to the conventional open approach.
Level of Evidence
4.
Salvage Procedures After Failed Facial Reanimation Surgery Using the Masseteric Nerve as the Motor Nerve for Free Functional Gracilis Muscle Transfer
Importance
Free muscle transfer innervated by a cross-facial nerve graft represents the criterion standard for smile reconstruction in facial paralysis. If primary reconstruction fails, a second muscle transfer is usually needed. Herein, we investigated the possibility of avoiding a second free muscle transfer by in situ coaptation of the gracilis muscle to the masseteric nerve.
Observations
We report a series of 3 failed free muscle transfers for facial reanimation among 21 free flap transfers performed for facial reanimation between March 2008 and August 2013. To salvage the muscle, we performed coaptation of the neural pedicle from the cross-facial nerve graft to the masseteric nerve. This method allows for leaving the fixation sutures of the muscle at the oral commissure in place. All patients showed muscle contraction after 3 months and a smile with open mouth after 6 months. No significant difference in the range of commissure excursion was observed between the healthy and operated sides.
Conclusions and Relevance
Recoaptation of the neural pedicle from the cross-facial nerve graft to the masseteric nerve, leaving the muscle transplant in place, is a suitable salvage procedure after unsuccessful reconstruction with a cross-facial nerve graft, avoiding a second free muscle transfer.
Level of Evidence
4.