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The goal of this review is to highlight the important clinical considerations that impact the facial aging process and discuss current assessment tools that are available to help guide the clinician on appropriate facial rejuvenation modalities. Extrinsic and intrinsic factors and their effects on facial aging continue to be studied. Ethnic and racial backgrounds play a critical role in the facial aging process. Gender’s impact on facial aging is explored. Several assessment tools have been developed to examine various subunits of the face, and other assessments have been created that account for the patient’s ethnic background. Facial aging is a dynamic and complex process. Understanding facial aging requires understanding changes in all layers of facial tissues as well as extrinsic and intrinsic factors that can affect the process, along with ethnic differences. Using appropriate assessment tools can help guide the clinician toward optimal treatment modalities.

The US population increases yearly and by 2050, experts predict the US population will be greater than 430 million. As the population has grown, it has diversified and includes the largest percentage of multiethnic Americans to date. Accessibility and popularity of aesthetic surgery also have increased. Approaches to rhinoplasty have evolved from a concept of cultural and ethnic transformation to concepts of ethnic preservation, with the goal of preserving features while harmonizing the nose with the rest of the face. To achieve this goal thoughtful consultation and consideration of the patient's self-defined ethnicity is paramount.

There are more than 11 million people in the world affected with keloids. Nevertheless, there is a lack of agreement in keloid management. Moreover, keloid research has left gaps in the understanding of its pathogenesis. Six questions are answered by 3 clinical scientists in an attempt to address common keloid controversies.

There are more than 11 million people in the world affected with keloids. Nevertheless, there is a lack of agreement in keloid management. Moreover, keloid research has left gaps in the understanding of its pathogenesis. Six questions are answered by 3 clinical scientists in an attempt to address common keloid controversies.

Objectives Create a head-and-neck keloid quality of life (QOL) questionnaire. Demonstrate the reliability of the keloid-specific QOL scale according to test-retest and internal consistency standards. Study Design Prospective cohort study. Methods Patients presenting to a keloid clinic in a tertiary referral institution between April 2012 and February 2013 were enrolled on their first visit. They were administered a questionnaire assessing demographics and a 21-item Likert keloid-specific survey assessing symptomatology, self-esteem, social functioning, and therapeutic motivation during their first three visits. Reliability of the keloid questionnaire was assessed for internal consistency (Cronbach's alpha) and test-retest correlations. Patients were treated with Kenalog steroid injections at each visit. The 126-point total score from the questionnaire was then compared to each subscale (physical symptoms, self-esteem, social function, and medical motivation) using a Pearson coefficient. Results The keloid QOL questionnaire showed a Cronbach's alpha of 0.87 for the overall questionnaire and ranged from 0.66 to 0.86 for individual questions. The test-retest Pearson's R was 0.70 between visits 1 and 2 and 0.77 between visits 2 and 3. The Pearson correlation between symptoms, self-esteem, social functioning, and medical motivation subscales and the overall scale were 0.77, 0.73, 0.72, and 0.57, respectively. Conclusion This head and neck keloid-specific QOL questionnaire proved to be a reproducible method of reliably assessing QOL burden on patients with head and neck keloids. Level of Evidence N/A. Laryngoscope, 125:2672–2676, 2015

The demand for facial rejuvenation and cosmetic procedures is rising among all ethnicities and skin types. The authors present a review of lasers and how to select a laser based on skin type and the treatment goals of laser resurfacing: skin laxity, dyschromia, hair removal, keloid, and hypertrophic scarring. In addition, they discuss preprocedural and postprocedural considerations, potential complications, and their management to maximize patient outcomes and minimize risk.

Keloids are benign, fibroproliferative growths that occur as a result of dermal injury in ~15% of the population. They are characterized by their extension beyond the confines of the original injury and often present with pain and pruritus. Additionally, these growths may result in cosmetic deformities and contribute to significant emotional distress. It is thought that keloids form as a result of aberrancies in the normal wound-healing process, which is complex and involves an elegant interplay between multiple cell types, cytokines, and proteins. The exact etiology is unknown, but significant research efforts have been made. These efforts have revealed that various cell types in keloids are either hyperresponsive and/or overproductive of various growth factors. Additionally, keloid cell types respond differently to mechanical strain than skin cells in patients who do not form keloids. This lack of understanding of keloid pathophysiology has left the care provider with a lack of a single definitive treatment strategy. Instead, a multitude of therapies exist ranging from surgery to injectables to lasers and any combination thereof. This purpose of this article is to highlight our current knowledge and emerging scientific understanding of keloid pathology and the current management strategies.

Keloid scarring is a form of fibroproliferative dermal wound healing characterized by growth beyond the confines of the original wound. Fibrocytes, derived from peripheral blood mononuclear cells and inhibited by serum amyloid P (SAP), have been linked to other fibroproliferative diseases. We hypothesized that peripheral blood mononuclear cells of keloid formers have a higher propensity to differentiate into fibrocytes and are more resistant to the effects of SAP. To test this hypothesis, plasma was isolated from peripheral blood samples of keloid (n = 10) and age/sex/race-matched control (n = 10) subjects, and SAP levels were measured by enzyme-linked immunosorbent assay. Equal numbers of peripheral blood mononuclear cells were also isolated from these samples and fibrocytes cultured in serum-free media with increasing concentrations of SAP. No difference in plasma SAP levels was found between keloid and control subjects. In the absence of SAP, keloid patients (n = 7) had almost 20 times more fibrocytes than controls (n = 7) in culture (median: 1,087 cells vs. 60 cells; p

Objective: HIV-associated lipodystrophy is considered a sequela of highly active antiretroviral treatment. We describe the characteristics, possible etiology, and pathophysiology of HIV-associated lipodystrophy and facial lipoatrophy and establish a validated grading scale for HIV-associated facial lipoatrophy using evidence-based techniques. Design/Methods: A grading scale was designed based on the severity of each patient's facial lipoatrophy. Preoperative photographs of HIV-infected patients seeking treatment for facial lipoatrophy and control subjects were reviewed by physicians qualified in facial plastic surgery. With use of the devised grading scale, each patient was assigned a severity score. These scores were then compared for interrater variability, and the distribution of scores was analyzed. Results: Preoperative photographs of 39 HIV-infected individuals with facial lipoatrophy and 6 normal subjects were obtained and reviewed. All patients were males. A Cohen kappa of 0.73 was calculated, and there was a fairly equal distribution of all severity grades throughout the 39 patients. Conclusion: HIV-associated facial lipoatrophy is a major stigma for HIV patients that can have dramatic effects on their self-esteem, social habits, and medication compliance. This current study introduces a validated evidence-based grading scale that can be implemented to categorize disease severity. Using this scale will hopefully generate improved treatment plans directed to each patient, which should produce enhanced postoperative results.

Create a head-and-neck keloid quality of life (QOL) questionnaire. Demonstrate the reliability of the keloid-specific QOL scale according to test-retest and internal consistency standards.Prospective cohort study.Patients presenting to a keloid clinic in a tertiary referral institution between April 2012 and February 2013 were enrolled on their first visit. They were administered a questionnaire assessing demographics and a 21-item Likert keloid-specific survey assessing symptomatology, self-esteem, social functioning, and therapeutic motivation during their first three visits. Reliability of the keloid questionnaire was assessed for internal consistency (Cronbach's alpha) and test-retest correlations. Patients were treated with Kenalog steroid injections at each visit. The 126-point total score from the questionnaire was then compared to each subscale (physical symptoms, self-esteem, social function, and medical motivation) using a Pearson coefficient.The keloid QOL questionnaire showed a Cronbach's alpha of 0.87 for the overall questionnaire and ranged from 0.66 to 0.86 for individual questions. The test-retest Pearson's R was 0.70 between visits 1 and 2 and 0.77 between visits 2 and 3. The Pearson correlation between symptoms, self-esteem, social functioning, and medical motivation subscales and the overall scale were 0.77, 0.73, 0.72, and 0.57, respectively.This head and neck keloid-specific QOL questionnaire proved to be a reproducible method of reliably assessing QOL burden on patients with head and neck keloids.N/A.

OBJECTIVE To test whether botulinum toxin-induced immobilization of facial lacerations enhances wound healing and results in less noticeable scars. PATIENTS AND METHODS In this blinded, prospective, randomized clinical trial, patients were randomized from February 1, 2002, until January 1, 2004, to botulinum toxin vs placebo injection into the musculature adjacent to the wound within 24 hours after wound closure. Blinded assessment of standardized photographs by experienced facial plastic surgeons using a 10-cm visual analog scale served as the main outcome measure. RESULTS Thirty-one patients presenting with traumatic forehead lacerations or undergoing elective excisions of forehead masses were included in the study. The overall median visual analog scale score for the botulinum toxin-treated group was 8.9 compared with 7.2 for the placebo group ( P =.003), indicating enhanced healing and improved cosmesis of the experimentally immobilized scars. CONCLUSIONS Botulinum toxin-induced immobilization of forehead wounds enhances healing and is suggested for use in selected patients to improve the eventual appearance of the scar.

Objectives The purpose of this study is to describe our experience with facial volume restoration in 39 HIV-associated facial lipoatrophy patients, and formulate a treatment algorithm that can be utilized for these patients based on their disease severity. Methods Preoperative and postoperative photographs were evaluated by 2 experienced facial plastic surgeons using grading scales. The reviewers’ scores were then compared and the distribution of scores was analyzed. Results Thirty-nine patients underwent malar silastic implantation. Seven patients required postoperative adjuvant filler injection. Most patients’ results were rated good to excellent. There were 4 late complications. Conclusion HIV-associated facial lipoatrophy is a socially disabling condition that causes noticeable disfigurement and stigmatizes the patient. We demonstrate the importance of combining a reliable grading scale with a strategic treatment algorithm that utilizes multiple modalities for volume restoration. EBM rating: C-4

Middle-aged men represent an emerging group expressing an interest in facial rejuvenation procedures. One must understand the complex differences in motivation, psychosocial factors, and aspects associated with anatomy and facial aging that are unique to men. To maximize postoperative results and increase patient satisfaction, the facial plastic surgeon must adjust perioperative management and surgical techniques when performing a male face-lift.

This article discusses the classic and contemporary management strategies for treating frontal sinus fractures. The goals of management of frontal sinus fractures are to create a safe sinus by minimizing the likelihood of early and late complications while preserving the function of the sinus and maintaining the cosmetic appearance of the upper face. The assessment and classification of patients with frontal sinus injuries, their management, and the treatment of complications are reviewed.

Objectives:1) Compare SF-12® scores by head and neck keloid patients to U.S. Norms. 2) Contrast SF-12® scores with keloid symptomatology, including pain, burning, itching, and infection. 3) Discuss the use of keloid-specific quality of life (QOL) instruments over global health-related QOL instruments in further research on head and neck keloids.Methods:Patients presenting to a keloid clinic in a tertiary referral institution between April 2012 and February 2013 were administered the SF-12® during their first three appointments. Mental health and physical health composite scores (MCS and PCS) were calculated from SF-12® surveys and compared with U.S. general population norm SF-36® scores using two-sample t-tests. Associations between SF-12® scores and symptoms were evaluated using Spearman’s Rho.Results:First, second, and third visits were completed by 24, 16, and 14 patients, respectively. Median age was 29.5 years (range 15-56), and 17% (4) were male. Average initial-visit MCS and PCS scores were 52.9 (±...

Objectives:Recognize that immediate post-reduction films: 1) Have a significant associated cost; 2) Do not alter management.Methods:A retrospective review of the medical record was performed on patients with mandible fractures operated on by the otolaryngology-head and neck surgery service between November 1, 2010, and November 30, 2012, at a level 1 county hospital. The post-operative imaging modalities were determined as well as if any changes in care were initiated by that image. Those patients who did have repeat imaging were evaluated to determine what led to the second image and what action was taken.Results:Fifty-seven patients met inclusion criteria. Fifty-five patients (96.5%) had a post-reduction image with 45 (79.0%) having a computed tomography (CT; $1,965) and 10 (17.5%) having a Panorex ($282). No immediate intervention was performed. Eleven patients (19.3%) had a second post-operative image with 4 (36.4%) receiving at least 1 panorex and 8 (72.7%) receiving at least one CT. Of these 11 pati...

Despite multiple fixation techniques, the optimal method of repairing mandibular angle fractures remains controversial.To evaluate the outcomes when using a 3-dimensional, curved strut plate in repair of angle of the mandible fractures.Retrospective cohort study.Level I trauma center at an academic institution in Harris County, Texas.Patients with diagnostic codes involving angle of the mandible fractures that were repaired by the otolaryngology-head and neck surgery service from February 1, 2006, through February 28, 2011.Open reduction internal fixation using either a 3-dimensional curved strut plate or any other type of repair technique for angle of the mandible fractures.Complication rates, postoperative complaints, and operative characteristics.Ninety patients underwent qualifying procedures during the study period. A total of 68 fractures (76%) were repaired using the 3-dimensional curved strut plate and 22 (24%) were repaired using other methods. The revision surgery rate was 10% for the strut plate group (7 patients) and 14% for the non-strut plate group (3 patients), with no significant differences in rates of infection (3 [4%] vs 2 [9%]), dehiscence (4 [6%] vs 2 [9%]), malunion (1 [1%] vs 2 [9%]), nonunion (3 [4%] vs 0), hardware failure (1 [1%] vs 1 [5%]), malocclusion (2 [3%] vs 2 [9%]), and injury to the inferior alveolar nerve (1 [1%] vs 1 [5%]). The most common postoperative complaints were pain (13 [19%] vs 6 [27%]), followed by numbness (5 [7%] vs 2 [9%]), trismus (4 [6%] vs 3 [14%]), edema (3 [4%] vs 3 [14%]), and bite deformity (2 [3%] vs 2 [9%]), with a mean (range) follow-up time of 54.7 (2-355) days for the strut plate group vs 46.8 (8-308) days for the non-strut plate group.The 3-dimensional curved strut plate is an effective treatment modality for angle fractures, with comparable infection rates, low incidence of alveolar nerve injury, and trends for decreased length of operation, complications, and infections compared with other techniques.

Keloid scarring is a form of fibroproliferative dermal wound healing characterized by growth beyond the confines of the original wound. Fibrocytes, derived from peripheral blood mononuclear cells and inhibited by serum amyloid P (SAP), have been linked to other fibroproliferative diseases. We hypothesized that peripheral blood mononuclear cells of keloid formers have a higher propensity to differentiate into fibrocytes and are more resistant to the effects of SAP. To test this hypothesis, plasma was isolated from peripheral blood samples of keloid (n = 10) and age/sex/race-matched control (n = 10) subjects, and SAP levels were measured by enzyme-linked immunosorbent assay. Equal numbers of peripheral blood mononuclear cells were also isolated from these samples and fibrocytes cultured in serum-free media with increasing concentrations of SAP. No difference in plasma SAP levels was found between keloid and control subjects. In the absence of SAP, keloid patients (n = 7) had almost 20 times more fibrocytes than controls (n = 7) in culture (median: 1,087 cells vs. 60 cells; p 0.01). SAP inhibited the differentiation of keloid fibrocytes in vitro, although a higher concentration of SAP was needed when compared with controls (20 μg/mL keloid vs. 5 μg/mL control). Fibrocytes may contribute to the pathogenesis of keloids, and SAP has potential as a therapeutic agent in the prevention of these lesions.

Patients of African descent are seeking rhinoplasties today more than ever. As a result, the rhinoplasty surgeon must be aware of the ethnic, cultural, anatomic, and surgical issues pertaining to this patient population. In this article, the nuances of rhinoplasty as it pertains to the nasal tip in patients of African descent are discussed.

Over the past three decades, an increasing number of African American patients have undergone rhinoplasty, and many continue to present to surgeons for rhinoplasty evaluation. The reality is that rhinoplasty is no longer an uncommon procedure in the African American population. Most patients desire nasal refinement while preserving their cultural identity. The African American nose has many unique features that have to be appreciated and understood to provide the desired outcome. In this paper, we present an overview of the unique anatomic features of the African American nose, rhinoplasty techniques tailored to this patient population, and complications encountered postoperatively.

The appearance of patients seeking cosmetic surgery is changing to reflect our multicultural society. Integral to addressing the desires of a cross-cultural patient population is an understanding of one's perception of race, ethnicity, and culture. Race is an objective description, whereas ethnicity is a subjective description of a person's social group. Culture, on the other hand, defines the behaviors, beliefs, and values of a group. How a person perceives their place within these groups affects his or her self-image and approach to cosmetic surgery. These cultural perceptions are important, as patients of Asian, Hispanic, and African descent make up the fastest growing groups that desire cosmetic surgery. Factors contributing to this trend include population growth, especially within multicultural communities, improvements in social status, and increasing disposable income, combined with a positive perception of cosmetic surgery. Surgical philosophies have also changed, shifting from the perspective of racial transformation, defined as the use of a common set of surgical goals for all ethnicities, toward a view of racial preservation, with the goal of preserving one's racial and ethnic features.

With the desire to create a more youthful appearance, patients of all races and ethnicities are increasingly seeking nonsurgical and surgical rejuvenation. In particular, facial rejuvenation procedures have grown significantly within the African-American population. This increase has resulted in a paradigm shift in facial plastic surgery as one considers rejuvenation procedures in those of African descent, as the aging process of various racial groups differs from traditional models. The purpose of this article is to draw attention to the facial features unique to those of African descent and the role these features play in the aging process, taking care to highlight the differences from traditional models of facial aging. In addition, this article will briefly describe the nonsurgical and surgical options for facial rejuvenation taking into consideration the previously discussed facial aging differences and postoperative considerations.

Cutaneous wound healing is a complex response to skin injury. Deregulation of this process can lead to excessive scar formation, as seen in keloids. Keloids are common skin lesions that are difficult to treat and are associated with high recurrence rates despite the large number of available treatment options. With increased knowledge of the disease process and further scientific advancements, future approaches will hopefully improve keloid treatment. In this article, we review the epidemiology, genetic basis, etiology, clinical features, pathogenesis, and management of keloids.

The issues related to preoperative evaluation and facial analysis for patients undergoing facial rejuvenation procedures are discussed in this article. A key component of the preoperative evaluation begins with a thorough understanding of the patient's concerns and desires for improvements. Other components of the evaluation should include a detailed assessment of the patient's medical and psychiatric history, informed consent, and photographic documentation. Additionally, we discuss facial changes associated with aging, paying special attention to some of the differences that occur between male and female patients. Different aesthetic scales and their applications in facial plastic surgery are also presented. Finally, we consider the process of facial analysis in the context of common facial plastic procedures including rhytidectomy, blepharoplasty, browlift, and minimally invasive techniques.

Background. Eighty-five percent of all Merkel cell carcinomas appear on sun-exposed areas, with 50% to 55% occurring on the head and neck. Methods. A chart review was performed on 22 patients treated for Merkel cell carcinoma of the head and neck between 1981 and 1998. Results. Fifteen patients were men (68%). The average age at operation was 69.9 years (range, 24-84 years). The average duration of follow-up was 3.6 years (range, 3 days-8.6 years). Overall survival at 1, 2, and 3 years postoperatively was 78%, 68%, and 68%, respectively. The only independent predictor of survival was the type of surgical therapy. All patients who underwent wide local excision (WLE) of the primary tumor with dissection of the lymphatic drainage basin were alive at 2 years as opposed to 68% who had WLE alone and 33% who had Mohs surgery. Conclusions. WLE and dissection of the lymphatic drainage basin provided the best overall survival.

The role of human papilloma virus (HPV) in the pathogenesis and biological behavior of tonsillar squamous cell carcinoma (TSCC) are areas of intense investigation.This study used PCR analysis to identify HPV in paraffin-embedded tonsillar and nodal tissue from 52 patients with TSCC and 48 age (+/-5 year)/gender-matched controls with benign tonsillar hyperplasia. Results were correlated with HLA-DRB1 haplotype and clinical outcome.HPV was identified in 46% of patients with TSCC and 6% of controls. DNA sequencing showed the presence of HPV type 16 in 21 patients (40%) with TSCC. There was no statistically significant association between HLA-DRB1 expression and TSCC or HPV infection. Fifteen of 16 patients with HPV-positive TSCC with regional metastases had evidence of HPV in pathologically involved lymph nodes. In eight HPV 16-positive TSCC patients with lymph node metastasis, PCR testing identified HPV 16 in 17 of 23 histologically negative lymph nodes. Patients with HPV-positive TSCC without metastatic disease had no evidence of HPV in their lymphatic tissue. Clinically, HPV-associated carcinoma was present in younger patients in comparison with HPV-negative TSCC patients (mean age, 56.6 versus 66 years; P = 0.001). The odds for patients with HPV infection to develop TSCC were 18.2 times greater than for patients without HPV infection (95% confidence interval 4.6, 73.1). There was no statistically significant association between presence of HPV and cause-specific survival (hazard ratio = 2.5 for HPV negative versus positive; P = 0.26), after adjusting for age in a Cox proportional hazards regression analysis.HPV is an independent risk factor for TSCC. Identification of HPV in the histologically positive and negative lymph nodes of patients with HPV-positive TSCC/metastatic disease supports the role of HPV in the oncogenesis of TSCC.

A scar contracture is the result of a contractile wound-healing process occurring in a scar that has already been reepithelialized and adequately healed. Keloids and hypertrophic scars (HTSs) are fibrous tissue outgrowths that result from a derailment in the normal wound-healing process. The exact incidence of keloids and HTSs remains unknown. Beyond the common belief that trauma is the initiating event of keloid and hypertrophic scar formation, the remainder of the process remains uncertain. A combination of biochemical factors, skin tension, endocrinologic factors, and genetic factors are the likely culprits. Treatment begins by educating the patient about the etiology of the scarring process. All treatment protocols are individualized, but the standard approach to keloids and HTSs begins with corticosteroid injection followed by surgical excision, pressure dressings, and long-term follow-up.

and 14% for the non–strut plate group (3 patients), with no significant differences in rates of infection (3 [4%] vs 2[9%]),dehiscence(4[6%]vs2[9%]),malunion(1[1%] vs2[9%]),nonunion(3[4%]vs0),hardwarefailure(1[1%] vs1[5%]),malocclusion(2[3%]vs2[9%]),andinjuryto the inferior alveolar nerve (1 [1%] vs 1 [5%]). The most common postoperative complaints were pain (13 [19%] vs 6 [27%]), followed by numbness (5 [7%] vs 2 [9%]), trismus (4 [6%] vs 3 [14%]), edema (3 [4%] vs 3 [14%]), andbitedeformity(2[3%]vs2[9%]),withamean(range) follow-uptimeof54.7(2-355)daysforthestrutplategroup vs 46.8 (8-308) days for the non–strut plate group. Conclusions and Relevance:The 3-dimensional curved strutplateisaneffectivetreatmentmodalityforanglefractures, with comparable infection rates, low incidence of alveolar nerve injury, and trends for decreased length of operation, complications, and infections compared with other techniques.