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A quantitative comparison of immediate and long-term results of surgical correction of the senile upper lip using lip advancement and lip lift.Retrospective review of 30 patients who underwent senile upper lip repair, including lip advancement or lip lift. Digital image analysis was used to standardize each patient's preoperative and postoperative photographs for accurate, objective comparison.Lip lift and lip advancement achieve significant improvement in the appearance of the senile upper lip (P.001). This improvement is sustained during many years (mean, 5 y; P.001). Using repeated measures analysis of variance, no significant difference was found in the operative group compared with the control group when examining age-related change.Lip advancement and lip lift can restore the senile upper lip to a more youthful and natural appearance with sustained long-term benefits.

Objective: Current treatments for vocal fold paralysis are suboptimal in that they fail to restore dynamic function. Autologous muscle stem cell (MSC) therapy is a promising potential therapy for vocal fold paralysis in that it can attenuate denervation-induced muscle atrophy and provide a vehicle for delivery of neurotrophic factors, thereby potentially selectively guiding reinnervation. The goal of this project was to characterize optimal conditions for injected autologous MSC survival in the thyroarytenoid (TA) muscle following recurrent laryngeal nerve (RLN) injury by local administration of adjuvant factors. Study Design: Animal experiment. Methods: Unilateral RLN transection and sternocleidomastoid muscle (∼1 g) biopsies were performed in 20 male Wistar rats. One month later, 106 autologous MSCs labeled via retroviral-enhanced green fluorescent protein (EGFP) transduction were injected into the denervated hemilarynx of each animal with one of four adjuvant therapies: cardiotoxin [(CTX) 10−5 M], insulin-like growth factor-1 [(IGF- 1) 100 μg/mL], ciliary neurotrophic factor [(CNTF) 50 μg/mL], or saline. Animals were euthanized 1 month later and larynges harvested, sectioned, and analyzed for MSC survival. Results: All specimens demonstrate extensive MSC survival, with fusion of the MSCs with the denervated myofibers. Based on mean fluorescent intensity of the laryngeal specimens, IGF-1 and CNTF had the greatest positive influence on MSC survival. Myofiber diameters demonstrated myofiber atrophy to be inversely related to MSC survival, with the least atrophy in the groups having the greatest MSC survival. Conclusions: Autologous MSC therapy may be a future treatment for vocal fold paralysis. These findings support a model whereby MSCs genetically engineered to secrete CNTF and/or IGF-1 may not only promote neural regeneration, but also enhance MSC survival in an autocrine fashion.

Purpose To describe the results of posterior conjunctival plication for the treatment of secondary eyelid ptosis after eyelid retraction repair in Graves disease. Methods Case series. All patients were evaluated preoperatively by routine eye examination and eyelid measurements including Margin Reflex Distance 1 and levator function. Two eyes of 2 patients who presented with ptosis following eyelid retraction repair were corrected with posterior conjunctival plication. Results Posterior conjunctival plication for secondary ptosis following eyelid retraction repair was successful in 2 eyelids of 2 patients with Graves disease. Follow up period ranged from 6–10 months over which no sign of recurrent ptosis was observed. Conclusions Posterior conjunctival plication is an effective surgical technique for the correction of secondary ptosis following eyelid retraction repair in patients with Graves disease.

The ultimate goal for most facial plastic surgeons is to develop a successful practice. For those currently owning a practice and those planning on developing a practice, the skills and training necessary to establish and manage a facial plastic practice are not taught in medical school, residency, or most fellowships. The goal of this article is to underline the key principles of running a successful business. This article does not replace an MBA, but it allows you to be aware of potential challenges that all businesses encounter.

Clinical management of nasal airway obstruction (NAO) in patients with and without nasal allergic symptoms and nasal valve collapse (NVC).To examine the impact that autologous alar batten grafts have on patients with NAO owing to NVC and their affect on nasal steroid use and allergic symptoms.A prospective study.Indiana University Medical Center, Indianapolis.Patients with NAO due to NVC with or without symptoms of nasal allergic symptoms.All of the patients had placement of autologous batten grafts during the study period.Prospective study of patients with dynamic NVC undergoing alar batten graft treatment.Nasal Obstruction Symptom Evaluation survey preoperatively and postoperatively, prospective outpatient questionnaire to determine use of nasal steroids and presence of nasal allergic symptoms preoperatively and postoperatively.A total of 126 patients underwent surgical intervention for the treatment of NAO due to NVC. All of these patients were using nasal steroid sprays, and 78 patients (62%) also reported nasal allergic symptoms at their initial presentation. At 6-month and 1-year postoperative evaluations, 118 (94%) and 122 (97%), respectively, reported significant improvement of their NAO, regardless if they had presented with or without allergic nasal symptoms. Sixty-two of the 78 patients (79%) who initially presented with NAO owing to NVC and nasal allergic symptoms preoperatively reported significant improvement in their NAO and nasal allergic symptoms postoperatively. Eight of 126 (6%) restarted their use of nasal steroids postoperatively. All 8 of these patients reported nasal allergic symptoms preoperatively. No patients in the nonallergic group continued the use of nasal steroids postoperatively. There was no increase in nasal steroid use at the 12-month follow-up visit.Nasal airway obstruction due to NVC in patients can be surgically treated with autologous alar batten grafts. In addition, the use of alar batten grafts may improve NAO in patients with nasal allergic symptoms and reduces their use of nasal steroids. These results support the idea of potential surgical repair of the nasal valve to treat patients with NAO due to nasal allergic symptoms and NVC.4.

Purpose To determine the role of fracture size and soft tissue herniation as measured by computed tomography in predicting the development of persistent diplopia in patients with isolated orbital floor fractures. Methods A retrospective chart review identified patients presenting between March 2009 and 2012 with isolated orbital floor fractures. Computed tomographic scans were assessed for transverse fracture size and absence or presence of soft tissue herniation and rectus involvement. Presence of diplopia at 6–10 days, decision for surgical repair, and presence of diplopia were recorded. Results Fifty-six patients fulfilled inclusion criteria. Eighteen of 56 patients (32%) had preoperative diplopia. In Type A fractures, 0/9 (0%) small, 1/8 (12.5%) medium, and 2/14 (14%) large fractures had diplopia. For Type B fractures, 3/4 (75%) small, 9/13 (69%) medium, and 4/8 (50%) large fractures had diplopia. Type B fractures were significantly more likely to cause diplopia than Type A fractures in the small (p = 0.003) and medium (p = 0.007) size groups but not in the large groups (p = 0.07). Conclusion Transverse fracture size and presence of soft tissue herniation on CT imaging can predict development of persistent diplopia in isolated orbital floor fractures. Small and medium sized fractures with soft tissue herniation are more likely to cause diplopia than large sized fractures. We recommend early repair or closer observation of small and medium sized orbital floor fractures with soft tissue herniation due to the high risk of diplopia.

Summary Background/Objective When adductor vocal fold paresis manifests without obvious motion impairment, identifying the paretic side can be challenging. Although increased vocal fold waveform amplitude (“floppiness”) on videostroboscopy may be helpful, it has been shown to have low interrater reliability. We have found that the interarytenoid spatial relationship (IASR) can often accurately be used to predict the sidedness of electromyography (EMG)-determined unilateral adductor (thyroarytenoid/lateral cricoarytenoid [TA/LCA]) paresis. The goal of this study was to determine if a series of otolaryngology residents could learn to assess the IASR on videostroboscopy and use the IASR to identify the side of EMG-documented adductor paresis with high accuracy and interrater reliability. Study Design Otolaryngology resident population surveys. Methods Ten residents were given videostroboscopy images on abduction/adduction from 10 consecutive patients with EMG-documented unilateral TA/LCA paresis and asked to identify the paretic side in a pretest. The IASR was then conceptually introduced to the otolaryngology residents in a brief presentation. Posttesting was then performed and used to assess EMG-based accuracy and interrater reliability. Results Before the IASR presentation, otolaryngology residents accurately identified the paretic side in 63% (95% confidence interval [CI]: 56–70%) of cases. In the posttest session, the residents accurately identified the paretic side in 93% (95% CI: 87–99%) of cases, and interrater reliability was 0.873. Conclusions The IASR may be useful in determining sidedness in cases of unilateral TA/LCA paresis. Further studies are needed to determine the sensitivity and specificity of the IASR for determining sidedness of unilateral TA/LCA paresis with intact mobility.

Objectives To learn how nasal batten grafts affect patients' assessment of their nasal airway patency and to determine the extent to which patients believe batten grafts altered their appearance. Methods A prospective survey study of 18 patients in a tertiary veterans hospital who had nasal airway obstruction (NAO) due to nasal valve collapse was completed. Patients had placement of bilateral polyethylene batten grafts during a 36-month study period. The Nasal Obstruction Symptom Evaluation (NOSE) validated survey was used to measure a patient's subjective postoperative change in nasal airway obstruction. In addition, the patients were asked to rate the extent their appearance had changed. Results All patients presented with complaints of NAO due to nasal valve collapse either in isolation or in combination with another anatomical source of obstruction. The nasal valve collapse was identified by clinical examination. All patients had preoperative photographs. Most patients had a trial with an intranasal stent before opting for surgical implantation of the batten grafts. The results of the NOSE survey demonstrate significant improvement in nasal obstruction. Patients also reported only a minimal change in appearance. There was 1 patient with implant extrusions and only a few implants were removed. Conclusions Nasal airway obstruction due to nasal valve collapse can be effectively treated with polyethylene batten grafts. The implants are well tolerated, and patients report a significant improvement in NAO. There is little risk of implant extrusion, exposure, or intolerance. In addition, patients did not note a significant change to their appearance.

The alar-spanning suture is a surgical technique used by an experienced rhinoplastic surgeon to address certain nasal tip deformities. Wide nasal tip deformities with strong, convex lower lateral cartilages are best indicated for treatment with this technique. The alar-spanning suture can improve lateral crural position and eliminate dead space by refining and narrowing the supratip, often without requiring extensive dissection or additional strut grafting. We use operative photographs and an intraoperative video to demonstrate the alar-spanning suture technique, which is a useful addition to the armamentarium of any rhinoplastic surgeon.

OBJECTIVES To offer a novel framework that provides residents and practitioners with a reliable and surgically relevant method for identifying the facial nerve trunk (CNVII) after exiting the skull base during parotidectomy. METHODS The currently available literature and textbooks do not completely address the challenges trainees encounter in learning how to identify CNVII during parotidectomy. In response to this gap in the literature and potential associated deficits in surgical training, we developed an approach that integrates multiplanar intersections (based on mathematical principles) with surgical anatomy to create a reliable method for CNVII identification during parotidectomy. RESULTS The multiplanar intersections shown via our medical illustrations and surgical photography demonstrate the application of the triangulation concept to improve the accuracy and efficiency in surgical localization of CNVII. CONCLUSIONS The integration of multiplanar localization with surgical anatomy provides a reliable method for a surgeon to consistently and rapidly identify the CNVII, which inherently reduces the risk for inadvertent injury to the CNVII.

Patients with facial paralysis present with a constellation of ocular manifestations. Ectropion resulting from downward displacement of the lower eyelid appears after loss of orbicularis tone and function.1 In addition, upper eyelid retraction, resulting in lagophthalmos and a decrease in tear production and/or proper tear distribution and channeling,may result in dry eyes and epiphora. Tear flow is impairedbecause of a dysfunctional orbicularis oculimuscle and a decrease in transportation of tears.2 Thegoalsof surgery forparalytic lowereyelidectropionand lagophthalmos are to preserve visual acuity, improve corneal exposure, reduce ocular complaints, and restore facial symmetry. Initial management would include the application of an ocular lubricant, use of a moisture chamber, or possibly temporary tarsorrhaphy.Whenparalysis is expected to persist, a more permanent procedure is needed. The use of a laterally based tarsoconjunctival flap combinedwith a standard lower eyelid ectropion repair allows for correction of the constellations of symptoms observed in patients with paralytic ectropion in a single-stage surgical procedure. The technique can be viewed in the Video.