Brendan Alleyne

Facial changes caused by smoking: a comparison between smoking and nonsmoking identical twins.

Background: The purpose of this study was to identify the specific components of facial aging secondary to smoking, by comparing standardized photographs of identical twins with different smoking histories. Methods: During the Twins Days Festival in Twinsburg, Ohio, from 2007 to 2010, 79 pairs of twins were identified, in which only one twin smokes or where one twin smoked at least 5 years longer than his or her counterpart. Questionnaires were obtained and standardized photographs were taken by professional photographers. A panel of three blinded judges analyzed the twins’ facial features and graded wrinkles using the validated Lemperle Assessment Scale, and ranked age-related facial features on a four-point scale. Results: Smoking twins compared with their nonsmoking counterparts had worse scores for upper eyelid skin redundancy, lower lid bags, malar bags, nasolabial folds, upper lip wrinkles, lower lip vermillion wrinkles, and jowls. Lower lid hyperpigmentation in the smoking group fell just short of statistical significance. Transverse forehead wrinkles, glabellar wrinkles, crow’s feet, and lower lip lines accentuated by puckering did not have a statistically significant differences in scores. Among twins with greater than 5 years’ difference in smoking duration, twins who had smoked longer had worse scores for lower lid bags, malar bags, and lower lip vermillion wrinkles. Conclusions: This study details the specifics of facial aging brought on by smoking, which primarily affects the middle and lower thirds of the face. It also demonstrates that a 5-year difference in smoking history can cause noticeable differences in facial aging in twins. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, II.

An anatomical study of the lesser occipital nerve and its potential compression points: implications for surgical treatment of migraine headaches.

Background: This study maps the course of the lesser occipital nerve and its potential compression sites in the posterior scalp. Methods: Twenty sides of 10 fresh cadaveric heads were dissected. Two fixed anatomical landmarks were used: the y axis was the vertical midline in the posterior scalp through the midline of the cervical spine. The x axis was a horizontal line drawn between the most anterosuperior points of the external auditory meatus. A topographic map of the lesser occipital nerve and its potential compression points was created. Results: The lesser occipital nerve emerged from the posterior border of the sternocleidomastoid muscle at an average of 6.4 ± 1.4 cm lateral to the y axis and 7.5 ± 0.9 cm caudal to the x axis. Branches of the occipital artery were found to interact with the lesser occipital nerve in 11 of the 20 hemiheads (55 percent). The mean location of the artery-nerve interaction was 5.1 ± 0.9 cm lateral to the y axis and 2 ± 1.45 cm caudal to the x axis. Two patterns of artery-nerve interaction were seen: a single site of artery crossing over the nerve in nine of 20 hemiheads (45 percent) and a helical intertwining relationship in two of 20 of hemiheads (10 percent). A fascial band was identified to compress the lesser occipital nerve in four of 20 hemiheads (20 percent). Conclusion: This anatomical study traced the lesser occipital nerve as it courses through the posterior scalp and mapped its potential decompression sites.

The auriculotemporal nerve in etiology of migraine headaches: Compression points and anatomical variations

Background: The auriculotemporal nerve has been identified as one of the peripheral trigger sites for migraine headaches. However, its distal course is poorly mapped following emergence from the parotid gland. In addition, a reliable anatomical landmark for locating the potential compression points along the course of the nerve during surgery has not been sufficiently described. Methods: Twenty hemifaces on 10 fresh cadavers were dissected to trace the course of the auriculotemporal nerve from the inferior border of the zygomatic arch to its termination in the temporal scalp. The compression points were mapped and the distances were measured from the most anterosuperior point of the external auditory meatus, which was used as a fixed anatomical landmark. Results: Three potential compression points along the course of the auriculotemporal nerve were identified. Compression points 1 and 2 corresponded to preauricular fascial bands. Compression point 1 was centered 13.1 ± 5.9 mm anterior and 5.0 ± 7.0 mm superior to the most anterosuperior point of the external auditory meatus, whereas compression point 2 was centered at 11.9 ± 6.0 mm anterior and 17.2 ± 10.4 mm superior to the most anterosuperior point of the external auditory meatus. A significant relationship was found between the auriculotemporal nerve and superficial temporal artery (compression point 3) in 80 percent of hemifaces, with three patterns of interaction: a single site of artery crossing over the nerve (62.5 percent), a helical intertwining relationship (18.8 percent), and nerve crossing over the artery (18.8 percent). Conclusion: Findings from this cadaver study provide information relevant to the operative localization of potential compression points along the auriculotemporal nerve.

Herbal products that may contribute to hypertension.

Background: The role of hypertension in the incidence of postoperative hematoma has been well documented. A large number of patients who undergo aesthetic surgery consume a variety of herbal products, some of which may cause or exacerbate hypertension. The purpose of this study was to review the herbal products that are known to cause hypertension and thus may play a role in postoperative complications. Methods: The MEDLINE and PubMed databases were searched for articles published from 1991 to 2011. Search terms included “hypertension,” “herbal supplements,” “herbals and hypertension,” “blood pressure,” and “dietary supplements.” References from reviews about herbal products and hypertension were searched for additional articles and case reports. A manual search was also conducted based on citations in the published literature. Results: Of 56 articles that were found to be related to herbal supplements that contribute to hypertension, 27 were excluded because of insufficient demonstration of the association or duplication. Twenty-nine articles, which examined the cause, pathophysiology, and risk factors of hypertension in addition to herbals, were included. In addition, four books were reviewed that contained some information regarding the association of hypertension and herbal products. The herbal products that may cause hypertension include arnica, bitter orange, blue cohosh, dong quai, ephedra, ginkgo, ginseng, guarana, licorice, pennyroyal oil, Scotch broom, senna, southern bayberry, St. Johns wort, and yohimbine. Conclusion: This study lists the herbal products that may cause hypertension and should be considered when a patient undergoes plastic surgery to reduce perioperative morbidity related to the herbal supplements.

Pharmaceutical and herbal products that may contribute to dry eyes.

Background: Symptomatic dryness of the eyes is a most common blepharoplasty complication. The authors reviewed the medications and herbal products that may potentiate this complication. Methods: The MEDLINE and PubMed databases were searched for the years 1991 to 2011. Search terms included “dry eye syndrome,” “keratitis sicca,” “keratoconjunctivitis sicca,” “ocular side effects,” “herbal supplements,” “herbals and dry eye,” “dry eye risk factors,” “etiology of dry eye,” “drugs side effects,” “drugs and dry eye,” “dietary supplements,” “ocular toxicity,” and “tear film.” References from herbal product reviews and eligible medication reports were searched for additional articles. A manual search was also conducted based on citations in the published literature. Results: Of 232 articles found to be related to dry eye syndrome and possible risk factors, 196 were excluded because they did not discuss medications or herbal products as risk factors in dry eye syndrome. Thirty-six articles that examined the pathophysiology and risk factors of dry eye were included. Nine books were reviewed that contained some information regarding the association of medications and herbal products with dry eye. These agents were then categorized based on mechanism of action and usage. Medications listed include antihistamines, decongestants, antidepressants, anticonvulsants, antipsychotics, antiparkinson drugs, beta-blockers, and hormone replacement therapy. The three main herbal products that contribute to dry eye are niacin, echinacea, and kava. There was a strong association between anticholinergic alkaloids and dry eye. Conclusion: This study identifies the medications and herbal products that should be considered when a patient undergoes blepharoplasty and complains of symptoms associated with dryness of the eyes.

Secondary cleft nasoplasty at primary school age: Quantitative evaluation of the efficacy of resorbable plates

Background: Secondary cleft nasal deformity in children of primary school age can result in permanent impact to a child’s self-esteem. The ideal technique and timing of addressing the deformity remain controversial, as harvest of septal cartilage affects nasal growth and limits future options. Methods: Fifty-three patients underwent secondary cleft nasoplasty with resorbable plate placement as a columellar strut. All patients had standardized preoperative and postoperative photographs. Basilar photographs were analyzed for height and width of each nostril, height and width of the nose, and deviation of the nasal tip from midline. Results: In unilateral clefts, improvements in nostril width, nostril height, tip height, and tip deviation were found to be statistically significant in early postoperative photographs; improvements in nostril height, tip height, and tip deviation remained statistically significant in late photographs. In patients with bilateral clefts, improvements in nostril height and tip height were found to be significant in early postoperative photographs, with improvement in nostril height remaining significant in the long term. Partial plate exposure limited to the columellar base occurred in five patients (9.4 percent), successfully treated in the clinic setting with no loss of nasal tip support. Conclusions: The authors provide quantitative data regarding nasal outcomes following secondary cleft nasoplasty using resorbable plates for tip support. Significant long-term improvements in nasal appearance are possible using this technique with minimal complications. In those patients presenting with cleft nasal deformity at primary school age, the use of resorbable plates can improve nasal symmetry and spare native cartilage and thereby reduce the potential for nasal growth disturbance. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

The incidence of vitamin, mineral, herbal, and other supplement use in facial cosmetic patients.

Background: Dietary supplement use is common in the United States. Some herbal supplements may cause coagulopathy, hypertension, or dry eyes. The goal of this study is to reveal the incidence of herbal supplement use in the cosmetic surgery population. Methods: A retrospective chart review of 200 patients undergoing facial cosmetic surgery performed by a single surgeon was performed. Variables studied included patient age, sex, surgical procedure, herbal medication use, and intraoperative variables. Exclusion criteria were age younger than 15 years, noncosmetic procedures such as trauma, and incomplete preoperative medication form. Patients were subdivided into the supplement user group (herbal) and the supplement nonuser group (nonherbal). Statistical analysis included descriptive statistics, t test, and chi-square analysis. Results: The incidence of supplement use was 49 percent in the 200 patients; 24.5 percent of patients used only vitamins or minerals, 2.5 percent of patients used only animal- and plant-based (nonvitamin/mineral) supplements, and 22 percent of patients used both types of supplements. In the herbal group, patients used an average of 2.8 supplements. The herbal and nonherbal groups differed significantly in sex (herbal, 89.8 percent female; nonherbal, 77.5 percent; p < 0.04) and age (herbal, 51.4 years; nonherbal, 38.5 years; p < 0.001). Conclusions: Herbal supplement use is prevalent in the facial cosmetic surgery population, especially in the older female population. Considering the potential ill effects of these products on surgery and recovery, awareness and careful documentation and prohibiting the patients from the consumption of these products will increase the safety and reduce the recovery following cosmetic procedures.

Primary correction of nasal asymmetry in patients with unilateral coronal synostosis.

Background: The optimal strategy for correction of significant nasal angulation in patients with unilateral coronal synostosis remains controversial. The authors report a novel technique for correction of significant nasal angulation in these patients, in which dissection of the nasal bones is limited to the site of the osteotomy, maintaining continuity with the soft-tissue envelope and the nasal cartilages. Methods: Seven successive patients with unilateral coronal synostosis and nasal deviation of greater than 6 degrees by computed tomographic analysis were evaluated. Three patients were treated using ex vivo repositioning in which the nasal bones were freed completely from the surrounding soft-tissue envelope, and four patients were treated with in vivo repositioning by performing a subperiosteal dissection only where required for lateral nasal osteotomies without separating the nasal bones from the cartilaginous framework of the nose. Nasal angulation was calculated using clinical photographs and three-dimensional computed tomography preoperatively and at 1-year follow-up. Results: Mean nasal angulation was reduced from 9.5 degrees to 2.5 degrees by computed tomographic analysis (p < 0.001) and from 6.9 degrees to 1.9 degrees by photographic analysis (p < 0.01) 1 year postoperatively. There was no significant difference in outcome between patients who underwent ex vivo or in vivo repositioning. Conclusions: Primary surgical correction of significant nasal angulation in patients with unilateral coronal synostosis can be achieved with less dissection and disruption of soft-tissue relationships than previously described without compromise in efficacy. The authors’ technique for osteotomy of the nasal bones preserves nasal architecture, minimizes periosteal dissection, and may theoretically reduce the potential for growth disruption. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

The Impact of Age Upon Healing: Absolute Quantification of Osteogenic Genes in Calvarial Critical-Sized Defects.

Background:The current study was performed to elucidate changes in growth factor expression over time in critical-sized calvarial defects in rats from infancy to skeletal maturity. Materials and Methods:Critical-sized parietal defects of 5, 6, and 8 mm were created in postnatal day 6 (P6), postnatal day (P20), and postnatal day (P84) adult rats, respectively. Dura was harvested at 3, 7, or 14 days after surgery, and serial micro–computed tomography imaging was performed through 12 weeks postoperatively. Absolute quantitative polymerase chain reaction was performed for Bone Morphogenic Protein-2 (BMP-2), Fibroblast Growth Factor-2 (FGF-2), Insulin-like Growth Factor-1 (IGF-1), and Transforming Growth Factor-&bgr;1 (TGF-&bgr;). Results:The P6 (6-d-old) rats showed the greatest difference in gene expression between the dura derived from the defect side and the dura derived from the control side, demonstrating significant differences in TGF-&bgr;1, BMP-2, IGF-1, and FGF-2 at various time intervals. Absolute gene expression in the defect dura was highest in the P6 rats and declined with age. Significant differences were noted at limited time points in the P20 rats for TGF-&bgr;1 and BMP-2 as well as in the P84 rats for TGF-&bgr;1. TGF-&bgr;1 was the only gene studied that showed significant differences at postoperative days 3, 7, and 14 in varying age groups. Conclusions:The P6 rats have a higher osteogenic potential accompanied by a more vigorous alteration in growth factor expression compared with the P20 or P84 rats. Decrease in BMP-2 and FGF-2 as well as relative increase in TGF&bgr;-1 messenger RNA were observed in healing defects. These data provide valuable insight into the mechanism of healing of critical-sized defects and may be of use to engineer factor-releasing implants to correct skull defects.

Cleft and Craniofacial Clinic Formats in the United States: National and Institutional Survey

Background: Craniofacial teams employ multidisciplinary clinics to optimize patient care. Different clinic formats exist among teams. Formats include providers rotating from room to room as separate specialties, patients rotating from room to room to either separate specialties or as 1 group, as well as providers rotating together as 1 group. Surveys were used to study family preferences between the different formats and to compare them with trends of national practices. Methods: Families of the authors’ team clinic patients were surveyed from November 2012 to February 2013, after a clinic format change from patients moving between rooms to see providers, to providers moving between rooms to see patients. This survey focused on patient satisfaction, clinic format preference, and their perception of efficiency. A second, national survey was distributed to 161 American craniofacial teams approved by the American Cleft Palate–Craniofacial Association to survey clinic formats, provider satisfaction, and experience with other formats. Institutional survey data were tabulated as percentages and further analyzed using the Mann–Whitney Test. The national survey data was then tabulated and compared with authors’ institutional results. Results: Thirty-nine of 54 (72.2%) families responded to the institutional survey. Providers moving between rooms were associated with greater patient satisfaction (mean 4.8 of 5, 5 being most satisfied) (0<0.0001), shorter perceived clinic time (76.9%), and an increased sense of comfort (84.6%). The difference in satisfaction rates was statistically significant (P <0.0001) between the primary clinic formats of providers rotating (mean of 4.8) and patients rotating (mean of 2.4). The national survey had 93 responses of 161 (57.7%). 54.9% of respondents have providers rotating between examination rooms, and 32.3% have patients moving between rooms. Other formats included the entire team moving as a group between rooms (10.8%) and specialties sitting together in 1 room while patients rotate (9.7%). Respondents were satisfied with current formats (mean 4.24 of 5, 5 being most satisfied). 22.2% had tried a different format previously. Conclusion: The most common American cleft and craniofacial clinic format is providers moving between rooms; however, all formats have high provider satisfaction. At our institution, patients prefer when providers move between rooms. Our study suggests that clinic formats do not need to be standardized, and the clinic format utilized should be tailored to the individual needs of the institution.