Clinton D. Humphrey

Nerve Repair and Cable Grafting for Facial Paralysis

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 surgeons 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.

Setting Up a Medical Portrait Studio

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.

The Spectrum of Isolated Congenital Nasal Deformities Resembling the Cleft Lip Nasal Morphology

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 patients 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.

Surgical Treatment of Orbital Blowout Fractures: Complications and Postoperative Care Patterns

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.

Digital asset management.

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 surgeons digital images.

Defect of the Eyelids

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.

Autologous Rib Grafts in the Management of the Crooked Nose

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.

Analysis of Facial Reanimation Procedures Performed Concurrently With Total Parotidectomy and Facial Nerve Sacrifice

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.

Association of Skin and Cartilage Variables With Composite Graft Healing in a Rabbit Model

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-&mgr;m 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.

Assessing Cosmetic Rhinoplasty Outcomes

Developing effective methods to evaluate surgical outcomes is more important than ever. Peers, patients, and payers increasingly judge the quality of surgical procedures based on measurable outcomes. The government, health care review websites, and others are actively seeking benchmarks to compare our individual surgical results with those of other surgeons across the country and around the world. It is in our best interest to identify equitable methods of measuring our outcomes, and cosmetic surgery outcomes are among the most difficult to measure. Rating cosmetic results in rhinoplasty—with wide variability in what is considered ideal or is even possible for a given patient—is particularly challenging. Prior studies1,2 have examined patients’ and surgeons’ perceptions following rhinoplasty. However, both patients and surgeons have inherent biases that interfere with objective analyses of rhinoplasty outcomes.3 Unbiased casual observers are better suited to independently rate improvement following cosmetic rhinoplasty. Nellis and coauthors4 present an innovative strategy to evaluate rhinoplasty outcomes using casual observers in this issue of JAMA Facial Plastic Surgery. Casual observers in this study rated attractiveness, perceived overall health, and perceived success while viewing rhinoplasty patient images. The observers looked at and evaluated a mix of both preoperative and postoperative images but never 2 images of the same patient. Patients who had undergone rhinoplasty consistently received higher ratings in all 3 categories. Only preoperative and postoperative images of patients with “ideal” rhinoplasty outcomes as defined by the surgeons were used in this study. With their results, Nellis et al4 provide some evidence that rhinoplasty surgeons’ aesthetic ideals are shared by society. It is indeed valuable to know that casual observers and rhinoplasty surgeons see the same noses as attractive. As aesthetic surgeons, it is possible to focus on the most we can achieve; this has left face-lift and rhinoplasty patients looking overly “done” or with an “operated” look. Dramatic changes may give some surgeons satisfaction, but dramatic changes are not always necessary or viewed favorably by society. An optimist’s interpretation of the study by Nellis et al4 is that contemporary rhinoplasty surgeons are not simply striving for dramatic surgical changes to the nose but for changes that look natural and that society will perceive as favorable. Do findings of Nellis et al4 make it prudent to counsel patients that they are likely to be perceived as more attractive, healthier, and more successful following rhinoplasty? Should the way that society views “ideal” rhinoplasty results effect our preoperative discussions with all patients seeking rhinoplasty? Although rhinoplasty revision rates are published,5 not all patients foregoing revision rhinoplasty have “ideal” outcomes. How often do optimal rhinoplasty outcomes occur? What is society’s perception of not just our ideal outcomes, but of the outcomes of a series of consecutive rhinoplasty patients? Knowing this may yield a more valid understanding of patient and surgeon rhinoplasty satisfaction. We should strive to answer these tough questions and others by building on the innovative strategies that Nellis and colleagues4 have devised to measure cosmetic rhinoplasty outcomes. Scrutinizing our results is always risky, but it is worth the risk to better understand cosmetic rhinoplasty outcomes, improve patient selection, and identify the most effective surgical techniques. We will ultimately be rewarded with more satisfied rhinoplasty patients.