Objectives  To evaluate the usefulness of resorbable polydioxanone plate attached to nasal septal cartilage in external septoplasty, to assess its mechanical stability until healing of cartilage fragments, and to describe the surgical technique and clinical experience.

Design  External septoplasty with polydioxanone plate has been performed in 396 patients since 1996. Indications were severe septal deformities (usually posttraumatic). Surgery included removal of the quadrilateral cartilage and division into straight fragments, which were sutured to resorbable polydioxanone plate and replaced as a free graft. If the nasal septal cartilage was partly or completely missing because of prior surgery or trauma, the missing cartilage was supplanted with auricular conchal cartilage. The study settings were Medicent Linz, Linz, Austria, and the Ear, Nose, and Throat Department, General District Hospital Steyr, Steyr, Austria.

Results  Functional and cosmetic outcomes were satisfactory. All patients experienced varying degrees of improvement in nasal blockage. There were no immediate (bleeding, septal hematomas, inflammatory reactions, or necrosis) or long-term (septal perforation, thickening of the nasal septum, or rejection of the implant) complications.

Conclusion  Use of polydioxanone plate attached to nasal septal cartilage facilitates surgical correction of severe septal deformities and supports the nasal dorsum until healing.

Objective  To evaluate whether mandibular distraction osteogenesis relieves tongue-based airway obstruction in patients with severe micrognathia.

Design  Retrospective medical review spanning a 7-year period in a tertiary care hospital. The inclusion criterion was defined as micrognathia associated with a severe tongue-based obstruction. The patients included 11 neonates and infants (mean age, 4.3 months) and 2 pediatric patients (mean age, 5.4 years). Two patients had already received tracheotomies, 11 had not. The intervention was bilateral mandibular osteotomies with distraction osteogenesis. The outcome measures were avoidance of tracheotomy and decannulation.

Results  Ten of 11 patients avoided tracheotomy. Two of 2 patients who had already undergone tracheotomies were successfully decannulated.

Conclusion  Mandibular distraction osteogenesis is an acceptable treatment alternative to tracheotomy in select pediatric patients with micrognathia and severe tongue-based obstruction.

Objectives  To eliminate the inconsistency in the nomenclature, to anatomically and definitively describe the topographic relationship of the temporal branch of the facial nerve to the fascial layers and the fat pads, and to create an effective algorithm to define the safest approaches and planes for surgical procedures in this area.

Methods  The study was performed using 18 hemifacial cadaveric specimens. In 12 hemifacial specimens, the facial halves were coronally sectioned and dissected. In 6 hemifacial specimens, planar dissection was performed layer by layer.

Results  The temporal branch of the facial nerve that traversed inside the deep layers of the temporoparietal fascia and the superficial musculoaponeurotic system coursed along the zygomatic arch as 1 (14.3%), 2 (57.1%), 3 (14.3%), and 4 (14.3%) twigs in the specimens. The temporoparietal fascia had no attachment to the zygomatic arch and continued caudally as the superficial musculoaponeurotic system. Adhesions were between the temporoparietal fascia and the superficial layer of the deep temporal fascia around the zygomatic arch. In most specimens, the superficial layer of the deep temporal fascia continued as the parotideomasseterica fascia, and a deep layer abutted the posterosuperior edge of the zygomatic arch.

Conclusion  An easy and safe surgical approach in this area is to elevate the superficial layer deep to the intermediate fat pad directly on the deep layer of the deep temporal fascia descending to the periosteum along the zygomatic arch.

Objective  To evaluate changes in lower eyelid position using digital image analysis in patients who have undergone an orbicularis suspension flap combined with blepharoplasty.

Methods  A total of 68 patients (136 eyes) underwent a lower eyelid orbicularis oculi suspension flap combined with blepharoplasty. Digital image analysis was used to standardize each patient's preoperative and postoperative photographs for accurate objective comparison. The photographs were analyzed for lower eyelid position.

Results  The mean (SD) preoperative standardized distance from the center of the pupil to the lower eyelid margin (MRD2) in all procedures was 5.53 (0.74) mm. The mean (SD) postoperative standardized MRD2 was 5.22 (1.0) mm. There was a statistically significant difference in MRD2 position such that the postoperative MRD2 position decreased or the lower eyelid position was elevated by an average of 0.31 mm in comparison to the preoperative position (P < .001).

Conclusions  A well-performed suspension flap can elevate the lower eyelid position to a more natural and anatomically appropriate position. By resuspending the ptotic orbicularis muscle, the suspension flap also reinforces the underlying attenuated orbital septum. Such cases may not achieve the optimum level of rejuvenation if isolated lower eyelid blepharoplasty is performed.

Objective  To determine the force requirements, optimal vector, and appropriate materials of a novel eyelid sling device that will be used to rehabilitate eyelid closure (blink) in congenital or acquired permanent facial paralysis with an artificial muscle.

Methods  The force required to close the eyelids in human cadavers (n = 6) were measured using a load cell system. The eyelid sling using either expanded polytetrafluoroethylene (ePTFE) or temporalis muscle fascia was implanted. The ideal vector of force and placement within the eyelid for a natural eyelid closure were compared.

Results  The eyelid sling concept was successful at creating eyelid closure in a cadaver model using an upper eyelid sling attached to the distal tarsal plate. Less force was necessary to create eyelid closure using a temporalis muscle fascia sling (627 ± 128 mN) than for the ePTFE eyelid sling (1347 ± 318 mN).

Conclusions  The force and stroke required to close an eyelid with the eyelid sling are well within the attainable range of the electroactive polymer artificial muscle (EPAM). This may allow the creation of a realistic and functional eyelid blink that is symmetric and synchronous with the contralateral, normally functioning blink. Future aims include consideration of different sling materials and development of both the EPAM device and an articulation between the EPAM and sling. The biocompatibility and durability studies of EPAM in a gerbil model are under way. The successful application of artificial muscle technology to create an eyelid blink would be the first of many potential applications.

Objective  To quantify tissue tearing force at various anchoring points on the face.

Methods  This is a prospective anatomic study using 4 fresh cadavers of persons aged 60 to 70 years at the time of death, for a total of 8 sides. Standardized 1-cm distances were measured at the various anchor points, and a single 0 Prolene suture loop was tied at each standardized anchoring point. Steady force was applied perpendicular to the plane of the face with a digital hanging scale. The scale was pulled until the suture ruptured the tissue at the anchoring point. The values at which the tissue ruptured were recorded, averaged, and compared.

Results  The average tissue force was 7.01 kg for the root of the zygoma vs 3.44 kg for the temporalis fascia (P < .05). The average tissue force was 5.50 kg for infralobular tissue vs 4.09 kg for tissue of the superficial musculoaponeurotic system located 1 cm anterior to the infralobular tissue (P < .05). The force for the fascia of the sternocleidomastoid was 3.89 kg vs 5.57 kg for the mastoid fascia (P < .05). There was a statistically significant difference between vertical bites of the temporalis fascia at 1.90 kg vs horizontal bites of the temporalis at 5.01 kg (P < .05).

Conclusion  The tissue tearing force varies by location on the face as well as suture orientation.

Objective  To determine the Sunderland classification of a bipolar electrocautery injury.

Methods  Twenty-two rats received crush (a reproducible Sunderland second-degree injury) or bipolar electrocautery injury and were evaluated for functional, histomorphometric, and immunohistochemical recovery at 21 or 42 days. Animal experiments were performed between July 3 and December 12, 2007. Axonal regeneration and end plate reinnervation were evaluated in double transgenic cyan fluorescent protein–conjugated Thy1 and green fluorescent protein–conjugated S100 mice.

Results  Compared with crush injury, bipolar electrocautery injury caused greater disruption of myelin and neurofilament architecture at the injury site and decreased nerve fiber counts and percentage of neural tissue distal to the injury (P =.007). Complete functional recovery was seen after crush but not bipolar electrocautery injury. Serial live imaging demonstrated axonal regeneration at week 1 after crush and at week 3 after bipolar electrocautery injury. Qualitative assessment of motor end plate reinnervation at 42 days demonstrated complete neuromuscular end plate reinnervation in the crush group and only limited reinnervation in the bipolar electrocautery group.

Conclusion  Bipolar electrocautery injury in a rodent model resulted in a Sunderland third-degree injury, characterized by gradual, incomplete recovery without intervention.

Objective  To establish whether nimodipine, a calcium channel blocker, accelerates or otherwise improves functional recovery of whisking after facial nerve crush injury in the rat.

Methods  Thirty rats underwent exposure of the left main trunk of the facial nerve followed by a standard crush injury and subsequent quantitative facial movement testing. Animals were randomized into an experimental group (n = 15) and a control group (n = 15). Four days prior to facial nerve manipulation, experimental animals underwent subcutaneous implantation of a nimodipine-secreting pellet. All animals were tested preoperatively and on postoperative days 2, 8 to 17, 20, 22, 24, and 31 using a validated, quantitative whisking kinematics apparatus. Whisks were analyzed for amplitude, velocity, and acceleration.

Results  Animals receiving nimodipine demonstrated significantly better whisking on 5 days (postoperative days 9, 11 to 13, and 20) compared with control animals (P < .001, P  = .003, P  = .009, P  = .009, and P  = .009, respectively; 1-tailed ttest). Overall, the nimodipine-treated animals showed earlier recovery compared with the untreated animals.

Conclusions  We demonstrate that nimodipine improves recovery of whisking after facial nerve crush. This finding corroborates the semiquantitative findings of others, and provides complete whisking kinematic data on its effects. Given the low adverse effect profile of nimodipine, there may be clinical implications in its administration in patients experiencing facial nerve injury.

Objective  To report our experience with the endoscopic brow-lift in male patients at a university-affiliated outpatient surgery center.

Methods  Retrospective case series.

Results  From 1995 to 2007, a total of 244 endoscopic brow-lift procedures were performed, 21 of which involved men. Thirteen of the male patients had receding hairlines or some degree of baldness. Two male patients had postoperative complications; 1 male patient had temporal branch neurapraxia that resolved; and 1 male patient had in-office scar revision.

Conclusions  We have found that the endoscopic brow-lift procedure is well suited for male facial rejuvenation. Furthermore, our combined stair-step approach and suture suspension technique provides consistent results and high satisfaction regardless of the patient's hairline.

While 7 face transplants have been performed around the world, to date, there remains debate regarding the validity of this procedure. We submit that performing a facial transplant—in the appropriately selected patient—is technically defensible and ethically sound. By outlining the technical and ethical boundaries of the debate, responding to the key arguments against the procedure, and describing its motivations and potential benefits, we state our justification of facial transplantation.