Publications by authors named "Patrick J Byrne"

120 Publications

Temporalis Tendon Transfer Versus Gracilis Free Muscle Transfer: When and Why?

Facial Plast Surg Clin North Am 2021 Aug;29(3):383-388

Head and Neck Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue A71, Cleveland, OH 44106, USA.

Temporalis tendon transfer (T3) and gracilis free muscle transfer (GFMT) are popular techniques in lower facial rehabilitation when reinnervation techniques are unavailable. T3 involves a single-stage outpatient procedure resulting in immediate improvement in resting symmetry and a volitional smile. GFMT allows a spontaneous smile, customized vectors, and increased excursion but requires longer surgical time, a delay before movement, and specialized equipment. Ultimately, shared decision making between the clinician and patient should focus on the patient's goals and unique medical condition.
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http://dx.doi.org/10.1016/j.fsc.2021.03.002DOI Listing
August 2021

A High-Content Screen for Mucin-1-Reducing Compounds Identifies Fostamatinib as a Candidate for Rapid Repurposing for Acute Lung Injury.

Cell Rep Med 2020 Nov 29;1(8):100137. Epub 2020 Oct 29.

Department of Immunology and Inflammation, Imperial College, Hammersmith Hospital, London, UK.

Drug repurposing has the advantage of identifying potential treatments on a shortened timescale. In response to the pandemic spread of SARS-CoV-2, we took advantage of a high-content screen of 3,713 compounds at different stages of clinical development to identify FDA-approved compounds that reduce mucin-1 (MUC1) protein abundance. Elevated MUC1 levels predict the development of acute lung injury (ALI) and acute respiratory distress syndrome (ARDS) and correlate with poor clinical outcomes. Our screen identifies fostamatinib (R788), an inhibitor of spleen tyrosine kinase (SYK) approved for the treatment of chronic immune thrombocytopenia, as a repurposing candidate for the treatment of ALI. , fostamatinib reduces MUC1 abundance in lung epithelial cells in a mouse model of ALI. , SYK inhibition by the active metabolite R406 promotes MUC1 removal from the cell surface. Our work suggests fostamatinib as a repurposing drug candidate for ALI.
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http://dx.doi.org/10.1016/j.xcrm.2020.100137DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7691435PMC
November 2020

Motor Relearning After Hypoglossal-Facial Nerve Anastomosis.

Am J Phys Med Rehabil 2021 06;100(6):e85-e88

From the Department of Physical Therapy, Marymount University, Arlington, Virginia (KJN); Medstar National Rehabilitation Hospital, Washington, DC (KJN); Division of Otolaryngology-Head and Neck Surgery, University of Calgary, Alberta, Canada (AR); and Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology-Head and Neck Surgery, Department of Dermatology, Department of Biomedical Engineering, The Johns Hopkins School of Medicine, The Johns Hopkins Hospital, Baltimore, Maryland (PJB).

Abstract: Facial paralysis is a clinical condition associated with significant functional and psychosocial morbidity (Facial Plast Surg FPS. 2011;27(4):346-57). The management paradigm for this condition continues to evolve with the use of both surgical and nonsurgical strategies (Facial Plast Surg FPS. 2011;27(4):346-57). Hypoglossal-facial nerve anastomosis is a surgical technique whereby the hypoglossal nerve acts as a donor motor nerve to restore facial muscle reinnervation via movements of the tongue (Plast Reconstr Surg. 1979;63(1):63-72). This case describes a 33-yr-old woman with unilateral facial paralysis who underwent hypoglossal-facial nerve anastomosis and 14 wks of postoperative rehabilitation. This report highlights the details of her rehabilitation regimen including the specific techniques used to enhance motor relearning of facial expression through movement of the tongue.
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http://dx.doi.org/10.1097/PHM.0000000000001562DOI Listing
June 2021

Free Functional Gracilis Flaps for Facial Reanimation in Elderly Patients.

Facial Plast Surg Aesthet Med 2021 May-Jun;23(3):180-186. Epub 2020 Aug 4.

Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.

The free functional gracilis flap (FFGF) is a versatile procedure in reanimating the paralyzed face, yet its application in seniors is limited by perceptions of morbidity and inefficacy. The study objective was to compare the morbidity and effectiveness of FFGF reanimation among senior and younger patients. A retrospective chart review was performed on 20 consecutive patients aged 60 years and above (seniors) and 35 patients aged 40 years and below (juniors) who underwent FFGF for facial reanimation. Among this group, 16 senior and 22 junior patients with available long-term follow-up data were analyzed for functional outcomes. The length of postoperative stay and postoperative complications were compared with assess immediate results. A second analysis for functional outcomes was assessed by resting and smile facial asymmetry index (FAI), as well as maxillary dental display to compare facial tone and lip excursion. The average age of seniors was 67 ± 5 years and that of juniors was 27 ± 10 years. Mean lengths of postoperative stay were 4 ± 2 versus 3 ± 1 days in seniors versus Juniors, respectively ( = 0.16). There were no intraoperative complications and postoperative complications in one (5%) senior and four (11%) juniors ( = 0.64). There was functional muscle recovery in all cases, with more pronounced correction of both resting (Δ3.0 mm vs. Δ2.4 mm,  = 0.66) and dynamic (Δ5.2 mm vs. Δ4.2 mm,  = 0.37) FAI in seniors than in juniors. Among patients who underwent a multivector FGFF, there was an additional three versus one visualized maxillary teeth ( = 0.03) in seniors versus juniors, respectively. The FFGF is effective for facial reanimation among seniors and can be performed with minimal morbidity. Age alone should not preclude the application of the FFGF in seniors with a preference for more dynamic options.
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http://dx.doi.org/10.1089/fpsam.2020.0292DOI Listing
August 2020

Predictors of Free Flap Volume Loss in Nonosseous Reconstruction of Head and Neck Oncologic Defects.

Ear Nose Throat J 2020 Jul 7:145561320938903. Epub 2020 Jul 7.

Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology-Head & Neck Surgery, Johns Hopkins Hospital, Baltimore, MD, USA.

Objectives: Free tissue reconstruction of the head and neck must be initially overcorrected due to expected postoperative free flap volume loss, which can be accelerated by adjuvant radiation therapy. In this study, we aim to identify patient and treatment-specific factors that may significantly contribute to this phenomenon and translate these characteristics into a predictive model for expected percent free flap volume loss in a given patient.

Methods: Patients with a history of oral cavity and/or oropharyngeal cancer who underwent nonosseous free flap reconstruction were reviewed between January 2009 and November 2018 at a tertiary care center. Demographics/characteristics, total radiation dose, radiation fractionation (RF), and pre/postradiation free flap volume as evaluated by computed tomography imaging were collected. Free flap volume was measured by a fellowship-trained neuroradiologist in all cases. Only patients receiving adjuvant radiotherapy with available pre/postradiation imaging were included. Multivariable linear regression modeling for prediction of free flap volume loss was performed with optimization via stepwise elimination.

Results: Thirty patients were included for analysis. Mean flap volume loss was 42.7% ± 17.4%. The model predicted flap volume loss in a significant fashion ( = .004, R = 0.49) with a mean magnitude of error of 9.8% ± 7.5%. Age (β = 0.01, = .003) and RF (β = -0.01, = .009) were individual predictors of flap volume loss.

Conclusions: Our model predicts percent free flap volume loss in a significant fashion. Age and RF are individual predictors of free flap volume loss, the latter being a novel finding that is also modifiable through hyperfractionation radiotherapy schedules.
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http://dx.doi.org/10.1177/0145561320938903DOI Listing
July 2020

Management of Large Facial Defects.

Facial Plast Surg 2020 Apr 15;36(2):148-157. Epub 2020 May 15.

Department of Otolaryngology-Head and Neck Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland.

There is considerable variation in the surgical management of patients with large facial defects after excision of skin malignancy. The surrounding facial subunits as well as local, regional, and distant soft-tissue flaps can be considered in more complicated facial defects. We place an emphasis on the versatility of adjacent tissue advancement and transposition flaps in the treatment of these defects. We also focus on the secondary reconstructive efforts necessary to achieve the best functional and aesthetic outcomes for patients.
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http://dx.doi.org/10.1055/s-0040-1709179DOI Listing
April 2020

Normal Gaze Patterns of the Face in Lateral View.

Facial Plast Surg Aesthet Med 2020 Mar/Apr;22(2):80-85

Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland.

Current efforts to quantify the attentional distraction of facial deformities have been limited to deformities that are best perceived when the face is in frontal view, and there remains a paucity of knowledge of societal perception of the face in lateral view. To date, no attempts have been made to characterize the fixation patterns of the face in lateral view. To characterize the fixation patterns and gaze patterns of the face in lateral view. This was a prospective randomized controlled trial at an academic tertiary medical center. Eighty participants (mean age 23.6 ± 1.7 years, 52.5% female) gazed freely at 11 images of faces in lateral view for 10 s each as an infrared eye-tracker recorded eye movements in real time. Recorded eye movements are superimposed on the images to visualize areas of interest (AOIs) that attract the most attention. Fixation duration targeted at each AOI is transformed into relative fixation of the entire face and neck. Hotelling's test of variance followed by post hoc -testing assessed for the significance of fixation differences between the mouth and cheeks. Participants spent an average of 6.0 (95% CI 5.8-6.2) s gazing at the face and neck areas of each image. Of this attention, 2.8 s or 49.8% (45.4-54.2%) was directed toward the eye, followed distantly by the nose (mean, 95% CI) (16.4%, 14.5-18.3%), cheek (12.0%, 11.4-14.5%), neck (4.6%, 3.8-5.4%), and mouth (4.0%, 3.4-4.6%). These differences were found to be significant by Hotelling's analysis and post hoc testing. A student's -test also indicated observers directed significantly more attention within the eye-nose-cheek triangle [4.6 s or 79.5% (75.6-83.5)] compared with the eye-nose-mouth triangle [4.1 s or 71.2% (66.9-75.5)] ( < 0.001). When perceiving novel faces in lateral view, casual observers preferentially directed attention toward the eye, nose, and cheek. These findings suggest that we draw from a slightly different collection of features to build a schema of the sagittal face, which may serve to complement the central triangle and build upon a three-dimensional model of the "normal" human face. NA.
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http://dx.doi.org/10.1089/fpsam.2019.29019.huyDOI Listing
August 2020

How Old Do I Look? Exploring the Facial Cues of Age in a Tasked Eye-Tracking Study.

Facial Plast Surg Aesthet Med 2020 Jan/Feb;22(1):36-41

Division of Rhinology, Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland.

This is the first eye-tracking study to use a tasked age estimation paradigm to explore the facial cues of age as seen by casual observers. Determine where observers gaze on faces when tasked with estimating an individual's age. This was a prospective controlled experiment, which took place at an academic tertiary referral center. In total, 220 casual observers (80 untasked, 140 tasked) viewed frontal facial images of women while an infrared eye-tracking monitor recorded their eye movements and fixations in real time. Multivariate Hotelling's analysis followed by planned posthypothesis testing was used to compare fixation durations for predefined regions of interest, including the central triangle, upper face, midface, lower face, and neck between tasked and untasked observers. A total of 80 observers (mean age 23.6 years, 53% female) successfully completed the first untasked eye-tracking experiment. A total of 140 observers (mean age 26.1 years, 60% female) successfully completed the second age estimation experiment. On multivariate analysis, there were significant differences in the distribution of attention between observers in the two experiments ( = 99.70; (5,2084) = 19.9012,  < 0.0001). On planned posthypothesis testing, observers attended significantly more to the lower third of the face (0.20 s,  < 0.0001, 95% confidence interval (CI) 0.14-0.27 s) and neck (0.05 s,  = 0.0074, 95% CI 0.01-0.08 s) and less to the upper third of the face (-0.27 s,  < 0.0001, 95% CI -0.40 to -0.14 s) when tasked. There was no significant difference in time spent on the whole face in the two experiments, suggesting that peripheral elements such as hair color or jewelry did not significantly influence gaze patterns. Humans form judgments about others every day of their lives, and age perception colors their every interaction. To our knowledge, this study is the first to use eye tracking to investigate facial cues of age. The results showed that when tasked with estimating age, casual observer visual attention was shifted toward the lower face when compared with those who were untasked. These data inform our understanding of facial age perception and potential areas to target for facial rejuvenation. NA.
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http://dx.doi.org/10.1089/fpsam.2019.29001.liaDOI Listing
August 2020

Measuring Outcomes of Mohs Defect Reconstruction Using Eye-Tracking Technology.

JAMA Facial Plast Surg 2019 Dec;21(6):518-525

Division of Rhinology, Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland.

Importance: Objectively measuring how Mohs defect reconstruction changes casual observer attention has important implications for patients and facial plastic surgeons.

Objective: To use eye-tracking technology to objectively measure the ability of Mohs facial defect reconstruction to normalize facial attention.

Design, Setting, And Participants: This observational outcomes study was conducted at an academic tertiary referral center from January to June 2016. An eye-tracking system was used to record how 82 casual observers directed attention to photographs of 32 patients with Mohs facial defects of varying sizes and locations before and after reconstruction as well as 16 control faces with no facial defects. Statistical analysis was performed from November 2018 to January 2019.

Main Outcomes And Measures: First, the attentional distraction caused by facial defects was quantified in milliseconds of gaze time using eye tracking. Second, the eye-tracking data were analyzed using mixed-effects linear regression to assess the association of facial defect reconstruction with normalized facial attention.

Results: The 82 casual observers (63 women and 19 men; mean [SD] age, 34 [12] years) viewed control faces in a similar and consistent fashion, with most attention (65%; 95% CI, 62%-69%) directed at the central triangle, which includes the eyes, nose, and mouth. The eyes were the most visually important feature, capturing a mean of 60% (95% CI, 57%-64%) of fixation time within the central triangle and 39% (95% CI, 36%-43%) of total observer attention. The presence of Mohs defects was associated with statistically significant alterations in this pattern of normal facial attention. The larger the defect and the more centrally a defect was located, the more attentional distraction was observed, as measured by increased attention on the defect and decreased attention on the eyes, ranging from 729 (95% CI, 526-931) milliseconds for small peripheral defects to 3693 (95% CI, 3490-3896) milliseconds for large central defects. Reconstructive surgery was associated with improved gaze deviations for all faces and with normalized attention directed to the eyes for all faces except for those with large central defects.

Conclusions And Relevance: Mohs defects are associated with altered facial perception, diverting attention from valuable features such as the eyes. Reconstructive surgery was associated with normalized attentional distraction for many patients with cutaneous Mohs defects. These data are important to patients who want to know how reconstructive surgery could change the way people look at their face. The data also point to the possibility of outcomes prediction based on facial defect size and location before reconstruction. Eye tracking is a valuable research tool for outcomes assessment that lays the foundation for understanding how reconstructive surgery may change perception and normalize facial deformity.
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http://dx.doi.org/10.1001/jamafacial.2019.1072DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6824233PMC
December 2019

Regional Reconstruction of Orbital Exenteration Defects.

Semin Plast Surg 2019 May 26;33(2):120-124. Epub 2019 Apr 26.

Division of Facial Plastics and Reconstructive Surgery, Department of Otolaryngology - Head and Neck Surgery, The Johns Hopkins University School of Medicine, Maryland.

Aggressive disease such as invasive fungal infections or malignancies may necessitate orbital exenteration. The defects of orbital exenteration are often complex involving adjacent structures. Rehabilitation of the orbital exenteration defect poses unique challenges to the reconstructive surgeon. Various options have been described ranging from secondary intention to microvascular free tissue reconstruction. Here the authors review local/regional options for reconstruction of orbital exenteration defects.
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http://dx.doi.org/10.1055/s-0039-1685475DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6486381PMC
May 2019

Assessment of the Influence of "Other-Race Effect" on Visual Attention and Perception of Attractiveness Before and After Rhinoplasty.

JAMA Facial Plast Surg 2019 Mar;21(2):96-102

Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland.

Importance: The "other-race effect" describes the phenomenon in which individuals demonstrate greatest recognition ability among faces of their own race. Thus, in our multicultural world, it follows that race influences social interactions. However, the association of race with perception of plastic surgery outcomes has not been studied.

Objective: To objectively measure how the other-race effect influences perception of white and Latin American patients undergoing rhinoplasty by using eye-tracking technology and survey methodology.

Design, Setting, And Participants: In the first part of the study, 134 participants viewed 32 paired facial images of white and Latin American patients, either prerhinoplasty or postrhinoplasty, on an eye-tracking system that recorded observer scan paths. In the second part of this study, the same patient images were individually graded by a separate group of 134 participants for degree of racial identification and perceived attractiveness.

Main Outcomes And Measures: The primary outcome was to measure the influence of patient and observer race on perception of rhinoplasty outcomes. For the eye-tracking part, planned hypothesis testing was conducted using an analysis of variance to compare patient race, rhinoplasty status, and attractiveness with respect to visual fixation time.

Results: Of the 134 eye-tracking participants, 68 (51%) were women and the mean (SD) age was 26.4 (7.7) years; of the 134 graders, 64 (48%) were women and the mean (SD) age was 25.0 (6.9) years. Rhinoplasty did not affect racial identity scores among either same-race or other-race evaluators. Visual fixation times for white faces were significantly increased compared with Latin American faces among all casual observer groups (white observers mean change, -20.14 milliseconds; 95% CI, -29.65 to -10.62 milliseconds; P < .001; Asian observers mean change, -39.04 milliseconds; 95% CI, -48.95 to -29.15 milliseconds; P < .001; and African American observers mean change, -20.73 milliseconds; 95% CI, -37.78 to -3.69 milliseconds; P < .02), with the exception of Latin American observers (mean change, -7.8 milliseconds; 95% CI, -29.15 to 14.39 milliseconds; P < .51). With respect to attractiveness, white graders reported a significant postrhinoplasty increase across both races (white patients mean change, 8.07 points; 95% CI, 5.01-11.12 points; P < .001; and Latin American patients mean change, 3.69 points; 95% CI, 0.87-6.49 points; P = .01), whereas Latin American graders only observed a significant attractiveness increase in their own race (Latin American patients mean change, 10.50 points; 95% CI, 1.70-19.32 points; P = .02). Neither perceived attractiveness nor rhinoplasty status influenced fixation times.

Conclusions And Relevance: Both patient and observer race influence visual attention and perception of attractiveness before and after rhinoplasty. These findings underscore the importance of counseling patients that the influence of rhinoplasty, as perceived by the casual observer, may vary by race or ethnicity of the observer group.

Level Of Evidence: NA.
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http://dx.doi.org/10.1001/jamafacial.2018.1697DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6439802PMC
March 2019

Reconstruction of the Ear.

Facial Plast Surg Clin North Am 2019 Feb;27(1):95-104

Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins School of Medicine, 601 North Caroline Street, 6th Floor, Baltimore, MD 21287, USA.

Skin cancer is a common indication for reconstructive surgery of the ear. The unique anatomy of the external ear makes the restoration of form and function challenging for the reconstructive surgeon. This article reviews the relevant anatomy of the ear, defines the goals of reconstruction, outlines the assessment of defects based on location, and describes specific surgical techniques useful in auricular reconstruction.
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http://dx.doi.org/10.1016/j.fsc.2018.08.010DOI Listing
February 2019

An Evaluation of Qualities of Nuclear Medicine Technology Programs and Graduates Leading to Employability.

J Nucl Med Technol 2019 Mar 9;47(1):29-34. Epub 2018 Nov 9.

Indiana University School of Medicine, Indianapolis, Indiana.

Our rationale was to evaluate how the qualities of nuclear medicine technology (NMT) programs and graduates associate with employability. We identified all Nuclear Medicine Technology Certification Board applicants who passed the entry-level NMT examination between 2012 and 2017. Certificants were e-mailed a survey with questions on graduate qualities, program qualities, and initial employment. Each quality was quantified. Age, sex, and desired employment within or outside the United States were also documented. An employability scale was created from the initial employment questions. Subjects were separated into 4 employability groups based on their employability score: poorly employable, marginally employable, satisfactorily employable, and optimally employable. An ANOVA test was performed on each quality using the 4 employability groups; a value of less than 0.05 was considered significant. Of the 3,930 surveys distributed, 885 (22.5%) were completed and returned. Six of the 10 qualities evaluated were significantly associated with employability: overall education ( < 0.01), number of clinic hours ( < 0.01), grade-point average ( < 0.01), number of schools within a 100-mile (161-km) radius ( < 0.01), number of attempts to pass the board examination ( < 0.01), and number of clinics ( = 0.04). The qualities that were not statistically significant were age, sex, employment location sought, board score, single versus dual certification, program level of education, and number of graduates in the class. There are multiple graduate and program qualities that are predictive of the employability of NMT graduates.
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http://dx.doi.org/10.2967/jnmt.118.219519DOI Listing
March 2019

Association Between Surgical Trainee Daytime Sleepiness and Intraoperative Technical Skill When Performing Septoplasty.

JAMA Facial Plast Surg 2019 Mar;21(2):104-109

Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland.

Importance: Daytime sleepiness in surgical trainees can impair intraoperative technical skill and thus affect their learning and pose a risk to patient safety.

Objective: To determine the association between daytime sleepiness of surgeons in residency and fellowship training and their intraoperative technical skill during septoplasty.

Design, Setting, And Participants: This prospective cohort study included 19 surgical trainees in otolaryngology-head and neck surgery programs at 2 academic institutions (Johns Hopkins University School of Medicine and MedStar Georgetown University Hospital). The physicians were recruited from June 13, 2016, to April 20, 2018. The analysis includes data that were captured between June 27, 2016, and April 20, 2018.

Main Outcomes And Measures: Attending physician and surgical trainee self-rated intraoperative technical skill using the Septoplasty Global Assessment Tool (SGAT) and visual analog scales. Daytime sleepiness reported by surgical trainees was measured using the Epworth Sleepiness Scale (ESS).

Results: Of 19 surgical trainees, 17 resident physicians (9 female [53%]) and 2 facial plastic surgery fellowship physicians (1 female and 1 male) performed a median of 3.00 septoplasty procedures (range, 1-9 procedures) under supervision by an attending physician. Of the 19 surgical trainees, 10 (53%) were aged 25 to 30 years and 9 (47%) were 31 years or older. The mean ESS score overall was 6.74 (95% CI, 5.96-7.52), and this score did not differ between female and male trainees. The mean ESS score was 7.57 (95% CI, 6.58-8.56) in trainees aged 25 to 30 years and 5.44 (95% CI, 4.32-6.57) in trainees aged 31 years or older. In regression models adjusted for sex, age, postgraduate year, and technical complexity of the procedure, there was a statistically significant inverse association between ESS scores and attending physician-rated technical skill for both SGAT (-0.41; 95% CI, -0.55 to -0.27; P < .001) and the visual analog scale (-0.75; 95% CI, -1.40 to -0.07; P = .03). The association between ESS scores and technical skill was not statistically significant for trainee self-rated SGAT (0.04; 95% CI, -0.17 to 0.24; P = .73) and the self-rated visual analog scale (0.19; 95% CI, -0.79 to 1.2; P = .70).

Conclusions And Relevance: The findings suggest that daytime sleepiness of surgical trainees is inversely associated with attending physician-rated intraoperative technical skill when performing septoplasty. Thus, surgical trainees' ability to learn technical skill in the operating room may be influenced by their daytime sleepiness.

Level Of Evidence: NA.
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http://dx.doi.org/10.1001/jamafacial.2018.1171DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6439798PMC
March 2019

Comparison of Objective Outcomes in Dynamic Lower Facial Reanimation With Temporalis Tendon and Gracilis Free Muscle Transfer.

JAMA Otolaryngol Head Neck Surg 2018 12;144(12):1162-1168

Facial Plastic & Reconstructive Surgery, Department of Otolaryngology, Johns Hopkins Hospital, Baltimore, Maryland.

Importance: Facial paralysis affects patients' physical, social, and psychological function. Dynamic smile reanimation can mitigate these effects, but there are limited data to guide the surgeon in selecting the best reanimation procedure for each patient.

Objective: To compare quantitative changes in oral commissure symmetry and smile excursion following temporalis tendon transfer (T3) and gracilis free muscle transfer.

Design, Setting, And Participants: Retrospective case series of 28 adults with unilateral facial paralysis seeking dynamic lower facial reanimation at a tertiary academic medical center between July 1, 2010, and July 30, 2014. Data were analyzed from May 1, 2016, to June 30, 2016.

Interventions: Minimally invasive T3 (n = 14) compared with gracilis free muscle transfer (n = 14).

Main Outcomes And Measures: Measured symmetry of the oral commissure between the healthy and paralyzed sides in the horizontal, vertical, and angular dimension and excursion of the paralyzed commissure following reanimation compared with the healthy commissure.

Results: Of the 28 patients, 19 (68%) were women; mean (SD) age was 51.7 (17) years. Commissure symmetry during smile improved significantly for the T3 patients in the vertical and angular dimensions, and the gracilis free muscle transfer patients had significant improvement in the vertical and horizontal dimensions. Commissure excursion significantly improved in both groups following surgery, with a larger improvement seen in the gracilis free muscle transfer group (11.3 mm; 95% CI, 7.0 to 15.5 mm) compared with the T3 group (4.8 mm; 95% CI, 0.2 to 9.3 mm), with a mean difference of 6.5 mm (95% CI, 0.7 to 12.4 mm; Cohen d, 0.86). Postoperative smile excursion of the paralyzed side was within 1.0 mm of the healthy side in the gracilis free muscle transfer group (95% CI, -2.1 to 4.0 mm).

Conclusions And Relevance: Temporalis tendon transfer and gracilis free muscle transfer both improve oral commissure symmetry and excursion in facial paralysis. The improvement in smile excursion appears to be larger in patients treated with gracilis free muscle transfer and, on average, the excursion approximates the contralateral healthy side.
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http://dx.doi.org/10.1001/jamaoto.2018.1964DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6583085PMC
December 2018

Use of Objective Metrics in Dynamic Facial Reanimation: A Systematic Review.

JAMA Facial Plast Surg 2018 Dec;20(6):501-508

Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland.

Importance: Facial nerve deficits cause significant functional and social consequences for those affected. Existing techniques for dynamic restoration of facial nerve function are imperfect and result in a wide variety of outcomes. Currently, there is no standard objective instrument for facial movement as it relates to restorative techniques.

Objective: To determine what objective instruments of midface movement are used in outcome measurements for patients treated with dynamic methods for facial paralysis.

Data Sources: Database searches from January 1970 to June 2017 were performed in PubMed, Embase, Cochrane Library, Web of Science, and Scopus. Only English-language articles on studies performed in humans were considered. The search terms used were ("Surgical Flaps"[Mesh] OR "Nerve Transfer"[Mesh] OR "nerve graft" OR "nerve grafts") AND (face [mh] OR facial paralysis [mh]) AND (innervation [sh]) OR ("Face"[Mesh] OR facial paralysis [mh]) AND (reanimation [tiab]).

Study Selection: Two independent reviewers evaluated the titles and abstracts of all articles and included those that reported objective outcomes of a surgical technique in at least 2 patients.

Main Outcomes And Measures: The presence or absence of an objective instrument for evaluating outcomes of midface reanimation. Additional outcome measures were reproducibility of the test, reporting of symmetry, measurement of multiple variables, and test validity.

Results: Of 241 articles describing dynamic facial reanimation techniques, 49 (20.3%) reported objective outcome measures for 1898 patients. Of those articles reporting objective measures, there were 29 different instruments, only 3 of which reported all outcome measures.

Conclusions And Relevance: Although instruments are available to objectively measure facial movement after reanimation techniques, most studies do not report objective outcomes. Of objective facial reanimation instruments, few are reproducible and able to measure symmetry and multiple data points. To accurately compare objective outcomes in facial reanimation, a reproducible, objective, and universally applied instrument is needed.
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http://dx.doi.org/10.1001/jamafacial.2018.0398DOI Listing
December 2018

Societal Identification of Facial Paralysis and Paralysis Location.

JAMA Facial Plast Surg 2018 Jul;20(4):272-276

Division of Rhinology, Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland.

Importance: When able to identify facial paralysis, members of society regard individuals with facial paralysis differently. They perceive a decrease in attractiveness, more negative affect, and lower quality of life. However, the ability of lay people in society to accurately identify the presence of facial paralysis has not yet been defined.

Objective: To determine societal members' ability to (1) identify paralysis in varying degrees of paralysis severity and (2) localize the defect on the face.

Design, Setting, And Participants: A prospective observational study conducted in an academic tertiary referral center using a group of 380 casual observers was carried out.

Main Outcomes And Measures: Surveys were designed containing smiling and repose images of normal faces and faces with unilateral facial paralysis of 3 severity levels (low, medium, and high) as categorized by House-Brackmann (HB) grade. The photographs were then shown to casual observers in a web-based survey. After reviewing both normal faces and faces with varying degrees of paralysis, they then indicated (1) whether paralysis was present and (2) if so, where the paralysis was on the face.

Results: A total of 380 participants (267 [70.3%] women and 113 [29.7%] men with a mean [SD] age of 29 [12] years) successfully completed the survey, viewing 2860 facial photographs in aggregate. The accuracy rate of identifying paralysis increased from low-grade through high-grade paralysis. Facial paralysis was identified in 249 (34.6%) of 719 facial photographs with low-grade paralysis, 448 (63.2%) of 709 with medium-grade paralysis, and 696 (96.7%) of 720 with high-grade paralysis (χ2 = 912.6, P < .001); 6.2% (44/731) of normal faces were incorrectly identified as having paralysis (χ2 = 912.6, P < .001). Participants correctly localized paralysis in 157 (63.0%) of 249 low-grade photographs, 307 (68.5%) of 448 medium-grade photographs, and 554 (79.6%) of 696 high-grade photographs (χ2 = 32.5, P < .001). In general, participants tended to identify facial paralysis more accurately in smiling vs repose faces (48.6% vs 20.6%, 92.4% vs 33.7%, and 96.7% vs 96.6% in low-, medium-, and high-grade paralysis, respectively) (χ2 = 62.2, P < .001; χ2 = 262.6, P < .001; χ2 = 0.0, P = .96, respectively).

Conclusions And Relevance: The ability of individuals to identify the presence of facial paralysis increased as paralysis severity increased. Further, smiling increased accurate identification. However, even when individuals can identify paralysis, they are not necessarily able to accurately localize the paralysis on a face. This may speak to a phenomenon in which perception of a facial defect comes from a holistic interpretation of a face, rather than a clinically accurate specification of the defect location. These findings are important in the future counseling of patients.

Level Of Evidence: NA.
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http://dx.doi.org/10.1001/jamafacial.2017.2402DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5876915PMC
July 2018

Experience with pharmacologic leeching with bivalirudin for adjunct treatment of venous congestion of head and neck reconstructive flaps.

Microsurgery 2018 Sep 18;38(6):643-650. Epub 2018 Jan 18.

Department of Otolaryngology, Massachusetts Eye and Ear Infirmary -Harvard Medical School, Boston, Maryland.

Objectives: The goal of this study was to review the feasibility of local bivalirudin injection for adjunct treatment of venous congestion of head and neck reconstructive flaps.

Methods: A retrospective chart review of patients who underwent bivalirudin treatment for venous congestion of head and neck reconstructive flaps in a single institution from September 1, 2012 to September 1, 2015 was undertaken. Individuals were treated with variable number of intradermal injections directly into the flap followed by a small skin incision to allow extended passive bleeding. The main outcome measure was improvement of flap congestion.

Results: Ten patients with free flap reconstruction (4 anterolateral thigh flaps, 2 pectoralis major flaps, 2 fibula osseocutaneous flaps, 1 supraclavicular flap, and 1 radial forearm free flap) of various head and neck defects underwent treatment with bivalirudin. Bivalirudin injections were utilized as adjunct therapy in 6 patients. Two individuals underwent alternate therapy for venous congestion immediately following injection and therefore the efficacy could not be assessed. Of the 8 remaining flaps, 4 developed partial necrosis, and 1 developed complete necrosis requiring additional reconstruction. Two individuals required blood transfusions during bivalirudin treatment.

Conclusions: Bivalirudin is a safe and feasible adjunct therapy for treatment of flap congestion. It may serve as a useful alternative to traditional leech therapy, as bivalirudin negates the need for antibiotic prophylaxis, eliminates the psychological aversion associated with leech therapy, and avoids the potential for leech migration. Further work to determine the efficacy of bivalirudin to standard leech therapy is warranted.
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http://dx.doi.org/10.1002/micr.30298DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6051927PMC
September 2018

Association of Rhinoplasty With Perceived Attractiveness, Success, and Overall Health.

JAMA Facial Plast Surg 2018 Mar;20(2):97-102

Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University, Baltimore, Maryland.

Importance: To date, the impact of rhinoplasty surgery on social perceptions has not been quantified.

Objective: To measure the association of rhinoplasty with observer-graded perceived attractiveness, success, and overall health.

Design, Setting, And Participants: In a web-based survey, blinded casual observers viewed independent images of 13 unique patient faces before or after rhinoplasty. Delphi method was used to select standardized patient images, confirming appropriate patient candidacy and overall surgical effect. Observers rated the attractiveness, perceived success, and perceived overall health for each patient image. Facial perception questions were answered on a visual analog scale from 0 to 100, where higher scores corresponded to more positive responses. A multivariate mixed-effects regression model was used to determine the effect of rhinoplasty while accounting for observer biases. To further characterize the effect of rhinoplasty, estimated ordinal rank change was calculated for each domain.

Main Outcomes And Measures: The primary objective was to measure the effect of rhinoplasty on observer-graded perceived attractiveness, success, and overall health.

Results: A total of 473 observers (mean age, 29 years [range, 18-73 years]; 305 [70.8%] were female) successfully completed the survey. On multivariate regression, patients after rhinoplasty were rated as significantly more attractive (rhinoplasty effect, 6.26; 95% CI, 5.10-7.41), more successful (rhinoplasty effect, 3.24; 95% CI, 2.32-4.17), and overall healthier (rhinoplasty effect, 3.78; 95% CI, 2.79-4.81). The ordinal rank change for an average individual's perceived attractiveness, success, and overall health was a positive shift of 14, 9, and 10 out of 100 rank positions, respectively.

Conclusions And Relevance: As perceived by casual observers, rhinoplasty surgery was associatedwith perceptions that in patients appeared significantly more attractive, more successful, and healthier. These results suggest patients undergoing rhinoplasty may derive a multifaceted benefit when partaking in social interactions. Furthermore, these results facilitate improved patient discussions aiming to provide more precise surgical expectations with an understanding that these results represent optimal outcomes.

Level Of Evidence: NA.
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http://dx.doi.org/10.1001/jamafacial.2017.1453DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5885959PMC
March 2018

Objective Outcomes of Minimally Invasive Temporalis Tendon Transfer for Prolonged Complete Facial Paralysis.

Plast Surg (Oakv) 2017 Aug 15;25(3):200-210. Epub 2017 Sep 15.

Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology-Head and Neck Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA.

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.
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http://dx.doi.org/10.1177/2292550317728033DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5626213PMC
August 2017

Trauma in Facial Plastic Surgery: Frontal Sinus Fractures.

Facial Plast Surg Clin North Am 2017 Nov;25(4):503-511

Facial Plastic and Reconstructive Surgery, Department of Otolaryngology Head and Neck Surgery, Greater Baltimore Cleft Lip and Palate Team, Johns Hopkins University School of Medicine, 6701 N Charles Street, Baltimore, MD 21204, USA; Department of Dermatology, Johns Hopkins University School of Medicine, 601 North Caroline Street 6th Floor, Baltimore, MD 21287-0910, USA.

The optimal management of frontal sinus fractures remains controversial. Fortunately, the severity of these injuries has diminished with more stringent auto-safety regulations, changing the treatment paradigms used to repair these injuries. Appropriate patient selection and close follow-up may allow for conservative management strategies when dealing with frontal sinus fractures, largely replacing the more morbid and invasive techniques that have been the mainstay for years. Because acute and delayed sequelae can arise after the initial injury, patients should be thoroughly counseled about the importance of follow-up and the need to seek medical care if they develop any concerning signs or symptoms.
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http://dx.doi.org/10.1016/j.fsc.2017.06.004DOI Listing
November 2017

A Dual Approach to Understanding Facial Perception Before and After Blepharoplasty.

JAMA Facial Plast Surg 2018 Jan;20(1):43-49

Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland.

Importance: Blepharoplasty consistently ranks among the most common facial plastic surgery procedure sought by both men and women. Despite the popularity of blepharoplasty, there has been little research focused on quantifying how eyelid surgery changes facial perceptions.

Objectives: To quantify the effect of blepharoplasty on facial perceptions and measure patient-reported ratings of fatigue before and after surgery to compare observer and patient perceptions.

Design, Setting, And Participants: A web-based survey experiment was conducted from January to February 2017, featuring photographs of female patients before and after blepharoplasty. Observers were randomly shown independent images of each patient and asked to rate perceived age, attractiveness, health, and energy level. Respondents saw only preoperative or postoperative photographs of each patient to reduce bias due to priming. Patient-reported outcomes were also collected.

Main Outcomes And Measures: A multivariate mixed effects regression model was used to quantify the changes in each domain after surgery. Ordinal rank change was calculated to provide a measure of clinical effect size across the domains. To analyze patient-reported outcomes, a Kruskal-Wallis test followed by Mann-Whitney tests were performed to determine if there were differences in patient-perceived tiredness based on operative status.

Results: A total of 401 participants (243 women, 152 men, and 6 not specified; mean age 25.9 years [range, 18-73 years]) successfully completed the survey and evaluated before-and-after photographs of 10 female patients (mean age, 59.8 years). The multivariable mixed effects model revealed that individuals are perceived as appearing significantly younger (-1.04 years; 95% CI, -1.70 to -0.37 years) and more attractive (coefficient, 4.92; 95% CI, 3.91-5.93) after blepharoplasty. Ratings of perceived health (coefficient, 4.33; 95% CI, 3.28-5.37) and energy level (coefficient, 9.83; 95% CI, 8.51-11.16) also improved significantly. After undergoing blepharoplasty, patients had significantly improved ratings of energy level compared with those who had not undergone blepharoplasty.

Conclusions And Relevance: This is the first study, to date, aimed at quantifying the perceptions of facial aesthetic changes following blepharoplasty. The data demonstrate that individuals are rated as appearing more youthful, attractive, and healthy following blepharoplasty. Furthermore, both patients and casual observers perceived a significant improvement in energy level following blepharoplasty, a meaningful finding as the appearance of fatigue is a chief concern of the patients before they undergo blepharoplasty.

Level Of Evidence: NA.
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http://dx.doi.org/10.1001/jamafacial.2017.1099DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5833663PMC
January 2018

Association Between Facial Rejuvenation and Observer Ratings of Youth, Attractiveness, Success, and Health.

JAMA Facial Plast Surg 2017 Sep;19(5):360-367

Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland.

Importance: Surgical procedures for the aging face-including face-lift, blepharoplasty, and brow-lift-consistently rank among the most popular cosmetic services sought by patients. Although these surgical procedures are broadly classified as procedures that restore a youthful appearance, they may improve societal perceptions of attractiveness, success, and health, conferring an even larger social benefit than just restoring a youthful appearance to the face.

Objectives: To determine if face-lift and upper facial rejuvenation surgery improve observer ratings of age, attractiveness, success, and health and to quantify the effect of facial rejuvenation surgery on each individual domain.

Design, Setting, And Participants: A randomized clinical experiment was performed from August 30 to September 18, 2016, using web-based surveys featuring photographs of patients before and after facial rejuvenation surgery. Observers were randomly shown independent images of the 12 patients; within a given survey, observers saw either the preoperative or postoperative photograph of each patient to reduce the possibility of priming. Observers evaluated patient age using a slider bar ranging from 30 to 80 years that could be moved up or down in 1-year increments, and they ranked perceived attractiveness, success, and health using a 100-point visual analog scale. The bar on the 100-point scale began at 50; moving the bar to the right corresponded to a more positive rating in these measures and moving the bar to the left, a more negative rating.

Main Outcomes And Measures: A multivariate mixed-effects regression model was used to understand the effect of face-lift and upper facial rejuvenation surgery on observer perceptions while accounting for individual biases of the participants. Ordinal rank change was calculated to understand the clinical effect size of changes across the various domains after surgery.

Results: A total of 504 participants (333 women, 165 men, and 6 unspecified; mean age, 29 [range, 18-70] years) successfully completed the survey. A multivariate mixed-effects regression model revealed a statistically significant change in age (-4.61 years; 95% CI, -4.97 to -4.25) and attractiveness (6.72; 95% CI, 5.96-7.47) following facial rejuvenation surgery. Observer-perceived success (3.85; 95% CI, 3.12-4.57) and health (7.65; 95% CI; 6.87-8.42) also increased significantly as a result of facial rejuvenation surgery.

Conclusions And Relevance: The data presented in this study demonstrate that patients are perceived as younger and more attractive by the casual observer after undergoing face-lift and upper facial rejuvenation surgery. These procedures also improved ratings of perceived success and health in our patient population. These findings suggest that facial rejuvenation surgery conveys an even larger societal benefit than merely restoring a youthful appearance to the face.

Level Of Evidence: NA.
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http://dx.doi.org/10.1001/jamafacial.2017.0126DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5815112PMC
September 2017

Association of Face-lift Surgery With Social Perception, Age, Attractiveness, Health, and Success.

JAMA Facial Plast Surg 2017 Jul;19(4):311-317

Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University, Baltimore, Maryland.

Importance: Evidence quantifying the influence of face-lift surgery on societal perceptions is lacking.

Objective: To measure the association of face-lift surgery with observer-graded perceived age, attractiveness, success, and overall health.

Design, Setting, And Participants: In a web-based survey, 526 casual observers naive to the purpose of the study viewed independent images of 13 unique female patient faces before or after face-lift surgery from January 1, 2016, through June 30, 2016. The Delphi method was used to select standardized patient images confirming appropriate patient candidacy and overall surgical effect. Observers estimated age and rated the attractiveness, perceived success, and perceived overall health for each patient image. Facial perception questions were answered on a visual analog scale from 0 to 100, with higher scores corresponding to more positive responses. To evaluate the accuracy of observer age estimation, the patients' preoperative estimated mean age was compared with the patients' actual mean age. A multivariate mixed-effects regression model was used to determine the effect of face-lift surgery. To further characterize the effect of face-lift surgery, estimated ordinal-rank change was calculated for each domain.

Main Outcomes And Measures: Blinded casual observer ratings of patients estimated age, attractiveness, perceived success, and perceived overall health.

Results: A total of 483 observers (mean [SD] age, 29 [8.6] years; 382 women [79.4%]) successfully completed the survey. Comparing patients' preoperative estimated mean (SD) age (59.6 [9.0] years) and patients' actual mean (SD) age (58.4 [6.9] years) revealed no significant difference (t2662 = -0.47; 95% CI, -6.07 to 3.72; P = .64). On multivariate regression, patients after face-lift surgery were rated as significantly younger (coefficient, -3.69; 95% CI -4.15 to -3.23; P < .001), more attractive (coefficient, 8.21; 95% CI, 7.41-9.02; P < .001), more successful (coefficient, 5.82; 95% CI, 5.05 to 6.59; P < .001), and overall healthier (coefficient, 8.72; 95% CI, 7.88-9.56; P < .001). The ordinal rank changes for an average individual were -21 for perceived age, 21 for attractiveness, 16 for success, and 21 for overall health.

Conclusions And Relevance: In this study, observer perceptions of face-lift surgery were associated with views that patients appeared younger, more attractive, healthier, and more successful. These findings highlight observer perceptions of face-lift surgery that could positively influence social interactions.

Level Of Evidence: NA.
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http://dx.doi.org/10.1001/jamafacial.2016.2206DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5519425PMC
July 2017

Microvascular Flaps in Nasal Reconstruction.

Facial Plast Surg 2017 Feb 22;33(1):74-81. Epub 2017 Feb 22.

Division of Facial Plastic and Reconstructive Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland.

Nasal reconstruction for subtotal and total rhinectomy defects is a challenging endeavor, which requires technical finesse, a keen artistic eye, and the ability to anticipate long-term changes that accompany postoperative healing. While local and regional flaps have traditionally been utilized to reconstitute missing nasal elements, certain situations may not provide sufficient or acceptable tissue for optimal reconstruction. In these situations, the three major components of the nose-lining, structural support, and external skin-may require reconstruction with tissues harvested from distant sites through microvascular free tissue transfer. Our objective in this article is to discuss the general approach to nasal reconstruction and present the considerations for free tissue transfer with regard to each nasal component. The virtues of free flap transfer as well as its shortcomings and potential complications are discussed.
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http://dx.doi.org/10.1055/s-0036-1597984DOI Listing
February 2017

Comparing Patient, Casual Observer, and Expert Perception of Permanent Unilateral Facial Paralysis.

JAMA Facial Plast Surg 2017 Dec;19(6):476-483

Division of Rhinology, Department of Otolaryngology-Head and Neck Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland.

Importance: Differences in perception of facial paralysis among patients, casual observers, and experts may have implications for outcomes research and patient care.

Objective: To compare multiple domains of casual observer and expert perception with the actual experience of patients with permanent unilateral facial paralysis.

Design, Setting, And Participants: This investigation was a prospective cohort study conducted at an academic tertiary referral center. Patients with permanent unilateral facial paralysis (House-Brackmann grades IV to VI) were randomly selected from The Johns Hopkins University Division of Facial Plastic and Reconstructive Surgery clinic. A diverse group of casual observers and experts were recruited to rate their perception of each patient with facial paralysis. The study dates were July 2014 to July 2015.

Main Outcomes And Measures: Patients rated their paralysis severity, attractiveness, quality of life, and affect using established metrics. Casual observers and experts viewed standardized facial videos of each patient and then used the same metrics to rate each patient's paralysis severity, attractiveness, quality of life, and affect.

Results: The analysis yielded 40 patient observations, 6400 casual observer observations, and 200 expert observations for each outcome metric in the study. Compared with the patients' self-perception, casual observers and experts rated patients with facial paralysis more negatively in all measured domains. A multivariable mixed-effects regression showed that observers perceived patients as having greater paralysis severity (8.49 [95% CI, -0.65 to 17.64] of 100 points; SE, 4.67), being less attractive (-7.71 [95% CI, -14.92 to -0.50] of 100 points; SE, 3.68), and having a worse quality of life (-7.76 [95% CI, -14.18 to -1.34] of 100 points; SE, 3.28) compared with the patients' perceptions. Logistic regression demonstrated that observers were less likely to rate patients' affect as positive (odds ratio, 0.28 [95% CI, 0.14-0.58]; SE, 0.10) compared with the patients' self-rating. The raw data and regression analyses also showed that patients, casual observers, and experts perceived faces with higher House-Brackmann grades more negatively in all measured domains of facial perception.

Conclusions And Relevance: This study found that casual observers and experts generally perceive patients with facial paralysis more negatively than patients perceive themselves. These findings have implications for patients and facial plastic surgeons alike. They also emphasize the importance of assessing outcomes from all 3 perspectives. This pilot study lays the groundwork for developing new tools to assess the social perception of facial deformity that could lead to advancement in facial paralysis outcomes research and improved care for patients with facial paralysis.

Level Of Evidence: NA.
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http://dx.doi.org/10.1001/jamafacial.2016.1630DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5498251PMC
December 2017

Association Among Facial Paralysis, Depression, and Quality of Life in Facial Plastic Surgery Patients.

JAMA Facial Plast Surg 2017 May;19(3):190-196

Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University, Baltimore, Maryland.

Importance: Though anecdotally linked, few studies have investigated the impact of facial paralysis on depression and quality of life (QOL).

Objective: To measure the association between depression, QOL, and facial paralysis in patients seeking treatment at a facial plastic surgery clinic.

Design, Setting, Participants: Data were prospectively collected for patients with all-cause facial paralysis and control patients initially presenting to a facial plastic surgery clinic from 2013 to 2015. The control group included a heterogeneous patient population presenting to facial plastic surgery clinic for evaluation. Patients who had prior facial reanimation surgery or missing demographic and psychometric data were excluded from analysis.

Main Outcomes And Measures: Demographics, facial paralysis etiology, facial paralysis severity (graded on the House-Brackmann scale), Beck depression inventory, and QOL scores in both groups were examined. Potential confounders, including self-reported attractiveness and mood, were collected and analyzed. Self-reported scores were measured using a 0 to 100 visual analog scale.

Results: There was a total of 263 patients (mean age, 48.8 years; 66.9% were female) were analyzed. There were 175 control patients and 88 patients with facial paralysis. Sex distributions were not significantly different between the facial paralysis and control groups. Patients with facial paralysis had significantly higher depression, lower self-reported attractiveness, lower mood, and lower QOL scores. Overall, 37 patients with facial paralysis (42.1%) screened positive for depression, with the greatest likelihood in patients with House-Brackmann grade 3 or greater (odds ratio, 10.8; 95% CI, 5.13-22.75) compared with 13 control patients (8.1%) (P < .001). In multivariate regression, facial paralysis and female sex were significantly associated with higher depression scores (constant, 2.08 [95% CI, 0.77-3.39]; facial paralysis effect, 5.98 [95% CI, 4.38-7.58]; female effect, 1.95 [95% CI, 0.65-3.25]). Facial paralysis was associated with lower QOL scores (constant, 81.62 [95% CI, 78.98-84.25]; facial paralysis effect, -16.06 [95% CI, -20.50 to -11.62]).

Conclusions And Relevance: For treatment-seeking patients, facial paralysis was significantly associated with increased depression and worse QOL scores. In addition, female sex was significantly associated with increased depression scores. Moreover, patients with a greater severity of facial paralysis were more likely to screen positive for depression. Clinicians initially evaluating patients should consider the psychological impact of facial paralysis to optimize care.

Level Of Evidence: 2.
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http://dx.doi.org/10.1001/jamafacial.2016.1462DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5469376PMC
May 2017

Societal Value of Surgery for Facial Reanimation.

JAMA Facial Plast Surg 2017 Mar;19(2):139-146

Division of Rhinology, Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland.

Importance: Patients with facial paralysis are perceived negatively by society in a number of domains. Society's perception of the health utility of varying degrees of facial paralysis and the value society places on reconstructive surgery for facial reanimation need to be quantified.

Objective: To measure health state utility of varying degrees of facial paralysis, willingness to pay (WTP) for a repair, and the subsequent value of facial reanimation surgery as perceived by society.

Design, Setting, And Participants: This prospective observational study conducted in an academic tertiary referral center evaluated a group of 348 casual observers who viewed images of faces with unilateral facial paralysis of 3 severity levels (low, medium, and high) categorized by House-Brackmann grade. Structural equation modeling was performed to understand associations among health utility metrics, WTP, and facial perception domains. Data were collected from July 16 to September 26, 2015.

Main Outcomes And Measures: Observer-rated (1) quality of life (QOL) using established health utility metrics (standard gamble, time trade-off, and a visual analog scale) and (2) their WTP for surgical repair.

Results: Among the 348 observers (248 women [71.3%]; 100 men [28.7%]; mean [SD] age, 29.3 [11.6] years), mixed-effects linear regression showed that WTP increased nonlinearly with increasing severity of paralysis. Participants were willing to pay $3487 (95% CI, $2362-$4961) to repair low-grade paralysis, $8571 (95% CI, $6401-$11 234) for medium-grade paralysis, and $20 431 (95% CI, $16 273-$25 317) for high-grade paralysis. The dominant factor affecting the participants' WTP was perceived QOL. Modeling showed that perceived QOL decreased with paralysis severity (regression coefficient, -0.004; 95% CI, -0.005 to -0.004; P < .001) and increased with attractiveness (regression coefficient, 0.002; 95% CI, 0.002 to 0.003; P < .001). Mean (SD) health utility scores calculated by the standard gamble metric for low- and high-grade paralysis were 0.98 (0.09) and 0.77 (0.25), respectively. Time trade-off and visual analog scale measures were highly correlated. We calculated mean (SD) WTP per quality-adjusted life-year, which ranged from $10 167 ($14 565) to $17 008 ($38 288) for low- to high-grade paralysis, respectively.

Conclusions And Relevance: Society perceives the repair of facial paralysis to be a high-value intervention. Societal WTP increases and perceived health state utility decreases with increasing House-Brackmann grade. This study demonstrates the usefulness of WTP as an objective measure to inform dimensions of disease severity and signal the value society places on proper facial function.

Level Of Evidence: NA.
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http://dx.doi.org/10.1001/jamafacial.2016.1419DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5469369PMC
March 2017

Measurement of the Quality of Facial Lesion Reconstruction With Observer-Graded Affect Display.

JAMA Facial Plast Surg 2016 Dec;18(6):467-473

Division of Facial Plastic & Reconstructive Surgery, Department of Otolaryngology-Head & Neck Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland.

Importance: The impact of facial reconstructive surgery on improving affect display for patients with facial lesions is incompletely understood.

Objectives: To measure the impact of surgically reconstructing facial lesions on observer graded affect display.

Design, Setting, And Participants: This was a prospective randomized controlled experiment at an academic tertiary referral center; 120 naïve observers completed one of 4 surveys of 20 images of faces.

Main Outcomes And Measures: A total of 80 different images of faces were used: 32 faces with lesions preoperatively and postoperatively, and 16 normal faces. The 32 lesion faces were categorized into 4 categories of lesion with 8 faces in each category: small peripheral, small central, large peripheral, and large central. Participants viewed 20 images of faces: 8 preoperative, 8 postoperative, and 4 normal. Observers rated faces by selecting all terms that applied from 8 affects of the Derogatis Affects Balance Scale (DABS), the Ekman scale's 6 basic emotions, and a neutral term. Latent class analysis and regression were used to determine number and characteristics of affect classes and significance of covariates: operation status, size, and location. Postoperative faces were compared with normal faces via bootstrap analysis to determine statistically significant differences in affect display. Analysis took place in August 2014 and was verified in December 2015.

Results: A total of 120 observers rated 80 facial images via 4 surveys. The mean (SD) age of the observers was 32.2 (13.5) years (range, 18-72 years). Both scales collapsed into 3 latent classes: positive, neutral, and negative for normal faces and faces with lesions. Using the DABS, faces with lesions preoperatively were more likely to be in the negative affect class (small peripheral [SP]: mean, 0.384; 95 % CI, 0.325-0.444; small central [SC]: mean, 0.505; 95% CI, 0.433-0.577; large peripheral [LP]: mean, 0.583; 95% CI, 0.519-0.647; large central [LC]: mean, 0.475; 95% CI, 0.412-0.539) than normal faces (mean, 0.235; 95% CI, 0.190-0.281) or postoperatively (SP: mean, 0.141; 95% CI, 0.106-0.176; SC: mean, 0.207; 95% CI, 0.160-0.254; LP: mean, 0.272; 95% CI, 0.219-0.325; LC: mean, 0.189; 95% CI, 0.149-0.228) and less likely to be in the positive affect class (SP: mean, 0.213; 95% CI, 0.168-0.257; SC: mean, 0.204; 95% CI, 0.164-0.243; LP: 0.130; 95% CI, 0.096-0.164; LC: mean, 0.213; 95% CI, 0.172-0.254) than normal faces (mean, 0.459; 95% CI, 0.399-0.519) or postoperatively (SP: mean, 0.384; 95% CI, 0.323-0.445; SC: mean, 0.410; 95% CI, 0.350-0.469; LP, 0.298; 95% CI, 0.243-0.354; LC: mean, 0.415; 95% CI, 0.358-0.472). Postoperatively, faces with SP, SC, and LC lesions were restored to similar or improved levels of positive and negative affect as normal faces. Faces with LP lesions were improved in positive and negative affect from preoperatively, and restored to similar levels of negative affect as normal faces, but still had lower levels of positive affect compared with normal faces. Results using the Ekman scale were similar.

Conclusions And Relevance: Facial reconstructive surgery was effective in restoring affect display in patients with facial lesions. This provides new data supporting the positive impact of reconstructive surgery on patients' quality of life.

Level Of Evidence: NA.
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http://dx.doi.org/10.1001/jamafacial.2016.0817DOI Listing
December 2016

Controversies in Contemporary Facial Reanimation.

Facial Plast Surg Clin North Am 2016 Aug;24(3):275-97

Division of Facial Plastic & Reconstructive Surgery, Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins Medicine, 601 North Caroline Street, 6th Floor, Baltimore, MD 21287-0910, USA. Electronic address:

Facial palsy is a devastating condition with profound functional, aesthetic, and psychosocial implications. Although the complexity of facial expression and intricate synergy of facial mimetic muscles are difficult to restore, the goal of management is to reestablish facial symmetry and movement. Facial reanimation surgery requires an individualized treatment approach based on the cause, pattern, and duration of facial palsy while considering patient age, comorbidities, motivation, and goals. Contemporary reconstructive options include a spectrum of static and dynamic procedures. Controversies in the evaluation of patients with facial palsy, timing of intervention, and management decisions for dynamic smile reanimation are discussed.
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http://dx.doi.org/10.1016/j.fsc.2016.03.016DOI Listing
August 2016
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