Patrick J. Byrne

Over 220,000 rhinoplasties are performed in the U.S. annually, with approximately 90% of all procedures requiring the use of cartilage autografts or allografts to augment nasal structure or contour. Prior to implantation, graft cartilage is shaped into the desired form by facial plastic surgeons through carving, crushing, or dicing, and molding of the tissue. The use of diced cartilage has been shown in literature to be the optimal technique for creating contour grafts, permitting increased graft moldability, and resulting in the fewest postoperative complications. Despite superior clinical outcomes, adoption of diced techniques is challenged by the laborious, time-intensive process of dicing tissue, which requires up to 2 h in the operating room and is currently performed manually with a blade. Manual dicing can result in inconsistently sized pieces, which can increase risk of graft breakage. Existing cartilage processing tools are primarily intended for crushing tissue and are unsuitable for dicing. This work describes the design and validation of an easy-to-use, effective device for rapid, consistent cartilage dicing. Cartilage sizing analysis demonstrated that the device produced approximately five times more diced cartilage within 5 min compared to manual dicing. The rapid dicer (RD) device consistently dices cartilage to a size suitable for grafting while significantly decreasing processing time and cartilage loss compared to current methods. Future development will focus on performing further user testing of the device to design a more ergonomic instrument casing.

Objectives: We describe an approach to reanimation of complete, prolonged facial paralysis using minimally invasive temporalis tendon transfer (MIT3) by the melolabial or transoral approach. Objective outcome measures are evaluated based on symmetry, and grading of preoperative/post-operative results and the scar at the melolabial fold. Study Design: Retrospective cohort study. Methods: Twenty-five patients undergoing the MIT3 technique were studied. Photographic analysis was used to determine the percentage of difference between the 2 sides (symmetry). Using the Delphi method to achieve consensus, a panel of experts graded pre/post-operative photos using the Terzis’ Facial Grading System and a 1 to 10 Likert-type scale and the melolabial scar using the Beausang Scar Scale. Results: Percentage of difference (symmetry) with smiling improved from 18.6% ± 1.5% (mean ± standard error of the mean [SEM]) preoperatively to 5.0 ± 0.9% (mean ± SEM) post-operatively. Expert grading by the Terzis system showed improvement post-operatively (mean 3.7/5; median 3.6/5) versus preoperatively (mean 1.5/5; median 1.2/5). Perceived improvement was also largely favourable (mean 8.1/10; median 8.0/10). Melolabial scar grading was favourable in terms of colour (mean 1.53/4), surface character (mean 1.05/2), contour (mean 1.60/4), and distortion (mean 1.74/4). Conclusions: The MIT3 technique offers immediate, predictable, and symmetrical return of smile function. Objective symmetry analysis and favourable expert grading of both pre-/post-operative photographs and the scar at the melolabial fold demonstrate applicability for facial reanimation in patients where other procedures have failed, or when a direct return to function is desired. Both the melolabial approach and transoral approach were found to be acceptable and effective, although applicability varies.

Facial Plastic Surgery & Aesthetic Medicine

It is my distinct honor to serve as guest editor of this Issue of Facial Plastic Surgery devoted to the management of facial paralysis. Our intention was to produce a very practical, valuable resource. I would like to share how I chose the contributors and the topics. First, we invited the contributors. Each author is an experienced leader in the field, and each sees atypically high volumes of patients with facial paralysis. You can know that the views presented here are thoughtful and based on personal experience. Next, we chose the topics. The decision was made to focus only on topics that matter. That is, scenarios that are both common and require you to make difficult decisions. Therefore, you will not find an exhaustive review of the causes of facial paralysis (many of which you will never encounter), nor will we present the current recommended management of Bell palsy upon presentation. You can look these up elsewhere. We do instead try to provide insight into how you may want to make decisions about management. These can be difficult. What will you offer the patient with a history of Bell palsy 2 years ago who has tone but wants to smile more (see Hadlock's article)? What do you tell the acoustic neuroma patient who presents with a 3-month history of complete paralysis, and who informs you that his neurosurgeon told him to wait a year because the nerve may regain function (see Boahene's article)? Should the patient with long-standing facial paralysis be offered a temporalis transfer or a gracilis free flap? Or something else? I hope that you will find guidance in this issue for these and many other practical problems that you face in your practice.

Paralytic lagophthalmos can lead to devastating exposure keratitis. The main surgical intervention consists of upper eyelid loading. However, adjunctive lower eyelid and brow procedures are also available as necessary. We sought to analyze the use of periocular procedures in paralytic lagophthalmos at Johns Hopkins. The method was a retrospective review of patients treated at a single tertiary care center from 2006 to 2012. One hundred one patients met inclusion criteria, and 20 patients were excluded for not meeting the minimum follow-up. Upper eyelid loading was required on 95/101 patients (95%). Adjunctive procedures were necessary in 73% (73/101) of patients. Lower eyelid procedures were used in 47% (47/101) and brow lifts in 47% (47/101). Older patients (>50 years) were more likely to require lower eyelid procedures (P = .04) and more likely to require revision (P = .003). Medial canthopexy and direct brow lift were associated with the need for revision (P = .006, P = .03). Paralytic lagophthalmos management is not one-size-fits-all. Upper eyelid loading is the mainstay of treatment; however, adjunctive procedures to the lower eyelid and brow are indicated in the majority of patients. Our retrospective review has allowed us to continue to refine our strategy for managing these patients.

Facial Plastic Surgery & Aesthetic Medicine

Research from JAMA Facial Plastic Surgery — Multidisciplinary Care of International Patients With Cleft Palate Using Telemedicine