Facial plastic surgery-otolaryngology responds to Sullivan inquest findings

The CIFPS members are individuals who have demonstrated competency to perform facial plastic surgical procedures. It is in the public interest that the public be aware of the various specialties performing facial plastic surgery, and that several specialties confine their training and interest to a particular region. The term "facial plastic surgery--otolaryngology" accurately and truthfully defines the practice and expertise of the otolaryngologist performing cosmetic and reconstructive facial surgery. It is in the interest of the medical community and the public that this term be recognized.     

Primary and adjunctive uses of botulinum toxin type A in the periorbital region

Chemodenervation with botulinum toxin has become an integral part of the facial plastic armamentarium. Although eyebrow and eyelid cosmetic deformities and asymmetries have traditionally been treated by surgical intervention, Botox can now be incorporated effectively into the surgical plan. When the surgeon has a complete understanding of facial anatomy and muscular interactions, Botox can be used as a primary treatment of the periorbital region or as an adjunct to surgical procedures of the periorbital region.     

Evaluation of conscious sedation in facial plastic surgery

Local anesthesia and conscious sedation are important aspects of facial plastic surgery. The safe and effective application of these techniques is important to produce happy, satisfied patients as well as good surgical results. Local anesthetic and sedative drugs will be discussed with respect to their mechanisms of action, doses, toxicities and appropriate selection. We will discuss the techniques we have developed using fentanyl and Versed and our evaluation of their effectiveness. Twenty sequential facial plastic surgical patients undergoing a total of 30 procedures will be reviewed. The average dose of fentanyl was 70 mcg and Versed was 3.1 mg. Significant amnesia occurred in 60% of patients, 80% experienced little or no discomfort and 90% would have no hesitation to undergo another procedure with similar anesthesia and sedation.     

Local anesthetics for facial plastic procedures.

The use of local anesthetic in facial plastic surgical procedures is well established as an effective and safe mode of anesthesia delivery. Local infiltration of anesthesia may be used alone for minor surgical procedures, or it may be used with general anesthesia or intravenous sedation and analgesia for more complex, lengthy procedures. When considered independently, the use of local anesthetic agents has undeniable limitations. Local anesthetics can cause toxicity and side effects. Injection of local anesthetics for subcutaneous infiltration frequently is painful until sensory anesthesia occurs. Local anesthetics have limited efficacy with respect to the intensity and duration of sensory blockade that can be achieved. In some situations, use of local anesthesia with the maintenance of an awake patient also may be undesirable for the surgeon and impractical for the patient. Despite these shortcomings, local anesthetics are fundamentally ideal for use in facial plastic surgery.     

Hypoglossal — facial nerve anastomosis: A review of forty cases caused by facial nerve injuries in the posterior fossa

Hypoglossal-facial anastomosis has been our procedure of choice in the repair of the permanently injured facial nerve in the cerebellopontine cistern, when the nerve cannot be primarily repaired. Total failures are few and complications are rare. Most results are good to excellent, if assessment is based upon realistic expectations. These include: 1. normal facial symmetry in repose, 2. good midface voluntary motion, 3. no reflex or emotional facial movement, 4. some synkinesis and donor-injected mass facial movement, and 5. surprisingly little functional loss from hypoglossal paralysis. Our experience indicates better results in younger patients and in those repairs completed shortly after injury. These findings correlate well with the experience gained in peripheral nerve repair in the extremities. There appears to be no absolute time period between injury and repair beyond which this anastomosis is definitely contraindicated. Finally, this procedure does not negate adjunctive plastic surgical procedures. Most of our patients have had tarsorrhaphy or physiologic protection of the eye, but few have had corrective cosmetic surgical procedures until the past few years. We have never used cervical sympathectomy to reduce the size of the palpebral fissure. Better surgical procedures to correct both extracranial and intratemporal facial nerve injuries have significantly reduced the indication for anatomosis procedures. Additionally, over the past two decades, the improved diagnostic and surgical techniques for posterior fossa tumors have considerably reduced the incidence of facial paralysis. As these trends continue, the number of patients requiring nerve anastomosis for facial paralysis will continue to decline and what was once the only surgical procedure to repair the paralyzed face will become a rare operation.     

Lidocaine v bupivacaine in facial plastic surgery. A clinical trial

The ideal local anesthetic agent for facial plastic surgery should have rapid onset, good surgical anesthesia, and reasonably long duration. The purpose of this prospective, randomized, double-blind study was to compare 1% lidocaine hydrochloride with 1:200,000 epinephrine with 0.5% bupivacaine hydrochloride with 1:200,000 epinephrine, a newer, longer-acting local anesthetic, in different facial operations. The results suggest that bupivacaine is an effective and safe agent for these procedures.     

Plastische Deckung von Weichteildefekten im Gesicht

The difficulties in facial reconstruction derive from the unique character of the face and the availability of local matching tissues. Facial reconstructive surgery must aim at a functionally and aesthetically rehabilitated patient. The performance of facial plastic surgery requires an understanding and the application of many important principles. The aim of this paper is to review the critical factors to be considered in the management of surgical wounds by second-intention healing, primary closure, skin grafting, and repair with local or distant free flaps. The key concepts useful in flap choice and implementation are discussed. In addition, an overview of new developments in tissue engineering and gene therapy as they relate to facial plastic surgery is provided.     

Hyperplastic scars and keloids: part II: Surgical and non-surgical treatment modalities

Aberrant wound healing results in unsightly scarring, hypertrophic scarring, and keloid formation, causing functional and cosmetic deformities, discomfort, psychological stress, and patient dissatisfaction. Scar management, both surgical and non-surgical, continue to be important issues for the facial plastic surgeon. Many techniques for the management of hypertrophic scars and keloids have been proven through extensive use, but few are supported by prospective studies with adequate control groups. Several new therapies showed good results in small-scale trials, but these have not been repeated in larger trials with long-term follow-up. This article presents an overview of the available therapies and provides recommendations for the treatment of abnormal scarring. The recommendations focus on the management of hypertrophic scars and keloids. Strategies for the management of keloids and hypertrophic scars are of continuing interest and studies are necessary to understand the basic mechanisms causing aberrant wound healing. In addition, an overview of new developments in molecular wound management and gene therapy, as they relate to facial plastic surgery, is provided.     

Hyperplastische Narben und Keloide

Aberrant wound healing results in unsightly scarring, hypertrophic scarring, and keloid formation, causing functional and cosmetic deformities, discomfort, psychological stress, and patient dissatisfaction. Scar management, both surgical and non-surgical, continue to be important issues for the facial plastic surgeon. Many techniques for the management of hypertrophic scars and keloids have been proven through extensive use, but few are supported by prospective studies with adequate control groups. Several new therapies showed good results in small-scale trials, but these have not been repeated in larger trials with long-term follow-up. This article presents an overview of the available therapies and provides recommendations for the treatment of abnormal scarring. The recommendations focus on the management of hypertrophic scars and keloids. Strategies for the management of keloids and hypertrophic scars are of continuing interest and studies are necessary to understand the basic mechanisms causing aberrant wound healing. In addition, an overview of new developments in molecular wound management and gene therapy, as they relate to facial plastic surgery, is provided.     

The otolaryngologist's attitude to facial plastic surgery

Of 453 Canadian otolaryngologist, 226 responded to a questionnaire, indicating significant interest in the state of facial plastic and reconstructive surgery. The majority of these otolaryngologists practised in larger cities and one-quarter received foreign training. Half of the respondents had academic affiliations and three-quarters considered themselves general otolaryngologists. Almost all the otolaryngologists believed that cosmetic and reconstructive surgery should form a major part of their specialty, this being unanimous among current residents. A large majority felt there should be more facial plastic surgical training, this both at the residency and fellowship levels, preferably through increased surgical exposure. With respect to sub-certification, only the resident group was in favor.     

Genioplasty, indications and therapeutic methods in dento-maxillary malformations

Genioplasty constitutes an adjunctive surgical procedure used in adult plastic surgery of the facial profile. It is used after dental malocclusion has been corrected and facial morphological features have been reassessed (soft tissue changes consecutive to maxillary osteotomy should be previously analyzed by cephalometry). Genioplasty permits achieving a modification of the chin point in the three planes. The authors describe several types of genioplastic operations, depending on the aim.     

Mimetic surgery for the paralyzed face

One hundred ten patients with facial nerve paralyses were treated by various surgical methods. Eighty-six patients had total facial nerve paralyses and 24 had segmental paralyses. In the total paralysis group, 62 patients had oncologic procedures or tumor induced paralysis. In the segmental paralysis group, 14 patients had malignancies. Two patients had idiopathic facial nerve paralysis. In the total paralysis group, 59 had neural reconstructions, 7 neuromuscular pedicles, and 20 muscle-fascia transpositions. The segmental paralysis group was divided into an upper facial palsy group (n = 11) and lower facial palsy group (n = 13). Five patients had neural transpositions, 5 had muscle-fascia transpositions, and 14 had plastic reconstructions. The results were analyzed by various methods and grading systems. The data indicate that neural repairs produce better results than muscle-fascia transpositions or plastic reconstructions. Within the repairs, the procedures are listed in an hierarchical order of cosmetic and functional results. The average follow-up for the entire group was 2.8 years. The average follow-up for the neural repair group was 3.2 years, and for the muscle fascia transpositions, 14.1 months.     

Analysis of the upper face and selection of rejuvenation techniques

A plethora of forehead rejuvenation techniques are available to the facial plastic surgeon. To optimize patient satisfaction, the selection of the appropriate technique should be individualized for each surgical patient and should be based on a balance among pre-existing anatomy, function, and the desired aesthetic outcome.     

The effects of computer simulated facial plastic surgery on social perception by others

Previous studies have demonstrated the remarkable impact of facial plastic surgery on the perception of facial features. However, pre- and postoperative differences other than the surgically changed features such as facial expression, hairstyle, make-up etc., have influenced the results of previous studies. To exclude these visual cues a computer composite photograph of the changed feature mounted upon the preoperative photograph, instead of the standard postoperative photograph, was presented to observers in this study. Computer graphic technology was used to superimpose the postoperative, surgically changed facial features such as the nose, ear and chin of 16 patients on standardized preoperative photographs. The randomized preoperative photographs and the ‘postoperative’ composed images were presented to 67 subjects, using a person-perception questionnaire. Multivariate analysis demonstrated a more favourable postoperative judgement in only two patients (12.5%). The exclusive effect of facial plastic surgery on the social perception of patients by others when excluding visual cues, such as facial expression, hairstyle, make-up etc, is limited. It is tentatively assumed that the role played by facial plastic surgery is one of initiating a positive cycle by changing the patient’s self-perception rather than one of direct social impact from the changed features.     

Cervicofacial liposuction: results and controversies

Obtaining ideal results with cervicofacial rhytidectomy has long frustrated facial plastic surgeons due to the difficulty of removing local excesses of adipose tissue in the parotid, melolabial, submental and submandibular areas. Open and closed liposuction techniques are being developed in conjunction with the facelift to improve definition of the facial, mandibular and cervical contours. A review of the senior author's (PAA) cases of cervicofacial liposuction and rhytidectomy is presented with emphasis placed on surgical techniques and results. Current literature is reviewed. Recommendations are made regarding analysis, surgical techniques and postoperative management of patients presenting for rejuvenation of the lower face.     

Submental surgery. A graduated approach to the aging neck

Adequate aesthetic contouring of the aging neck often presents a difficult surgical challenge to the facial plastic surgeon. The apparent failure of the classic rhytidectomy to achieve acceptable results in the submental region has encouraged previous surgeons to develop surgical techniques specifically addressing this area. Definitive procedures were developed to treat the excess skin, fat, or muscle. Aesthetic results have progressively improved with the introduction of liposuction, judicious muscle rearrangement, and more conservative submental skin violation. This article describes our experience with these concepts and presents a useful classification devised to serve as an operative guide in the management of the aging neck.     

Update on lasers in facial plastic surgery

PURPOSE OF REVIEW: Since the theory of selective photothermolysis was described, the field of facial plastic surgery has advanced the science behind laser: tissue interactions. Particular advances in skin cooling, hair removal, intense pulsed light, and uses for aesthetic and nonaesthetic skin problems are described in this review. RECENT FINDINGS: Continued basic science research in lasers has led to improvements in current technology available to the facial plastic surgeon. Advances in skin cooling have allowed for wider use in all Fitzpatrick skin types without concomitant adverse reaction. SUMMARY: Our understanding of laser science continues to expand our knowledge in basic laser: tissue interaction. An improvement in various laser mediums and adjunctive devices provides the facial plastic surgeon with instruments to treat a wider patient population. The benefit is a successful clinical and aesthetic result with improved safety.     

Anaphylactic reaction to lidocaine

Lidocaine hydrochloride is an amide-type local anesthetic, commonly used for facial plastic as well as other surgical procedures. In an unusual case of reproducible anaphylactic reaction to lidocaine, early treatment with epinephrine, oxygenation, and intravenous fluid resuscitation resulted in relief of the symptoms. This case demonstrates the importance of sensitivity testing and choosing an appropriate alternative local anesthetic in a patient with a history of possible allergy to lidocaine.     

Achieving symmetry in browplasty

As is well known by facial plastic surgeons, the browplasty serves to augment the favorable aesthetic effect of blepharoplasty as well as delay or reduce the effect on the forehead that the ptotic brow creates in compensatory elevation. A method of achieving postoperative symmetry in performing direct browplasty is described utilizing: direct measurement of the amount of preoperative ptosis; and known anatomic reference points in which to correlate these measurements on the face. The surgical technique involving a layered plastic closure is also described in order to further obtain the most desirable postoperative result.     

Computer imaging for instruction in facial plastic surgery in a residency program

Aesthetic analysis of the face has advanced from a purely subjective opinion to complicated formulas based on measuring various combinations of angles, distances, and ratios. These concepts of facial harmony and surgical alterations have been difficult to teach in a residency program, especially regarding preoperative evaluation and a clear idea of the desired surgical results. The authors have utilized a computer imaging system to facilitate the preoperative facial analysis and to project what the postoperative surgical result should achieve based on these measurements. The use of this system has helped enhance the communication between resident and attending surgeon as well as educate the resident in important facial relationships. A degree of experimental freedom in alteration of facial features is provided. The methods of facial analysis and the advantages of computer imaging in a residency program are discussed.