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We report a case of diplopia that was exacerbated by chewing in a patient who had sustained facial fractures in a motorcycle crash. The diplopia was corrected surgically 1 year following the accident. To the best of our knowledge, masticatory diplopia as a result of adhesion of the temporalis muscle to the periorbita secondary to facial trauma has not been previously reported. [ABSTRACT FROM AUTHOR]

Study Design: Survey., Objective: Subcondylar fractures stand out as a particular challenge when treating maxillofacial trauma. The fracture site is often difficult to access and adjacent to critical structures like the facial nerve. Current treatment paradigms vary widely and we endeavored to elucidate these approaches from surgeons across the full breadth of Craniomaxillofacial Surgery., Methods: A survey was designed to gather general background training and experience information, perceived indications for ORIF of subcondylar fractures, options for treating subcondylar fractures, and reasoning for choosing or not choosing a given treatment approach. The survey was sent to members of AO CMF and the American Academy of Facial Plastic Surgery. Responses were collected for 4 weeks., Results: 514 total responses to the survey were obtained (response rate 17%). Of these, 43 (8.4%) identified as Otolaryngology trained, 417 (81.1%) as OMFS trained, and 54 (10.5%) as Plastic Surgery trained. While there was broad agreement in the indications for open repair, surgical approaches differed by specialty background as well as AO faculty member status. Those with less experience were less likely to perform open approaches due to lack of comfort with this skill set., Conclusions: There are some key differences in approaches to treatment of subcondylar fractures based upon specialty background and experience level. This provides an opportunity for further education to ensure optimal treatment for patients., Competing Interests: The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: C. Humphrey is a consultant for Invisian Medical LLC. All other authors deny any potential conflicts of interest., (© The Author(s) 2023.)

Importance: Cross-Facial Nerve Grafting (CFNG) for facial palsy offers potential to restore spontaneous facial expression, but specific indications and associated outcomes are limited. Updates to this technique have aided in its successful employment in select cases. This review aims to explore the context in which CFNG has been successfully utilized as a primary modality. Observations: Literature review was performed auditing all studies investigating CFNG as a primary modality, which reported outcomes. A total of 326 cases reporting outcomes for primary CFNG were included. Eye closure outcomes were 83.3% successful at ages 0-18, 77.3% successful at ages 19-40, and 57.1% successful at ages 41+. Smile outcomes were 73.7% successful at ages 0-18, 81.5% successful at ages 19-40, and 52.8% successful at ages 41+. For synkinesis, 89% of cases were considered successful; 100% successful at ages 0-18, and 78.4% successful in adults. Conclusions and Relevance: CFNG may offer return of spontaneous facial function in select cases. Higher percentages of successful outcomes are observed in younger patients, when performed in two stages, and when performed earlier from the onset of FP in cases of eye closure restoration. In the modern era, CFNG has been more commonly employed as an adjunctive procedure to other reanimation techniques.

Study Design: Retrospective chart review., Objective: Restoration of premorbid occlusion is a key goal in the treatment of mandibular fractures. Placement of the patient in maxillomandibular fixation (MMF) is performed during mandibular fracture repair to help establish occlusion. A number of techniques are available to achieve MMF. We sought to examine trends in MMF technique at our institution., Methods: A retrospective chart review was conducted to evaluate patients who underwent surgical treatment of mandibular fractures between January 1, 2011 and March 31, 2021. Data including fracture characteristics, mechanism of injury, patient demographics, complication rates, and MMF technique utilized were collected., Results: One hundred sixty-three patients underwent MMF (132 males). The most common etiology of fracture was assault (34%). There was an increasing preference for rapid MMF techniques over time, as opposed to standard Erich arch bars. No significant difference in obtaining adequate fracture reduction as determined by postoperative imaging or complications were noted between those who underwent MMF with newer rapid techniques vs traditional MMF techniques., Conclusions: Our institution has demonstrated changing trends in the technique utilized for establishing occlusion intraoperatively, more recently favoring rapid MMF techniques, with similar rates of complications and ability to adequately reduce fractures., Competing Interests: The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: C. Humphrey received a consulting fee from Invisian Medical LLC in 2021. All other authors deny any potential conflicts of interest., (© The Author(s) 2023.)

Background: The objective of this study was to develop guidelines for the transfer of patients with isolated craniomaxillofacial trauma., Methods: A national, multidisciplinary expert panel was assembled from leadership in national organizations and contributors to published literature on facial reconstruction. The final panel consisted of five plastic surgeons, four otolaryngologist-head and neck surgeons, and four oral and maxillofacial surgeons. The expert panelists' opinions on transfer guidelines were collected using the modified Delphi process. Consensus was predefined as 90 percent or greater agreement per statement., Results: After four Delphi consensus building rounds, 13 transfer guidelines were established, including statements on fractures of the frontal sinus, orbit, midface, and mandible, as well as soft-tissue injuries. Twelve guidelines reached consensus., Conclusions: The decision to transfer a patient with craniomaxillofacial trauma to another facility is complex and multifactorial. While a percentage of overtriage is acceptable to promote safe disposition of trauma patients, unnecessarily high rates of secondary overtriage divert emergency medical services, increase costs, delay care, overload tertiary trauma centers, and result in tertiary hospital staff providing primary emergency coverage for referring hospitals. These craniomaxillofacial transfer guidelines were designed to serve as a tool to improve and streamline the care of facial trauma patients. Such efforts may decrease the additional health care expenditures associated with secondary overtriage while decompressing emergency medical systems and tertiary emergency departments., Competing Interests: Disclosure : The authors have no relevant disclosures or conflicts of interest to report. No financial support was received for this project., (Copyright © 2022 by the American Society of Plastic Surgeons.)

Background: During online search queries, Google uses machine learning algorithms to provide frequently associated ("People Also Ask" [PAA]) questions with corresponding websites answering the question. We aimed to identify the most frequent questions about rhinoplasty asked online and the sources used to answer them. Materials and Methods: PAA questions were extracted for the terms "rhinoplasty," "nose surgery," and "nose job." Questions were categorized into specific topics. Websites were categorized by type and assessed for quality using Journal of the American Medical Association ( JAMA ) benchmark criteria. A search engine optimization tool determined search volume for individual questions and specific topics. Results: Internet searches for the PAA questions ( n  = 102) and associated websites were related to preoperative factors (46%), cost (35.7%), and recovery timeline (7.3%). Sources for the answers to PAA questions were single surgeon personal (39.3%) and medical practice (20.6%) websites. Conclusions: Surgeons may wish to emphasize specific patient education topics, including preoperative factors, cost, and recovery timeline, on their websites to address the most frequently sought-after information regarding rhinoplasty online.

Competing Interests: None declared.

Brow ptosis is an abnormal descent of the eyebrow resulting in a displeased appearance and/or functional deficit. While most cases of brow ptosis do not result in a functional impairment, functional brow surgery is generally reserved for individuals with severe brow asymmetry or visual field deficit related to excess soft tissue pushing downward on the eyelid. A combination of both intrinsic and extrinsic anatomic factors contributes to an unfavorable brow shape, contour, and position. Proper management of brow ptosis requires an understanding of both surgical and nonsurgical modalities. Traditionally, individuals with functional brow ptosis are treated by browpexy via blepharoplasty approach, direct browlift, mid-forehead browlift, or less commonly endoscopic browlift., Competing Interests: None declared., (Thieme. All rights reserved.)

Background: Mindfulness meditation has been shown to alleviate pain and may be an appealing adjunctive pain management option. Objective: To compare measures of pain, mindfulness, and opioid usage, and collect evaluative feedback among patients undergoing septorhinoplasty with and without guided meditation. Methods: Patients undergoing septorhinoplasty were randomized to online-guided meditation postoperative days 0-3 versus standard care; all received the same pain medications. Primary outcome measures included pain intensity, opioid consumption, mindfulness scores, and evaluative feedback. Results: Twenty-one patients received guided meditation and 24 received standard care. No significant difference in opioid consumption or pain scores was seen with the exception of higher opioid use in patients with intranasal splints in the standard care group. Twenty out of 21 patients provided evaluative feedback; all recommended mindfulness meditation to friends undergoing nasal surgery, 90% reported it was beneficial, 85% believed it eased pain/discomfort, and 80% believed it aided with sleep. Conclusion: Although no objective difference was found in opioid consumption or pain scores, most patients reported that guided mindfulness meditation was beneficial to their recovery following septorhinoplasty.

Importance: A centralized repository of clinically applicable facial images with unrestricted use would facilitate facial aesthetic research. Objective: Using a machine learning neural network, we aim to (1) create a repository of synthetic faces that can be used for facial aesthetic research and (2) analyze synthetic faces according to contemporary aesthetic principles. Design, Setting, and Participants: Synthetic facial images were generated using an open source generative adversarial network. Images were refined and then analyzed using computer vision technology. Interventions: Not applicable. Main Outcomes and Measures: Synthetic facial images were created for use as a facial aesthetic research data set. Results: One thousand synthetic images were generated, and 60 images underwent analysis. Image attributes, including age, gender, image principle axis, facial emotion, and facial landmark points, were attained. Images demonstrated accordance with contemporary aesthetic principles of horizontal thirds and vertical fifths. Images demonstrated excellent correspondence when compared with real human facial photographs. Conclusions and Relevance: We have generated realistic synthetic facial images that have potential as a valuable research tool and demonstrate similarity to real human photographs while adhering to contemporary aesthetic principles.

Objective: To assess the efficacy of a novel systematic approach aimed at improving a resident physician's ability to perform analysis of the aging face., Study Design: Prospective randomized case-control study., Setting: Accreditation Council for Graduate Medical Education accredited Otolaryngology-Head and Neck Surgery residency program., Methods: Twenty otolaryngology-head and neck surgery residents were randomized into 2 groups with even representation in each postgraduate year level in each cohort. One group used traditional materials (textbooks), and the other group was given exclusive access to the online learning module featuring a systematic approach to aging-face analysis. Both groups completed preactivity, postactivity, and retention assessments to gauge their ability to perform a comprehensive analysis of the aging face., Results: When compared with a matched control cohort, the residents who used the systematic approach performed more comprehensive facial aging assessments immediately after the intervention and at a retention time point., Conclusion: A systematic approach delivered via an 11-minute online module can significantly improve a resident physician's ability to perform analysis of the aging face. This systematic approach could be easily integrated into other online or traditional educational curriculums. Moreover, this methodology could be applied to additional areas in which residents have limited exposure but must develop expertise., (© The Authors 2021.)

Importance: Having a noninvasive tool that quantifies the amount of remaining septal cartilage in the setting of prior septoplasty would be useful for surgical planning and patient counseling. Objective: The objective of this pilot study is to determine if endocavitary ultrasound can be used to evaluate the presence and thickness of septal cartilage in vivo. Design, Setting, and Participants: A small prospective observational study was designed to assess the feasibility of using intranasal ultrasound to verify the presence and measure the thickness of septal cartilage. Imaging was undertaken by the principle investigator using a protocol developed by the research team. Six healthy volunteers were enrolled including three subjects who have had prior septoplasty. Images and measurements of the nasal septum were obtained. Main Outcomes: Confirming the presence of the nasal septum was the main outcome with a secondary outcome of measurement of septum thickness. Results: The endonasal ultrasound probe was able to identify the septum and resected areas. The mean thickness of the septum in subjects without surgery was 1.0 mm and those with prior septoplasty was 0.8 mm. Student's t -test show a statistically significant difference in septum thickness between these two groups with a p -value of 0.0093. Conclusions and Relevance: This study demonstrates a novel method of determining the presence of septal cartilage after septoplasty surgery. This information may be useful for operative planning in revision rhinoplasty.

Importance: Composite grafting in nasal reconstruction involves transplanting auricular chondrocutaneous grafts, but the optimal design of these grafts is unknown., Objectives: To investigate the ideal ratio of skin to cartilage as well as study the importance of the perichondrial attachment for graft survival., Design, Setting, and Participants: A New England white rabbit model was used in this study, performed at the Laboratory for Animal Research at University of Kansas Medical Center from January 25 to March 18, 2016. Four varying designs of chondrocutaneous auricular grafts were transplanted to dorsal back defects, with a total of 10 grafts per treatment arm completed. The following 4 chondrocutaneous circular grafts were designed: group A, 1.5-cm diameter graft of equal skin to cartilage ratio; group B, 2.0-cm diameter skin and 1.5-cm diameter cartilage; group C, 1.5-cm diameter skin and 2.0-cm diameter cartilage; and group D, 1.5-cm diameter skin and cartilage separated and placed back together in a layered fashion. Grafts were observed until postoperative day 21, harvested, and evaluated with visual observation as well as histopathologic assessment., Main Outcomes and Measures: Visually graded areas of survival were marked by 2 blinded academic facial plastic surgeons and calculated for approximate survival. Hematoxylin-eosin-stained, paraffin-embedded 5-μm slides were evaluated for overall survival rate, rate of cartilage necrosis, and mean vessel density per high-power field. In both cases, observers were blinded as to the study group., Results: Visual assessments of the 5 female rabbits showed significant agreement between surgeons and consistency, with a Spearman coefficient of 0.84 and an intraclass correlation of 0.98. Group D (skin and cartilage separation) was visually graded to have significantly decreased mean survival (45.4%; 95% CI, 23.3%-67.4%) compared with group A (mean survival, 97.4%; 95% CI, 94.8%-99.9%; P < .001), group B (mean survival, 87.6%; 95% CI, 69.9%-100%; P = .004), and group C (mean survival, 82.1%; 95% CI, 66.0%-98.1%; P = .008). Histopathologic assessment revealed that group D again showed significantly inferior overall survival, increased cartilage necrosis, and decreased mean vessel density compared with group A. Group C additionally showed significantly decreased cartilage survival compared with group A (65% vs 0%; P < .001) and group B (65% vs 35%; P = .02)., Conclusions and Relevance: These results represent preliminary evidence that the attachment of skin to perichondrium in a composite graft plays an important role for graft survival. Clinicians performing nasal reconstruction with chondrocutaneous composite grafts should consider preserving attachments at this junction to improve graft survival., Levels of Evidence: NA.

Importance: Facial reanimation procedures share the same surgical field as a parotidectomy and are most easily accomplished at the time of facial nerve sacrifice. Early reanimation would also reduce the duration of paralysis and may lead to better functional outcomes., Objective: To assess the incidence and types of facial nerve reanimation performed concurrently with total parotidectomy and facial nerve sacrifice using the American College of Surgeons National Surgical Quality Improvement Project (ACS-NSQIP) database., Design, Setting, and Participants: This cross-sectional study identified 285 patients who underwent total parotidectomy with facial nerve sacrifice (Current Procedural Terminology code 42425) and evaluated the various types of facial reanimation procedures performed concurrently. Patients were identified from the ACS-NSQIP database encompassing 603 community and academic hospitals and underwent treatment from January 1, 2010, through December 31, 2015. Data were analyzed from September 20, 2017, through February 21, 2018., Main Outcomes and Measures: Comparison of demographics in nonreanimation and reanimation groups and subgroups of nerve- and sling-type reanimation procedures., Results: Of 285 patients who underwent total parotidectomy with facial nerve sacrifice (61.8% men; mean [SD] age, 64 [15] years), 89 (31.2%; 95% CI, 26.0%-37.0%) underwent at least 1 concurrent facial reanimation procedure. Of the facial nerve procedures performed, 41 (46.1%; 95% CI, 36.0%-56.0%) were nerve-type repairs, 31 (34.8%; 95% CI, 26.0%-45.0%) were sling-type repairs, and 17 (19.1%; 95% CI, 12.0%-29.0%) included both types. Patients treated with nerve-type repairs only were significantly younger than those treated with sling-type repairs only (mean [SD] age, 57.6 [16.0] vs 72.1 [13.8] years; P < .001). Forty-nine patients underwent free tissue reconstruction. Of those, 24 patients (49.0%) had concurrent facial reanimation procedure(s) performed; this proportion was significantly more than those who did not undergo free tissue reconstruction (65 of 236 [28.0%]; P = .003)., Conclusions and Relevance: In patients undergoing total parotidectomy with facial nerve sacrifice, many are not receiving a concurrent facial reanimation procedure at the time of their tumor resection. Those patients who underwent free tissue reconstruction were significantly more likely to receive a concurrent facial reanimation procedure. These findings may reveal an opportunity for earlier facial reanimation in this patient population., Level of Evidence: NA.

Although surgical techniques for rhinoplasty and nasal reconstruction are well established, prospective research on postoperative morbidity remains limited. The aim of this pilot study was to assess costal and auricular cartilage donor site pain and morbidity in patients undergoing rhinoplasty and nasal reconstruction. In this prospective cohort study, we enrolled 55 patients undergoing nasal surgery that required costal or auricular cartilage harvest from February 2015 through May 2016. Each patient was given a symptom-specific patient survey that assessed general pain, nasal pain, graft donor site pain, graft donor site itching, color variation, skin stiffness and thickness, and graft donor site appearance at 1, 4, and 12 weeks after surgery. Our patient group was 55% female ( n  = 30); the mean age was 47 years. Rib cartilage graft patients had significantly greater nasal pain than cartilage donor site pain. There was no significant difference in rib versus ear cartilage donor site pain. Nearly all patients reported that they were not at all concerned about their scar appearance or ear shape and appearance. No prior studies compare cartilage donor site morbidity in patients undergoing nasal surgery. Our findings challenge the conventional wisdom that utilizing auricular and costal cartilage results in high levels of donor site pain. Surgeons should have a low threshold to harvest rib or ear cartilage when it can improve surgical outcome.

The periorbital region is a focal point on the face. Dermatochalasis, fat herniation, blepharoptosis, brow ptosis, deep tear troughs, and malar fat pad descent are all age-related changes that occur around the eyes, and successful rejuvenation involves addressing all of these changes. Restoring a youthful, vibrant appearance to the eyes and periorbital areas can often only be accomplished with a combination of surgical and nonsurgical interventions. Facial plastic surgeons should have a comprehensive knowledge of all of these options and their applications to ensure good patient outcomes and satisfaction., Competing Interests: The authors have no financial relationships or conflicts of interest to disclose., (Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.)

Nasal fractures are the most frequently fractured facial bone from blunt facial trauma resulting in a significant number of patients seeking treatment. Proper evaluation and treatment in the acute setting can minimize secondary surgeries, lower overall health care costs, and increase patient satisfaction. Nasal fracture management, however, varies widely between surgeons. The open treatment of isolated nasal fractures is a particularly controversial subject. This review seeks to describe the existing literature in isolated nasal fracture management., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Objectives: The aim of this study was to measure the length, width, and surface area of costal and auricular cartilage harvested for grafting in rhinoplasty and nasal reconstruction. We also compared the sizes of ear cartilage grafts harvested from the anterior and posterior approaches., Methods: Fifty-eight nasal reconstructive surgeries requiring rib or ear cartilage were performed by 2 facial plastic surgeons from February 2015 through January 2016. Among the 57 cases that met inclusion criteria, they comprised of 33 costal cartilage grafts and 24 auricular cartilage grafts (17 via anterior approach and 7 via posterior approach)., Results: The mean length, width, and surface area for the auricular cartilage grafts were 3.39 cm, 1.22 cm, and 4.38 cm 2 , respectively. The mean length, width, and surface area of the costal cartilage grafts were 4.21 cm, 1.46 cm, and 17.87 cm 2 , respectively. The differences in length, width, and surface area between the anterior versus posterior approach groups were all statistically significant., Conclusions: In our study, ear cartilage grafts harvested from the posterior approach had significantly greater length, width, and surface area. While this analysis has several limitations, it sets quantitative norms for costal and auricular cartilage harvest that can aid in surgical planning.

Eyelid defects disrupt the complex natural form and function of the eyelids and present a surgical challenge. Detailed knowledge of eyelid anatomy is essential in evaluating a defect and composing a reconstructive plan. Numerous reconstructive techniques have been described, including primary closure, grafting, and a variety of local flaps. This article describes an updated reconstructive ladder for eyelid defects that can be used in various permutations to solve most eyelid defects., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Purpose of Review: To review recent literature pertaining to the use of masseteric-facial nerve neurorrhaphy (MFNN) for facial reanimation in patients with facial paralysis., Recent Findings: First, MFNN effectively restores some midface tone and function, including the ability to smile. Second, use of the masseteric nerve minimizes synkinesis, dysarthria, and dysphagia that frequently occur after hypoglossal-facial nerve neurorrhaphy. Third, concurrent cable grafting to the zygomatic branch from an intact proximal facial nerve remnant - when available - can restore dynamic eye closure., Summary: Masseteric nerve transfer is an alternative to hypoglossal nerve transfer that improves midface appearance and function for properly selected patients with facial paralysis.

A mastery of advancement flap design, selection, and execution greatly aids the surgeon in solving reconstructive dilemmas. Advancement flaps involve carefully planned incisions to most efficiently close a primary defect in a linear vector. Advancement flaps are subcategorized as unipedicle, bipedicle, V-to-Y, and Y-to-V flaps, each with their own advantages and disadvantages. When selecting and designing an advancement flap, the surgeon must account for primary and secondary movement to prevent distortion of important facial structural units and boundaries., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Facial plastic surgeons use a variety of reconstruction techniques to overcome challenges in restoring the function, structural integrity, and intricate nasal contour in nasal reconstruction. Local cutaneous flaps provide excellent skin texture, thickness, and color match in nasal reconstruction. They offer an excellent cosmetic appearance for small- to medium-sized defects and are preferentially utilized when feasible. This article aims to provide an updated review of local cutaneous flaps for nasal defect repair and describe the major principles related to flap selection., (Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.)

Orbital fractures are a common result of facial trauma. Sequelae and indications for repair include enophthalmos and/or diplopia from extraocular muscle entrapment. Alloplastic implant placement with careful release of periorbital fat and extraocular muscles can effectively restore extraocular movements, orbital integrity, and anatomic volume. However, rare but devastating complications such as retrobulbar hematoma (RBH) can occur after repair, which pose a risk of permanent vision loss if not addressed emergently. For this reason, some surgeons take the precaution of admitting patients for 24-hour postoperative vision checks, while others do not. The incidence of postoperative RBH has not been previously reported and existing data are limited to case reports. Our aim was to examine national trends in postoperative management and to report the incidence of immediate postoperative complications at our institution following orbital repair. A retrospective assessment of orbital blowout fractures was undertaken to assess immediate postoperative complications including RBH. Only patients treated by a senior surgeon in the Department of Otolaryngology were included in the review. In addition, we surveyed AO North America (AONA) Craniomaxillofacial faculty to assess current trends in postoperative management. There were 80 patients treated surgically for orbital blowout fractures over a 9.5-year period. Nearly all patients were observed overnight (74%) or longer (25%) due to other trauma. Average length of stay was 17 hours for those observed overnight. There was one (1.3%) patient with RBH, who was treated and recovered without sequelae. Results of the survey indicated that a majority (64%) of responders observe postoperative patients overnight. Twenty-nine percent of responders indicated that they send patients home the same day of surgery. Performance of more than 20 orbital repairs annually significantly increased the likelihood that faculty would manage patients on an outpatient basis postoperatively ( p  = 0.04). For orbital blowout fractures, the number of immediate postoperative complications at our institution is low. In addition, North American trends in postoperative management of orbital blowout fractures may suggest that selected patients can be managed on an outpatient basis, which would have a positive effect on conservation of diminishing healthcare resources.

Rhinoplasty is arguably one of the most challenging procedures a facial plastic surgeon performs. Numerous techniques have been developed since the inception of rhinoplasty to aid in correction of aesthetic and functional issues. Congenital, iatrogenic, and traumatic etiologies can all lead to a crooked nose. Autologous rib or costal cartilage grafting is a powerful tool that can aid the surgeon in successful correction of the crooked nose., (Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.)

Purpose of Review: The management of nasoethmoid or naso-orbito-ethmoid (NOE) fractures requires a thorough knowledge of the central facial anatomy, surgical techniques, available tools and patient factors to obtain optimal restoration of aesthetic form and function. This review article describes the current methods of NOE fracture diagnosis, classification, surgical techniques and complication management, with a review of the current literature published over the past 18 months., Recent Findings: Advanced imaging modalities, bioabsorbable versus titanium rigid fixation, nasolacrimal duct stenting, NOE fracture management in children and the elderly, and novel techniques of medial canthopexy., Summary: The treatment of NOE fractures has not changed dramatically in the last 5 years. Advanced surgical techniques, intraoperative computed tomography and absorbable plating hold promise requiring future research prior to broad implementation.

Purpose of Review: Auricular composite grafting is a useful technique for the reconstruction of select nasal defects. However, unpredictable graft survival has been the primary limitation of this technique. The literature was reviewed to evaluate the effectiveness of various surgical, pharmacologic, hyperbaric, and hypothermic interventions to improve composite graft survival., Recent Findings: Although no statistically significant surgical interventions were found, several techniques appear promising. There are a number of studies demonstrating the beneficial effects of perioperative and postoperative corticosteroid administration. Other agents studied have had modest to no benefit. Hyperbaric oxygen therapy holds promise but the expense, practicality, and lack of an established optimal treatment protocol remain obstacles to routine use., Summary: The use of corticosteroids and postoperative cooling are relatively inexpensive and effective modalities to improve auricular composite graft survival when used for nasal reconstruction. Hyperbaric oxygen therapy may have a role, but more research is needed before it is employed routinely.

Objective: To define the intrinsic (hypoplasia) and extrinsic (deformational) contributions to congenital nasal deformities and the potential of a carrier state for orofacial clefting., Methods: Retrospective case series., Results: The factors affecting 4 congenital nasal deformities are postulated after contrasting the patient's characteristics., Conclusions: The spectrum of congenital nasal deformities includes those that resemble the cleft lip nasal deformity, but careful inspection is needed for proper classification. Classifying congenital nasal deformities can be difficult in part due to the highly variable normal range. The most minor form of the typical unilateral cleft lip nasal deformity is the microform cleft. The potential of an isolated cleft lip nasal deformity without obvious cleft lip has been previously suggested to represent a carrier state for orofacial clefting. Definitive genetic studies and continued anthropometric documentation in relatives of patients with orofacial clefts are needed if we are to uncover previously unidentified associations, and a potential carrier state.

Objective: To create a clinical consensus statement to address ambiguities and disparities in the diagnosis and management of nasal valve compromise (NVC)., Subjects and Methods: An updated systematic review of the literature was conducted. In addition, a Modified Delphi Method was used to refine expert opinion and facilitate a consensus position., Results: After two rounds of surveys and conference calls, 36 items reached consensus, six items reached near consensus, and 10 items reached no consensus. The categories that had the greatest percentage of consensus or near consensus items were as follows: definition, history and physical examination, outcome measures, and management. Conversely, the categories with greater percentage of no consensus items were adjunctive tests and coding., Conclusion: The consensus panel agreed that NVC is a distinct clinical entity that is best evaluated with history and physical examination findings. Endoscopy and photography are useful but not routinely indicated, whereas radiographic studies are not useful in evaluating NVC. Other objective nasal outcome measures may not be useful or accepted for NVC. Nasal steroid medication is not useful for treatment of NVC in the absence of rhinitis, and mechanical treatments may be useful in selected patients. Surgical treatment is the primary mode of treatment of NVC, but bill coding remains ambiguous and confusing., (2010 American Academy of Otolaryngology-Head and Neck Surgery Foundation. Published by Mosby, Inc. All rights reserved.)

Consistency of photographic documentation is essential for facial plastic surgery, a visual surgical subspecialty. Photographs are often used to validate surgical outcomes but have many other uses including education, publication, and marketing. Utilization of a properly equipped medical portrait studio will dramatically increase the quality of photographic images. In this article, the authors discuss the steps necessary to set up and use an officebased portrait studio., (Copyright 2010 Elsevier Inc. All rights reserved.)

Intraoperative photographs are a necessity when sharing unusual pathology or details of a procedure with peers in presentations or publications. Obtaining the proper equipment and taking time to refine settings for the operative suite will typically yield excellent images. Regularly taking time out of procedures to shoot photographs can yield a formidable archive of intraoperative images that will regularly be accessed for many purposes., (Copyright 2010 Elsevier Inc. All rights reserved.)

Facial plastic surgeons are accumulating massive digital image databases with the evolution of photodocumentation and widespread adoption of digital photography. Managing and maximizing the utility of these vast data repositories, or digital asset management (DAM), is a persistent challenge. Developing a DAM workflow that incorporates a file naming algorithm and metadata assignment will increase the utility of a surgeon's digital images., (Copyright 2010 Elsevier Inc. All rights reserved.)

Facial nerve injury and facial paralysis are devastating for patients. Although imperfect, primary repair is currently the best option to restore facial nerve function. Cable, or interposition, nerve grafting is an acceptable alternative when primary repair is not possible. Several donor nerves are at the surgeon's disposal. Great auricular, sural, or medial and lateral antebrachial cutaneous nerves are all easily obtained. Both primary repair and interposition grafting typically result in better facial function than do other dynamic and static rehabilitation strategies. Proficient anastomotic technique and, when necessary, selection of an appropriate interposition graft will optimize patient outcomes. Promising research is under way that will enhance future nerve repair and grafting efforts.

Objective: To evaluate the successes and challenges of endoscopic orbital floor fracture repairs., Methods: We analyzed 53 orbital floor repairs and recorded the indications for surgery, factors that complicated the endoscopic repair or necessitated conversion to an open approach, and outcomes for each., Results: Forty-five procedures were completed endoscopically. Repairs of smaller injuries confined entirely to the medial floor were readily accomplished, particularly when entrapment was the primary indication for surgery. Endoscopic repair became very difficult and often not possible when a large amount of soft tissue was herniated through the floor defect and when dissection medially onto the lamina papyracea and lateral to the infraorbital nerve was required for implant placement. Duration of follow-up was short for some patients, but no adverse trends in outcomes were identified., Conclusions: Blowout fractures can be approached endoscopically. However, the technical challenge of working from below with a telescope tends to increase the difficulty of many repairs without improving results. Most blowout fractures are probably still best treated through an open approach, assuming that the lower eyelid incision is correctly performed.

Objective: We sought to evaluate the functional and aesthetic outcomes of immediate facial reconstruction with a Gore-Tex (expanded polytetrofluoroethylene) sling in irradiated patients undergoing large head and neck tumor extirpation with facial nerve resection., Study Design and Setting: We conducted a retrospective study of 17 patients at two academic institutions who underwent extirpative surgery with immediate Gore-Tex sling reconstruction and completed radiotherapy. Functional and aesthetic results were evaluated at three intervals., Results: All patients had excellent immediate results and good or excellent intermediate-term results. At long-term follow-up, results were good to excellent in 47% and unacceptable in 35% of patients., Conclusion: In irradiated patients undergoing total parotidectomy with immediate facial reconstruction using Gore-Tex slings, early results are excellent, but there is a high incidence of major wound complications and unacceptable results in long-term follow-up., Significance: There is a high rate of late complications associated with immediate facial reconstruction with Gore-Tex slings in irradiated patients.

Background: Static facial suspension (SFS) continues to play a role for rehabilitation in patients with facial paralysis. We perform SFS almost exclusively with a suture technique in our practice. Monofilament polypropylene suture (Prolene) is commonly used for SFS, but we have witnessed occasional failure and some stretching with this material. The purpose of this study was to establish and compare the biomechanical properties of 3 suture types-polypropylene, polybutilate-coated braided polyester (PBCP) (Ethibond Excel), and braided polyester impregnated with polytetrafluoroethylene (PIP) (Tevdek)-to assess their suitability for SFS., Methods: Six samples of 0, 2-0, and 3-0 polypropylene, PBCP, and PIP were tested. The mean load to failure was calculated for each suture type. Stiffness and elongation at specific loads were calculated to compare stretch between materials., Results: The load to failure of PBCP and PIP was significantly greater than that for polypropylene for all suture sizes. In addition, PBCP and PIP had significantly less elongation than did polypropylene at clinically relevant loads., Conclusions: Both PBCP and PIP had superior load-bearing properties and decreased stretch when compared with polypropylene. These properties suggest that, for SFS with suture, use of PBCP or PIP may reduce the incidence of breakage and elongation, improving outcomes.

Objective: To evaluate the role of the osteocutaneous radial forearm free flap (OCRFFF) in the treatment of mandibular osteoradionecrosis (ORN)., Study Design and Setting: Retrospective case review of patients who underwent OCRFFF oromandibular reconstruction after resection of nonviable tissue at an academic tertiary care center because of ORN. Patients with reconstructions other than OCRFFF were excluded from this study., Results: Nine patients underwent a composite oromandibular resection for ORN with a reconstruction using an OCRFFF between April 1998 and February 2003. All patients had failed previous less aggressive surgical and medical management of the ORN. Mean follow-up was 36 months (range, 14-67 months). There were no flap failures or significant immediate postoperative or long-term complications observed. All patients had successful restoration of mandibular integrity and continuity, with 100% success rate of stabilization of ORN. All patients were able to tolerate PO diet, with only one third having to supplement their diet with gastrostomy feedings, compared with 89% gastrostomy dependence preoperatively., Conclusions: Primary or adjuvant radiotherapy for head and neck malignancies can result in ORN of the mandible. This difficult problem often requires surgical intervention. In our experience, the OCRFFF can be successfully used for oromandibular reconstruction, even in the setting of the heavily radiated tissue with excellent postoperative outcomes., Significance: This is the first study that demonstrates the efficacy of the OCRFFF as a treatment of mandibular ORN.

Objective: To compare our experience with the osteocutaneous radial forearm free flap (group 1) (n = 108) with other commonly used osteocutaneous free flaps (group 2) (n = 56) such as the fibula and scapula in single-stage oromandibular reconstruction., Design: Retrospective case review., Setting: Tertiary-care academic medical center., Patients: One hundred sixty-three consecutive patients who underwent 164 mandibular reconstructions with osteocutaneous free flaps., Main Outcome Measures: Assessment of preoperative and intraoperative variables for both groups. We compared recipient-site complication rate, intensive care unit stay, total hospital stay, and postoperative function., Results: The most common donor site used was the radius (n = 108 [66%]), followed by the fibula (n = 36 [22%]) and scapula (n = 20 [12%]). Mean follow-up was 29 months (range, 1-116 months). Group 2 patients had larger soft tissue and/or bony defects. Surgical and medical complication rates and major donor site morbidity in group 1 were similar or better when compared with those in group 2. The lengths of the intensive care unit (4 vs 7 days; P = .009) and hospital stays (13 vs 15 days; P = .06) were shorter in group 1. Although the microvascular success rate was similar in both groups, the local wound complication rate was significantly better for group 1. The difference for the length of intensive care unit stay was statistically significant and potentially amounts to more than 6000 dollars of savings. Functional outcomes, including the ability to tolerate oral diet, tracheostomy presence, and dental rehabilitation, were similar between the groups., Conclusions: The primary site long-term morbidity, donor site morbidity, and postoperative function of osteocutaneous radial forearm free flaps are comparable to those of other commonly used osteocutaneous free flaps such as the fibula and scapula when used in single-stage oromandibular reconstruction.

Object: Penetrating brain injuries caused by self-inflicted gunshot wounds are very often fatal and survivors suffer serious disabilities. Recognition of a possibly more favorable prognosis for a specific type of injury, the submental or transoral handgun or low-energy rifle wound, prompted the authors to review their experience with patients who had attempted suicide in this manner., Methods: The records of 11 consecutive patients seen over a 10-year period (1992-2001) were retrospectively reviewed. Handguns were used by eight patients and .22 caliber rifles by the others. The patients presented with predominantly unilateral frontal brain injuries that required urgent attention. One elderly patient who had made an advance directive concerning care died. All other patients underwent craniotomy and repair of associated ophthalmological and maxillofacial injuries. Follow-up review ranged from 9 months to 3 years, during which time there were no repeated suicide attempts. All but one patient expressed satisfaction with their appearance and returned to a self-sufficient lifestyle., Conclusions: Self-inflicted submental and transoral handgun and low-energy rifle wounds may produce serious but survivable brain injuries if the path of the bullet is limited to the frontal area. Early aggressive management of brain, dural, and craniomaxillofacial injuries should return the patient to a highly functional neurological status and restore an acceptable outward appearance. Outcomes, therefore, appear to be much better for these patients than for most patients with a penetrating brain injury due to a self-inflicted gunshot wound.

The development of nasal reconstruction concepts such as the three-layered (lining, structure, and covering) repair has led to remarkable esthetic and functional improvements. The authors present a variety of techniques for providing nasal structure and internal lining and discuss the application of these methods to specific nasal defects.