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Importance: A gap in the reconstructive ladder exists in which complex defects may benefit from skin grafting but are not amenable due to their anatomic limitations. Similarly, some patients are intolerant of more invasive techniques in cosmetically sensitive areas. In these scenarios, augmented skin grafts may represent a unique alternative to traditional reconstructive options. Observations: This report is a clinical overview of skin grafting in complex nasal defects. We describe three types of augmented skin grafts, with examples of each. These include preliminarily augmented grafts with a dermal biomatrix, simultaneous augmentation with a perichondrocutaneous pseudo-composite graft, and delayed augmentation with staged structural grafting. Conclusions and Relevance: Augmented skin grafts represent unique methods of reconstruction for complex wounds in cosmetically sensitive areas. We propose these techniques as an evolving unique rung in the reconstructive ladder.

IMPORTANCE: In the last decade, there has been a significant increase in the number of practitioners administering botulinum toxin for facial synkinesis. However, there are few resources available to guide treatment patterns, and little is known about how these patterns are associated with functional outcomes and quality of life. OBJECTIVE: To evaluate botulinum treatment patterns, including the dosing and frequency of muscle targeting, for treatment of facial synkinesis and to quantify patient outcomes. DESIGN, SETTING, AND PARTICIPANTS: This prospective cohort study of 99 patients treated for facial synkinesis was conducted from January 2016 through December 2018 at the Vanderbilt Bill Wilkerson Center in Nashville, Tennessee, a tertiary referral center. INTERVENTION: Onabotulinum toxin A treatment of facial synkinesis. MAIN OUTCOMES AND MEASURES: Patient-reported outcomes on the Synkinesis Assessment Questionnaire and botulinum treatment patterns, including the dosages and frequency of injection for each facial muscle, were compared at the initiation of treatment and at the end of recorded treatment. RESULTS: In total, 99 patients (80 female patients [81%]) underwent botulinum injections for treatment of facial synkinesis. The median (interquartile range) age was 54.0 (43.5-61.5) years, and the median (interquartile range) follow-up was 27.1 (8.9-59.7) months. Most patients underwent injections after receiving a diagnosis of Bell palsy (41 patients, 41%) or after resection of vestibular schwannoma (36 patients [36%]). The patients received a total of 441 treatment injections, and 369 pretreatment and posttreatment Synkinesis Assessment Questionnaire scores were analyzed. The mean botulinum dose was 2 to 3 U for each facial muscle and 9 to 10 U for the platysma muscle. The dose increased over time for the majority of all muscles, with steady state achieved after a median of 3 treatments (interquartile range, 2-3). Linear regression analysis for cluster data of the mean total questionnaire score difference was −14.2 (95% CI, −17.0 to −11.5; P

This cohort study examines subjective patient-reported outcomes after nasal breathing surgery and identifies factors associated with patients’ perception of the procedure’s value.

Objective The objective of this case series was to describe botulinum toxin therapy as a novel treatment of intractable head pain following lateral skull base surgery. Background Intractable headaches following lateral skull base surgery are described in 23%-75% of patients and can significantly impact quality of life. Currently, the etiology of the headaches is unclear and treatment options are limited. Botulinum toxin is indicated for a multitude of functional and cosmetic reasons, including chronic migraine, and has been further described in treatment of various postsurgical pain syndromes. Methods In this case series, 4 patients underwent subcutaneous peri-incisional injections of botulinum toxin for intractable headache and head pain syndromes. Three patients had undergone lateral skull base surgery and the fourth patient had undergone a temporoparietal fascial flap harvest. Average injection dose ranged from 20 to 60 units with an average duration of effect ranging from 2 weeks to 4 months. Results All patients experienced significant relief of chronic head pain and returned for additional peri-incisional botulinum toxin injections, suggesting meaningful patient-perceived value. Conclusions Botulinum toxin therapy may represent a novel treatment for intractable head pain following lateral skull base surgery and temporoparietal fascial flap harvest. This study represents a small case series and, although 100% of the patients who were treated significantly improved, future inquiry is necessary to confirm these findings.

The prominence of the nose renders it susceptible to soft tissue trauma of multiple etiologies. In this review, we present a framework for evaluation and treatment of nasal soft tissue injuries. Initial evaluation of nasal soft tissue injuries should include a complete trauma assessment, history, and physical examination. Mechanisms described include lacerations, abrasions, bites, and thermal injuries. Finally, we discuss wound care and surgical treatment options, including local flap and free tissue transfer. Though timing of repair remains somewhat controversial, most sources indicate that immediate reconstruction should be undertaken when possible.

The buccinator, despite being a prominent midface muscle, has been previously overlooked as a target in the treatment of facial synkinesis with botulinum toxin.To evaluate outcomes of patients treated with botulinum toxin to the buccinator muscle in the setting of facial synkinesis.Prospective cohort study of patients who underwent treatment for facial synkinesis with botulinum toxin over multiple treatment cycles during a 1-year period was carried out in a tertiary referral center.Botulinum toxin treatment of facial musculature, including treatment cycles with and without buccinator injections.Subjective outcomes were evaluated using the Synkinesis Assessment Questionnaire (SAQ) prior to injection of botulinum toxin and 2 weeks after treatment. Outcomes of SAQ preinjection and postinjection scores were compared in patients who had at least 1 treatment cycle with and without buccinator injections. Subanalysis was performed on SAQ questions specific to buccinator function (facial tightness and lip movement).Of 84 patients who received botulinum toxin injections for facial synkinesis, 33 received injections into the buccinator muscle. Of the 33, 23 met inclusion criteria (19 [82.6%] women; mean [SD] age, 46 [10] years). These patients presented for 82 treatment visits, of which 44 (53.6%) involved buccinator injections and 38 (46.4%) were without buccinator injections. The most common etiology of facial paralysis included vestibular schwannoma (10 [43.5%] participants) and Bell Palsy (9 [39.1%] participants). All patients had improved posttreatment SAQ scores compared with prebotulinum scores regardless of buccinator treatment. Compared with treatment cycles in which the buccinator was not addressed, buccinator injections resulted in lower total postinjection SAQ scores (45.9; 95% CI, 38.8-46.8; vs 42.8; 95% CI, 41.3-50.4; P = .43) and greater differences in prebotox and postbotox injection outcomes (18; 95% CI, 16.2-21.8; vs 19; 95% CI, 14.2-21.8; P = .73). Subanalysis of buccinator-specific scores revealed significantly improved postbotox injection scores with the addition of buccinator injections (5.7; 95% CI, 5.0-6.4; vs 4.1; 95% CI, 3.7-4.6; P = .004) and this corresponded to greater differences between prebotulinum and postbotulinum injection scores (3.3; 95% CI, 2.7-3.9; vs 2.0; 95% CI, 1.4-2.6; P = .02). The duration of botulinum toxin effect was similar both with and without buccinator treatment (66.8; 95% CI, 61.7-69.6; vs 65.7; 95% CI, 62.5-71.1; P = .72).The buccinator is a symptomatic muscle in the facial synkinesis population. Treatment with botulinum toxin is safe, effective and significantly improves patient symptoms.3.

Objectives/hypothesis The wound healing characteristics of incisions made with the short pulsed CO2 laser tuned to 9.55 microm versus the traditional 10.6 microm were investigated. Previous studies have shown that at 9.55 microm, collagen is targeted more selectively than at 10.6 microm, which results in decreased acute thermal injury patterns. This study investigates the difference in wound healing over time between lasers and compares laser incisions with cold knife techniques. Study design Randomized controlled trial using a porcine model. Methods Tissue from 10.6-microm and 9.55-microm incisions of 10 piglets was evaluated with histological analysis and tensiometry at 3, 7, 14, and 21 days postoperatively. A Bonferroni-Dunn corrected analysis of variance analysis at a 95% significance level was used to compare the effect of wavelength. Results The results demonstrate that although knife incisions are consistently stronger than laser incisions, the 9.55-microm CO2 laser incisions are no stronger than incisions made with the conventional 10.6-microm laser. Furthermore, histological analysis shows no difference in lateral thermal damage between lasers at 3, 7, 14, and 21 days postoperatively. The progression of collagen formation and inflammation does not differ over time. Conclusion This study of wound healing using a porcine model demonstrates that the 9.55-microm CO2 laser does not demonstrate an improvement in wound healing over the traditional 10.6-microm CO2 laser. These results may be secondary to the common explosive vaporization mechanism produced by both lasers in the infrared spectrum.

Objectives To investigate the effects of thermally conductive, optically transparent media placed on skin during treatment with the flashlamp excited dye laser (FEDL). The use of higher energy densities to treat persistent cutaneous vascular lesions may result in a decrease in the number of treatment sessions. However, increased fluences can cause complications of scarring, hyperpigmentation, infection, skin texture changes, or hypopigmentation. The thermally conductive media should assist in dissipating surface thermal energy and thereby protect the skin from the complications. Study Design This was a prospective laboratory study using an animal model. The results were verified in a prospective, pilot, human-use trial. Methods The threshold for acute skin damage and measurements of the thermal transients were made using a rabbit model. The threshold for purpura was noted with and without the use of a sapphire as a thermal conductor. The thermal transients were measured with small thermocouples placed subcutaneously. On a human subject, purpura intensities were photographed and measured using computer morphometrics after treatment with the FEDL and skin surface protection with air, glass, sapphire, and diamond as conductive media. Results With the interposition of the sapphire thermal conductor during the FEDL treatment, excessive temperature increases of the epidermis were prevented during the laser pulse compared with glass and controls. Both sapphire and diamond resulted in decreased purpuric intensities with the applications of equivalent fluences. Wound recovery time for the purpura was decreased by approximately half a day when any of the surface conductors were used. Conclusions The decreased transient temperature and decrease in purpura seen with the use of sapphire and diamond protecting the epidermis during treatment with the FEDL should result in fewer untoward effects during treatment of vascular lesions and facilitate their management.

Yellow wavelength lasers have revolutionized the treatment of benign vascular cutaneous lesions. The flashlamp excited dye laser provides optimal clearing of most benign lesions. Patients of all ages may be treated safely with minimal risk of inducing scarring or skin texture changes. Our technique for using the flashlamp excited dye laser is described.

Patient evaluation and selection for aesthetic facial surgery and rhinoplasty in particular goes beyond assessment of anatomical indications. The selection of appropriate candidates involves an understanding of the patient's motivations for the procedure, expectations for the surgical outcome, and ego strength for tolerating the stress of operative intervention. The patient interview must be structured to give the surgeon ample information to determine the psychological and emotional stability of the candidate. Psychiatric consultation may be required if evidence is uncovered indicating psychiatric illness. Time spent informing the patient preoperatively will pay off great dividends in the postoperative period. If patient dissatisfaction does occur, validate and address the patient's concerns with a nondefensive posture.

Background and Objective A number of lasers are available for cutaneous periorbital surgery, yet not all eye shields are appropriate for all applications. We tested a variety of commercially available eye shields to assess their safety features. Study Design/Materials and Methods Six commercially available eye protectors were studied. A focused laser was incident upon the shield, and the intensity and exposure duration required for visible damage to the shield were measured. We then measured the temperature on the underside of the eye shield during exposure from the laser. Time-dependent temperature measurements were made with a type-T thermocouple fixed to the eye shield with silicon grease. Results Thermal response curves and rates of warming for each of the six eye shields were generated. Plastic shields showed significant thermal damage with most of the lasers tested. The metallic shields warmed more slowly and to a lesser degree. Conclusion Overall, the metallic eye shields had the most acceptable safety profile. Many of the plastic shields exhibited significant thermal damage, and therefore we discourage their use in periorbital laser surgery. © 1996 Wiley-Liss, Inc.