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Management of the aging brow and forehead has recently evolved based on available innovative technologies. Likewise, procedure-specific indications have changed based on collective surgical experiences. No longer is the approach based solely on hair pattern or degree of brow ptosis. Patients require varying combinations of brow elevation (prior to blepharoplasty), correction of brow asymmetries, and hairline-preserving forehead elevation. Some may only require excisional or paralytic procedures of the frontalis muscle (horizontal forehead creases), corrugator supercilii muscles (vertical glabellar furrows), and procerus muscle (horizontal glabellar furrows). We present a 3-year experience using a problem-specific approach. This incorporates endoscopic technology, botulinum toxin type A purified neurotoxin complex (Botox, Allergan, Irvine, CA) intramuscular injection, and traditional procedures such as the coronal, pretrichial, midforehead, and direct browlift. Current indications, patient selection, and results are also discussed. [ABSTRACT FROM AUTHOR]

Laser-assisted uvulopalatoplasty (LAUP) has been introduced as an alternative to uvuloplatopharyngoplasty for the treatment of snoring. Despite limited study, the use of this procedure has been expanded to include patients with obstructive sleep apnea syndrome. Although the potential cost-savings of performing sleep apnea surgery on an outpatient basis are self-evident, concern exists regarding the safety of this practice. In an effort to characterize the risk of performing LAUP on an outpatient basis, eight patients with mild or no sleep apnea were identified and intensively studied before and after the first stage of LAUP to cure snoring. Assessment included preoperative magnetic resonance imaging (MRI) scans, polysomnography, and videoendoscopy. Each of these diagnostic studies was then repeated between 48 and 72 hours after LAUP. Complete polysomnographic data were available for seven of the eight patients. The mean ( +/- SD) preoperative respiratory disturbance index (RDI) was 11.3 +/- 10.9, and the mean oxygen saturation nadir (LSAT) was 87.7 +/- 6.2% (n = 7). The mean airway cross-sectional area at the palate (by MRI) was 49.8 +/- 22.8 mm2 (n = 8). After LAUP, the mean RDI nearly doubled to 21.7 +/- 9.9 (P > .1). The apnea index increased fourfold from 3.3 +/- 3.5 to 14.8 +/- 10.9 (P < .03). The mean LSAT remained stable at 87.4 +/- 4.1% (P > .5). The cross-sectional area of the airway decreased to a mean of 47.9 +/- 22.4 mm2 (P > .5). These data suggest that LAUP may temporarily worsen obstructive sleep apnea. Although the clinical significance of this degree of worsening is uncertain, it would be prudent to consider perioperative use of nasal continuous positive airway pressure in patients with more than mild obstructive sleep apnea who undergo ambulatory LAUP. [ABSTRACT FROM AUTHOR]

Background: Hip augmentation increases the hip width utilizing fat transfer and/or subcutaneous implants, creating a more feminine hourglass shape. Custom hip implant surgery requires proper patient selection, correct body frame analysis, appreciation of hip aesthetics, understanding surgical anatomy, optimal aesthetic planning, a favorable implant design and fabrication, skilled surgical implant placement, diligent postoperative patient care, and proper complication management., Objectives: The authors sought to evaluate the pioneering clinical experience with cosmetic custom hip silastic implants., Methods: A consecutive patient surgical series of patients seeking custom aesthetic hip implant surgery was tabulated. Similar hip analysis, implant design and fabrication, surgical technique, and postoperative follow-up were performed in 3 practices., Results: The overall patient satisfaction rate (87%, 47 of 54 patients) was favorable. There was a total of 29 (54%) medical complications and 20 (37%) cosmetic complications (implant show). A total of 17 patients (31.5%) requested revision surgery secondary to implant show (n = 10) and an infected implant (n = 6). No patient experienced an acute implant infection, incisional scar hypertrophy, wound dehiscence, implant extrusion, parasthesias, muscle dysfunction, or hip joint injury., Conclusions: The utilization of hip implants represents a new type of body contouring implant that has some unique differences in anatomic location, implant design, and tissue pocket location. Their utilization is an evolving one in aesthetic body implants, for which clinical experience to date remains limited in number. The proper surgical placement, postoperative management, and treatment of complications to include revision surgery are essential to achieving a successful body contouring outcome., (© The Author(s) 2022. Published by Oxford University Press on behalf of The Aesthetic Society. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

The current medical information reviewing the use of radiofrequency in tissue volumetric reduction in the upper airway for nasal obstruction, primary snoring, and sleep-disordered breathing is reviewed. Reviews of the pathophysiology of sites of obstruction of the upper airway, indications for radiofrequency, procedure, technique, results, limitations and potential complications for each procedure, with the author's recommendations, are presented. The radiofrequency procedures are technically simple, minimally invasive, are associated with reduced postoperative pain compared with traditional surgical approaches, and can be performed on an outpatient basis under local anesthesia with a low complication rate and generally good therapeutic results. Future studies will aid in delineating the specific role of radiofrequency in nasal obstruction and sleep-disordered breathing.

Purpose: This study evaluated the accuracy of a genioglossus advancement (GA) technique (rectangular window) to incorporate the genial tubercle/genioglossus muscle complex (GGC) in patients with obstructive sleep apnea., Methods: This prospective study consisted of 38 consecutive patients who underwent GA. Preoperative localization of the GGC was based on the cephalometric and panoramic radiographs, as well as digital palpation in the floor of mouth. Immediately after completion of the osteotomy, the presence of the genial tubercles and the amount of the genioglossus muscle captured in the bone flap were examined directly., Results: All 38 pairs of genial tubercles were captured. Thirty-one patients had both bellies of the genioglossus muscle incorporated. Two patients had a complete belly and a partial (>50%) belly of the muscle captured. Five patients had only a portion (>50%) of both muscle bellies included. The incomplete incorporation of the muscles in the bone flap was caused by the limited lateral extension of the osteotomy beyond the genial tubercles. The causes of the limited lateral osteotomy extension included crowding of the lower incisors as well as the presence of elongated and/or medially angulated canine roots., Conclusion: The results of this study show that the rectangular osteotomy technique accurately captures the genial tubercles and enables an adequate amount of the genioglossus muscle to be incorporated and advanced. However, limited lateral extension of the osteotomy can result in a decreased incorporation of genioglossus muscle in some patients., (Copyright 2001 American Association of Oral and Maxillofacial Surgeons)

Objective: The goal of this study was to assess the outcomes of obstructive sleep apnea (OSA) surgery based on the patient perspective and polysomnographic data., Study Design: Fifty-six patients with severe OSA completed the 2-phase reconstructive protocol. A minimum of 6 months after the phase II surgery and after the postoperative polysomnography, questionnaires with visual analog scales (VAS 0-10) were mailed to the patients to assess their perceptions of treatment results., Results: Forty-two (75%) questionnaires were returned. The mean patient age was 46.3 years. The mean respiratory disturbance index improved from 58.7 to 10.0. The mean lowest oxygen saturation improved from 76.3 to 87.3%. All 42 patients reported improved sleep (VAS 8.7). Although 10 patients reported changes in speech, the changes were insignificant, with 9 of the patients scoring 0 on the VAS (VAS 0.08 +/-0.3). Five patients reported changes in swallowing, and their VAS scores were 0.5, 0.9, 1.0, 2.7, and 6.9 (mean VAS 2.4+/-2.7). Forty patients (95%) were satisfied with their results and would undergo the reconstruction again., Conclusion: Surgical airway reconstruction for severe OSA is a highly effective treatment option base on the objective as well as the subjective assessment.

Objective: Outcome data on the surgical treatment of obstructive sleep apnea are, in general, based on short-term follow-up (<6-9 months). This examination was undertaken to assess long-term results., Methods: Forty patients who underwent soft tissue and skeletal surgery were the subjects of this review. Methods of evaluation included polysomnographic variables (respiratory disturbance index [RDI], low oxyhemoglobin desaturation [LSAT]), body mass index, quality-of-life assessments, roentgenographic analysis, and complications. Statistical analysis used the SAS 6.12 system., Results: Thirty-six of 40 patients (90%) showed long-term clinical success. The mean preoperative RDI, nasal continuous positive airway pressure RDI, and long-term RDI were 71.2 +/- 27.0, 7.6 +/- 5.2 and 7.6 +/- 5.1, respectively. The mean preoperative LSAT, nasal continuous positive airway pressure LSAT, and long-term LSAT were 67. 5% +/- 14.8%, 87.1% +/- 3.2%, and 86.3% +/- 3.9%, respectively. The mean follow-up was 50.7 +/- 31.9 months. The patients showed a statistically significant long-term weight gain (P = 0.0002) compared with their 6-month postoperative level (body mass index 31. 4 +/- 6.7 vs 32.2 +/- 6.3). There was a positive correlation with the amount of skeletal advancement and clinical outcome., Conclusion: Comprehensive evaluation and surgical treatment can result in successful long-term clinical outcome.

Objective: The goal was to evaluate the effect of radiofrequency (RF) of the palate on speech, swallowing, taste, sleep, and snoring 12 to 18 months after treatment., Methods: Twenty-two patients were evaluated by clinical examination, questionnaires, and visual analog scales. The patients with relapse of snoring were offered further RF treatment., Results: After a mean follow-up of 14 months, no adverse effect was reported. Subjective snoring scores relapsed by 29% overall. Nine patients (41%) noted relapse of snoring from 2.1 +/- 1. 1 to 5.7 +/- 2.7 (P < 0.001). Eight of the patients underwent further RF treatment with a reduction of snoring from 5.8 +/- 2.9 to 3.3 +/- 3.1 (P = 0.01)., Conclusion: The success of RF volumetric reduction of the palate diminishes with time, as with other surgical procedures of the palate. However, the minimal invasiveness of the RF provided a high patient acceptance for retreatment, and relapse of snoring can be improved.

Objectives: This study compares the posttreatment discomfort between laser-assisted uvulopalatoplasty (LAUP), uvulopalatopharyngoplasty (UPPP), and radiofrequency volumetric tissue reduction (RFVTR) of the palate through the use of visual analog pain scales and a quantitative assessment of the analgesic medication taken., Methods: In one group, LAUP (n = 10) or UPPP (n = 9) was used to treat patients' snoring or sleep-disordered breathing (SDB), and the other group underwent RFVTR (n = 22)., Results: The mean numbers of days with pain after RFVTR, LAUP, and UPPP were 2.6, 13.8, and 14.3 days, respectively. Narcotic analgesics were required in the RFVTR, LAUP, and UPPP groups in 9%, 100%, and 100% of the subjects, respectively. The mean number of these days requiring narcotic pain medications for RFVTR, LAUP, and UPPP was 0.2, 11.8, and 12.4 days, whereas the total narcotic equivalent was 0.3, 7.4 and 29.6 days, respectively., Conclusion: RFVTR of the soft palate produced less posttreatment pain than LAUP or UPPP. LAUP and UPPP appeared to show little difference in the severity or duration of posttreatment discomfort.

Objective: A new operative technique to improve nasal valve collapse by placement of cartilage struts along the alar rim was compared with the standard nasal valve cartilage graft (NVG) technique., Methods and Patients: A retrospective study of consecutive patients with nasal valve collapse was performed at Stanford University Medical Center. Seventy-nine patients with nasal valve collapse underwent reconstruction with either the classic NVG technique or a newly developed nasal alar rim reconstructive (NARR) procedure. The mean age of the NARR group was 50.13 years (SD +/- 9.40), with 36 men (92.3%) and 3 women (7.7%). The mean age of the NVG group was 52. 14 years (SD +/- 10.83), with 36 men (90%) and 4 women (10%)., Main Outcome Measures: These included functional and subjective evaluation of nasal valve collapse., Results: Forty patients (50.6%) underwent the NVG technique, and 39 (49.4%) received the NARR procedure. The NVG technique revealed 0% worsened, 15.0% (6/40) unchanged, 25.0% (10/40) improved, and 60% (24/40) free of obstruction. The NARR procedure revealed 2.6% worsened, 2.6% unchanged, 7.7% improved, and 87.1% free of obstruction., Conclusions: Nasal alar cartilage struts placed along the caudal alar rim offers sufficient support to the alar rim and valve area. This procedure appears to be as effective as currently available reconstructive alternatives, while being technically uncomplicated.

Surgery is a major modality in the treatment of obstructive sleep apnea syndrome (OSAS), and maxillomandibular advancement (MMA) has been shown to be the most effective surgical option. However, despite the successful short-term (6-9 months) results reported by various investigators, little is known of the long-term clinical outcomes. A review of our long-term clinical results demonstrated that MMA achieves long-term cure in most patients. Aging and minor weight gain did not appear to have a significant adverse effect on the long-term results; however, major weight gain did seem to have a significant negative impact on the long-term outcomes. Therefore, long-term follow-up with proper counseling on weight maintenance or reduction is essential in improving long-term results.

The etiology of sleep disordered breathing is collapse or obstruction of the upper airway during sleep. This obstruction may be localized to one or two areas or may encompass the entire upper airway passages to include the nasal cavity, nasopharynx, oropharynx, hypopharynx, and larynx. The presurgical evaluation, which includes polysomnography, a comprehensive head and neck physical examination, fiberoptic nasopharyngoscopy, and lateral cephalometric analysis is essential in directing surgical therapy in a site specific approach. The surgical procedures available to address hypopharyngeal and base of the tongue collapse include inferior sagittal mandibular osteotomy and gengioglossus advancement, hyoid myotomy and suspension, laser midline glossectomy, lingualplasty, partial glossectomy, and maxillomandibular advancement surgery. The Riley-Powell-Stanford Surgical Protocol has proven to be an effective and safe method for controlling upper airway collapse in sleep disordered breathing.

Objectives: Ideal treatment for nasal obstruction caused by turbinate hypertrophy remains in question. Medical therapy is often ineffective. Surgical procedures have associated morbidity including pain, bleeding, crusting, adhesion, infection, and dryness. Radiofrequency has recently been shown to be safe and effective in volumetric tissue reduction of the tongue in the animal model and of the palate in human beings. We prospectively evaluate the safety and effectiveness of radiofrequency volumetric tissue reduction (RFVTR) for the treatment of nasal obstruction caused by inferior turbinate hypertrophy., Methods: Twenty-two consecutive patients with nasal obstruction and associated inferior turbinate hypertrophy refractory to medical therapy were evaluated for RFVTR. The study design limited the region of treatment to the anterior third of the inferior turbinate. The procedures were performed in an ambulatory facility with patients under local anesthesia. Clinical examinations, patient questionnaires, and visual analog scales were used to assess treatment outcomes., Results: No adverse effects were encountered, including bleeding, crusting, dryness, infection, adhesion, or a worsening of obstruction. Mild edema was noted in all patients but was of short duration (24 to 48 hours). Posttreatment discomfort was well controlled with acetaminophen. Eight weeks after treatment, nasal breathing improved in 21 of 22 patients, with a 58.5% reduction in severity and a 56.5% decrease in the frequency of nasal obstruction., Conclusion: The results of this study demonstrate that RFVTR of the hypertrophic inferior turbinate is associated with minimal adverse effects. Furthermore, this new treatment modality achieves subjective improvement in patients with symptoms of nasal obstruction. However, because of the small sample size and short follow-up, future investigations are needed to fully evaluate the use of RFVTR in the treatment of nasal obstruction caused by turbinate hypertrophy.

The etiology of sleep disordered breathing (SDB), which includes upper airway resistance syndrome (UARS) and obstructive sleep apnea syndrome (OSAS), is collapse or obstruction of the upper airway during sleep. Surgical management was the first treatment modality available for SDB. Since the introduction of the tracheotomy to treat OSAS, there have been numerous procedures discovered to address the various sites of obstruction of the upper airway. This article reviews the long-term surgical results and may improve one's insight into the successes of surgical therapy for SDB.

Study Objectives: To evaluate pain, swallowing, speech, edematous response, tissue shrinkage, sleep, snoring, and safety (energy limits and adverse effects) following radiofrequency (RF) treatment to the palate in 22 subjects with sleep-disordered breathing., Design: This investigation is a prospective nonrandomized study. Polysomnography, radiographic imaging, and infrared thermography, along with questionnaires and visual analog scales, were used to evaluate the effects of RF treatment to the palate., Setting: Treatments were delivered on an outpatient basis at Stanford University Medical Center., Patients: Twenty-two healthy patients (18 men), with a mean age of 45.3+/-9.1 years, were enrolled. All were snorers seeking treatment and met predetermined criteria: a respiratory disturbance index < or = 15, oxygen saturation > or = 85%, and a complaint of daytime sleepiness., Intervention: RF was delivered to the submucosa of the palate with a custom-fabricated electrode for a mean duration of 141+/-30 s with a mean of 3.6+/-1.2 treatments per patient. Reduction of their snoring scores determined the end point of the study., Results: Neither speech nor swallowing was adversely affected. Pain was of short duration (0 to 48 h) and was controlled with acetaminophen. There were no infections. Although there was documented edema at 24 to 48 h, there were no clinical airway compromises. Polysomnographic data showed improvement in esophageal pressure measurements of the mean nadir and the 95th percentile nadir (p=0.031, p=0.001) respectively, as well as the mean sleep efficiency index (p=0.002). Radiographic imaging showed a mean shrinkage of 5.5+/-3.7 mm (p< or =0.0001). Subjective snoring scores fell by a mean of 77% (8.3+/-1.8 to 1.9+/-1.7, p=0.0001) accompanied by improved mean Epworth sleepiness scores (8.5+/-4.4 to 5.2+/-3.3, p=0.0001)., Conclusion: The results of this investigation allowed the formulation of safety parameters for RF in this defined population with mild sleep-disordered breathing. There was a documented tissue reduction and improvement in symptoms in all subjects. However, given the small sample size and short-term follow-up, these results should be confirmed by further investigation.

Background: Hypoxemia, hypertension, airway obstruction, and death have been associated with surgery for obstructive sleep apnea syndrome (OSAS). Patient analysis was undertaken to identify potential factors that could affect risk-management outcome., Methods: One hundred eighty-two consecutively treated patients with OSAS undergoing 210 procedures were evaluated. Fifty-four factors were analyzed., Results: Group characteristics included a mean age of 48.2 years, a mean respiratory disturbance index of 42.3, and a mean low oxyhemoglobin desaturation (LSAT) of 77.5%. Surgery included a combination of uvulopalatopharyngoplasty (162 patients; 77%) and maxillofacial procedures (173 patients; 82%). Patients with a respiratory disturbance index greater than 40 and an LSAT less than 80% (117 patients; 64%) were maintained on nasal continuous positive airway pressure. Thirty-nine patients (18.6% had difficult intubations. There was a positive correlation (p > 0.001) of difficult intubations, neck circumference (> 45.6 cm) and skeletal deficiency (Sella-Nasion-Point B < 75 degrees). All tubes were removed with the patient awake in the operating room with two transient episodes of airway obstruction. One hundred forty-eight of the patients (70.5%) required postoperative intravenous antihypertensive medications. Patients with a preoperative history of hypertension had a significantly increased risk (p > 0.01) of requiring intraoperative and postoperative intravenous antihypertensive medications. The mean hospital stay was 2.2 days (SD +/- 0.9). Analgesia was achieved with intravenous morphine sulfate or meperidine HCl (intensive care unit) and oral oxycodone (non-intensive care unit). There were no significant oxyhemoglobin desaturations, irrespective of severity of OSAS or obesity (mean LSAT day 1, 94.8% (SD +/- 2.4); mean LSAT day 2, 95.5% (SD +/- 1.6)). Complications included postoperative bleeding (n = 4), infection (n = 5), seroma (n = 3), arrhythmia (n = 4), angina (n = 1), and loss of skeletal fixation (n = 1)., Conclusion: Intraoperative airway risks can be reduced by use of fiberoptic intubation in patients with increased neck circumference and skeletal deficiency. Patients with OSAS are at a significantly increased risk for hypertension. Nasal continuous positive airway pressure eliminated the postoperative risk of hypoxemia, which allowed the use of adequate parenteral or oral analgesics.

Study Objective: To investigate, in an animal model, the feasibility of radiofrequency (RF) volumetric tongue reduction for the future purpose of determining its clinical applications in obstructive sleep apnea syndrome (OSAS)., Design: The study was performed in three stages, one in vitro bovine stage and two in vivo porcine stages. The last stage was a prospective investigation with histologic and volumetric analyses to establish outcomes., Setting: Laboratory and operating room of veterinary research center., Participants: A homogeneous population of porcine animal models, including seven in stage 2 and 12 in stage 3., Intervention: RF energy was delivered by a custom-fabricated needle electrode and RF generator to the tongue tissue of both the in vitro and in vivo models., Measurements and Results: Microultransonic crystals were used to measure three-dimensional changes (volumetric reduction). Lesion size correlated well with increasing RF energy delivery (Sperman correlation coefficient of 0.986; p = 0.0003). Histologic assessments done serially over time (1 h through 3 weeks) showed a well-circumscribed lesion with a normal healing progression and no peripheral damage to nerves. Volumetric analysis documented a very mild initial edematous response that promptly tapered at 24 h. At 10 days after RF, a 26.3% volume reduction was documented at the treatment site (circumscribed by the microultrasonic crystals)., Conclusion: RF, in a porcine animal model, can safely reduce tongue volume in a precise and controlled manner. Further studies will validate the use of RF in the treatment of OSAS.