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Lower facial rejuvenation is an expanding area in facial plastic surgery with both surgical and nonsurgical treatment options. Evidence-based medicine is essential to providing high-quality care and creating long-lasting results. A systematic approach and understanding of the layers of the aging lower face is important to develop an individualized treatment plan. This review will focus on surgical and nonsurgical treatments for the aging lower face with an emphasis on evidence-based medicine., Competing Interests: None declared., (Thieme. All rights reserved.)

Importance: Paramedian forehead flaps are commonly used to reconstruct facial defects caused by skin cancers. Data are lacking on the complications from this procedure, postoperative outcomes, and association of cancer diagnosis with rate of deep venous thrombosis (DVT)., Objectives: The primary objective was to determine complication rates after paramedian forehead flap reconstruction for defects resulting from resection of facial cancers; and the secondary objective was to determine patient factors and complications that are associated with readmission., Design, Setting, and Participants: Retrospective cohort study of patients who underwent paramedian forehead flap reconstruction for skin cancer reconstruction from January 1, 2007, through December 31, 2013. Data analysis took place between October 1, 2017, and June 1, 2018., Main Outcomes and Measures: Complication rates including DVT, emergency department visits, and hospital readmissions., Results: A total of 2175 patient were included in this study; mean (SD) age, 70.3 (13.4) years; 1153 (53.5%) were men. Postoperative DVT occurred in 10 or fewer patients (≤0.5%); postoperative bleeding in 30 (1.4%), and postoperative infection in 63 (2.9%). Most patients went home on the day of surgery (89.6%; n = 1949), while 10.4% stayed one or more days in the hospital (n = 226). Overnight admission was associated with tobacco use (odds ratio [OR], 1.65; 95% CI, 1.11-2.44), hypothyroidism (OR, 1.93; 95% CI, 1.10-3.39), hypertension (OR, 1.82; 95% CI, 1.29-2.57), ear cartilage graft (OR, 2.20; 95% CI, 1.51-3.21), and adjacent tissue transfer (OR, 1.88; 95% CI, 1.33-2.67). Risk factors strongly associated with immediate return to the emergency department or readmission within 48 hours of surgery included postoperative bleeding (OR, 13.05; 95% CI, 4.24-40.16), neurologic disorder (OR, 4.11; 95% CI, 1.12-15.09), and alcohol use (OR, 7.70; 95% CI, 1.55-38.21)., Conclusions and Relevance: In this study, the most common complication of paramedian forehead flap reconstruction was infection. Risk factors for readmission included development of postoperative bleeding, having a neurologic disorder, and alcohol use. Deep venous thrombosis was a rare complication. Because bleeding is a more common complication in this patient population, discretion should be used when deciding to administer anticoagulation medication to low- to medium-risk patients prior to surgery., Level of Evidence: NA.

Objective: To identify the method and rate at which cosmesis is reported after reconstruction from head and neck surgery among adults., Data Sources: A medical librarian implemented search strategies in multiple databases for head and neck reconstruction, outcome assessment/patient satisfaction, and cosmesis/appearance., Review Methods: Inclusion and exclusion criteria were designed to capture studies examining adults undergoing reconstruction after head and neck cancer surgery with assessment of postoperative cosmesis. The primary outcome was the method to assess cosmesis. Secondary outcomes were types of instruments used and the rate at which results were reported. Validated instruments used in these studies were compared and critically assessed., Results: The search identified 4405 abstracts, and 239 studies met inclusion and exclusion criteria. Of these, 43% (n = 103) used a scale or questionnaire to quantify the cosmetic outcome: 28% (n = 66), a visual analog, Likert, or other scale; 13% (n = 30), a patient questionnaire; and 3% (n = 7), both. Of the 103 studies that used an instrument, 14% (n = 14, 6% overall) used a validated instrument. The most common validated instrument was the University of Washington Quality of Life (UWQOL) questionnaire (4%, n = 9). The most highly rated instruments were the UWQOL and the Derriford Appearance Scale., Conclusions: Reporting of cosmetic outcomes after head and neck cancer reconstruction is heterogeneous. Most studies did not report patient feedback, and a minority used a validated instrument to quantify outcomes. To reduce bias, improve reliability, and decrease heterogeneity, we recommend the UWQOL to study cosmetic outcomes after head and neck reconstruction.

Importance: After reduction of complex mandibular fractures, contouring of the fracture plates to fixate the reduced mandibular segments can be time-consuming., Objective: To explore the potential application of a 3-dimensional (3-D)-printed short-segment mandibular template in the management of complex mandibular fractures., Design, Setting, and Participants: A feasibility study was performed at a tertiary academic center using maxillofacial computed tomography data of 3 patients with comminuted mandibular fractures who required preoperative planning with a perfected complete mandible model., Interventions: Thresholding, segmentation, and realignment of the fractured mandible were performed based on computed tomography data. Each reduced mandible design was divided to create 3-D templates for 6 fracture sites: right and left angle, body, and symphyseal/parasymphyseal. Sessions were conducted with junior otolaryngology and plastic surgery residents, during which mandibular fracture plates were contoured in a "preoperative" setting against the 3-D-printed short-segment templates, and an "intraoperative" setting against the previously manufactured, complete mandible model. The previously manufactured, complete model served as a surrogate for the intraoperative mandible with the fracture site reduced., Main Outcomes and Measures: The time for 3-D template printing, the "preoperative" (measure of the time consumed preoperatively), and "intraoperative" (measure of the time saved intraoperatively) times were recorded. Comparisons were made for cost estimates between a complete model and the 3-D-printed short-segment template. The operating room charge equivalent of the intraoperative time was also calculated., Results: Of the 3 patients whose data were used, 1 was a teenager and 2 were young adults. The total time for 3-D modeling and printing per short-segment template was less than 3 hours. The median (range) intraoperative time saved by precontouring the fracture plates was 7 (1-14), 5 (1-30), and 7 (2-15) minutes, and the operating room charge equivalents were $350.35 ($50.05-$700.70), $250 ($50.05-$1501.50), and $350.35 ($100.10-$750.75) for the angle, body, and symphyseal/parasymphyseal segments, respectively. The total cost for a single 3-D-printed template was less than $20, while that for a perfected complete model was approximately $2200., Conclusions and Relevance: We demonstrate that patient- and site-specific 3-D-printed short-segment templates can be created within the timeframe required for mandibular fracture repair. These novel 3-D-printed templates also demonstrate cost efficiency in the preoperative planning for complex mandibular fracture management compared with perfected models and facilitate plate contouring in a similar fashion. Estimation of reduced operative room cost and time with the application of these short-segment templates warrants studies in actual patient care., Level of Evidence: NA.