Kofi Boahene

What makes a good flap go bad? A critical analysis of the literature of intraoperative factors related to free flap failure.

The purpose of this article is to discuss the various factors related to poor outcome in free flap reconstructions of the head and neck (H&N). Free tissue transfer has become the standard reconstruction technique for complex H&N defects. With the evolution of free flap use in H&N surgery, numerous factors have been proposed that adversely affect flap outcome, many with the support of only anecdotal experience. We seek to critically review the literature to assess what evidence exists for the relation of various intraoperative factors to free flap complications.

Not just another face in the crowd: society's perceptions of facial paralysis.

There is a paucity of data showing the perception penalty caused by facial paralysis. Our objective was to measure societys perception of facial paralysis on the characteristic of beauty. We hypothesized that patients with paralysis would be considered by society as less attractive than normals, a difference amplified by smiling.

Use of Customized Polyetheretherketone (PEEK) Implants in the Reconstruction of Complex Maxillofacial Defects

Extensive maxillofacial defects resulting from trauma or oncologic resection present reconstructive challenges. Various autografts and alloplastic materials in conjunction with standard soft-tissue techniques have been used in the reconstruction of these types of defects. Polyetheretherketone (PEEK) is a semicrystalline polyaromatic linear polymer exhibiting an excellent combination of strength, stiffness, durability, and environmental resistance. Recent investigations of PEEK as a biomaterial resulted in the successful treatment of cervical disk disease. We describe a series of 4 patients whose defects were reconstructed using customized PEEK implants. All had excellent postoperative aesthetic and functional results without complications such as infections or extrusions. Because PEEK implants are customizable, easily workable, inert, and nonporous, they represent an ideal alloplastic material for maxillofacial reconstruction.

Minimally Invasive Temporalis Tendon Transposition

OBJECTIVE To describe a minimally invasive approach of the temporalis tendon transposition technique for dynamic reanimation in patients with long-standing facial paralysis. METHODS We report a case series of 17 consecutive patients with facial paralysis who underwent minimally invasive temporalis tendon transposition surgery for dynamic facial reanimation between January 1, 2006, and December 31, 2008. The minimally invasive technique is described. Preoperative and postoperative records, photographs, and videos were reviewed for feasibility of the technique, symmetry, oral competence, and dynamic oral commissure movement. RESULTS All the patients tolerated the procedure well, and none developed procedure-related complications. All the patients achieved improved symmetry at rest and voluntary motion of the oral commissure. In all the patients, the temporalis tendon was transposed to the modiolus without the need for fascial extension or lengthening myoplasty. CONCLUSIONS The temporalis tendon can be transposed for immediate dynamic reanimation of the paralyzed lower face using a minimally invasive approach. This procedure involves a single small incision and minimal dissection, with no major osteotomies. Acquisition of desired facial movement requires intensive physiotherapy and a motivated patient.

Alar Rim Grafting in Rhinoplasty Indications, Technique, and Outcomes

OBJECTIVE To determine the potential indications for placement of cartilaginous alar rim grafts in primary and revision septorhinoplasty. METHODS Retrospective medical chart analysis of all patients undergoing septorhinoplasty from March 2003 through June 2004 in a private facial plastic and reconstructive surgery center and a tertiary teaching hospital. Patients who received alar rim grafts were identified. The indications for placement of the alar rim grafts were deduced from their preoperative evaluation and intraoperative assessment as noted in their comprehensive operative notes. Preoperative and postoperative digital photographs as well as postoperative medical records were analyzed for alar contour, pertinent patient complaints, and complications. RESULTS During the 15-month study period, 150 patients underwent septorhinoplasty performed by the senior author. Of these patients, 31 received alar rim grafts. The most frequent indications for placement of alar rim grafts were cephalic malposition of the lower lateral cartilage with inadequate alar support (9 patients [29%]), correction of alar flare (9 patients [29%]), and correction of dynamic alar margin collapse (8 patients [26%]). At a mean 6-month follow-up, there were no graft displacements or extrusion. CONCLUSION Alar rim grafting is a simple and versatile approach to providing additional support to the external nasal valve and for improving nasal base contour.

Body Dysmorphic Disorder in a Facial Plastic and Reconstructive Surgery Clinic: Measuring Prevalence, Assessing Comorbidities, and Validating a Feasible Screening Instrument

IMPORTANCE Body dysmorphic disorder (BDD) is underrecognized and underdetected among patients undergoing facial plastic and reconstructive surgery. Patients with BDD require psychiatric care, not cosmetic surgery. OBJECTIVES To measure the prevalence of BDD in a facial plastic and reconstructive surgery clinic, to validate the Body Dysmorphic Disorder Questionnaire (BDDQ) in that setting, to assess the feasibility of implementing a standardized process for identifying patients with BDD accurately in a busy clinical practice, and to assess the comorbidity of BDD, depression, and anxiety in our patient population. DESIGN, SETTING, AND PARTICIPANTS We performed a prospective prevalence and instrument validation study in an academic facial plastic and reconstructive surgery clinic. We included 234 consecutive patients 18 years or older presenting to the clinic from March 3 to June 30, 2014. MAIN OUTCOMES AND MEASURES Prevalence of BDD as determined by the BDDQ and the criterion-standard BDD Structured Clinical Interview for DSM-IV (BDD SCID). The BDD SCID and a defect severity scale were used to confirm the BDD diagnosis and to validate the BDDQ finding. We also assessed demographic characteristics, depression, and anxiety in all patients. RESULTS As confirmed by the BDD SCID, 13.1% of patients undergoing cosmetic surgery and 1.8% of those undergoing reconstructive surgery had BDD. We found the BDDQ to be an accurate (91.7%), sensitive (100%), and specific (90.3%) screening instrument for BDD. Patients with a positive BDD finding were most commonly concerned with their nose (10 of 18 [56%]), skin (5 of 18 [28%]), hair (1 of 18 [6%]), chin (1 of 18 [6%]), and ears (1 of 18 [6%]), that is, areas commonly addressed by facial plastic surgeons. Furthermore, compared with patients who did not have BDD, patients with BDD had elevated depression scores (mean [SD], 12.6 [10.8] vs 3.2 [4.2]). In the non-BDD population, mean (SD) state and trait anxiety scores resembled the norm (30.0 [7.7] and 30.3 [7.7], respectively, for men; 31.7 [10.0] and 32.1 [8.7], respectively, for women); in the BDD population, these scores were elevated (53.8 [23.4] and 50.4 [19.5], respectively, for men; 47.8 [12.7] and 49.0 [11.6], respectively, for women). Depression and anxiety scores were highly correlated in patients with BDD (r = 0.84 for patients with a BDDQ-positive screen result; r = 0.94 for patients with a positive BDD SCID finding) compared with those who did not have BDD (r = 0.51). CONCLUSIONS AND RELEVANCE Patients with BDD often seek cosmetic treatment. Given the documented risks and harms of surgery for patients with BDD, a systematic process for identifying such patients who seek cosmetic surgery is imperative. We found a BDD screening instrument (BDDQ) followed by the BDD SCID for patients with a BDDQ-positive screen result to be a feasible and effective way to identify patients with BDD. LEVEL OF EVIDENCE NA.

What faces reveal: Impaired affect display in facial paralysis

To evaluate affect display in patients with facial paralysis as compared with normal subjects. We hypothesized that patients with facial paralysis would have impaired affect display and be perceived as displaying a negative affect as compared with normal subjects.

Dynamic muscle transfer in facial reanimation.

Dynamic muscle transfers offer the hope of improved facial support and symmetry, with volitional movement. These are most commonly employed for reanimation of the oral commissure to produce a smile. In addition, muscle transfers have been used successfully to reestablish eye closure. Facial paralysis of long-standing duration presents challenges quite distinct from paralysis that is managed early after onset. It is in this situation, most commonly, that dynamic muscle transfers are used. In this respect, the alternative is free tissue transfer. Each of these two options have advantages and disadvantages.

Changing perception: facial reanimation surgery improves attractiveness and decreases negative facial perception.

Determine the effect of facial reanimation surgery on observer‐graded attractiveness and negative facial perception of patients with facial paralysis.

How facial lesions impact attractiveness and perception: Differential effects of size and location

To determine the effect of facial lesion size and location on perceptions of attractiveness and importance for repair. We hypothesized that attractiveness scores and importance for repair would be dependent on lesion size and location.