Babak Azizzadeh, MD, FACS

The surgical approach to facial rejuvenation has evolved significantly over the last century. As surgeons have deepened their understanding of facial anatomy over the last half century, so have their surgical approaches to the rhytidectomy, with increasingly extensive manipulation of the underlying soft tissue in the face. While these procedures have become more comprehensive and natural in their approach, the risk of temporary facial palsy also appears to be on the rise. In this text, we… Show more

The surgical approach to facial rejuvenation has evolved significantly over the last century. As surgeons have deepened their understanding of facial anatomy over the last half century, so have their surgical approaches to the rhytidectomy, with increasingly extensive manipulation of the underlying soft tissue in the face. While these procedures have become more comprehensive and natural in their approach, the risk of temporary facial palsy also appears to be on the rise. In this text, we review the technique for deep plane facelifts and neck contouring with an emphasis on the facial nerve anatomy and methods to preserve the intricate facial nerve network during tissue dissection and modification. Careful execution of the surgical steps involved, including deep neck contouring, SMAS (superficial musculoaponeurotic system) suspension, and skin management, is essential to achieve the authentic aesthetic outcomes that patients desire while ensuring patient safety. Show less

While rhytidectomy can yield remarkable results, some patients may subsequently require revision rhytidectomy due to either unsatisfactory outcomes from primary surgery or the natural aging process many years later. Like most other secondary plastic surgical procedures, revision rhytidectomy is a complex undertaking and fraught with potential pitfalls. This can be attributable to natural or postsurgical alterations that can occur with the facial skin, superficial musculoaponeurotic… Show more

While rhytidectomy can yield remarkable results, some patients may subsequently require revision rhytidectomy due to either unsatisfactory outcomes from primary surgery or the natural aging process many years later. Like most other secondary plastic surgical procedures, revision rhytidectomy is a complex undertaking and fraught with potential pitfalls. This can be attributable to natural or postsurgical alterations that can occur with the facial skin, superficial musculoaponeurotic system/platysma muscle, and/or facial nerve landmarks. Additionally, complications such as cobra neck deformity, pixie ear deformity, and synkinesis can add an extra level of complexity to revisional surgery. Furthermore, as more surgeons are performing deep-plane facelifts and more aggressive neck procedures, the risks are further amplified in revisional surgery. In this article, we review the challenges that a facelift surgeon may face when performing revision rhytidectomy and the technical considerations to overcome these obstacles. Show less

Rhytidectomy has witnessed significant advancements in recent years, particularly in the realms deep plane facelift and more aggressive neck contouring. As the procedures have become increasingly intricate and invasive, the imperative to develop refined tools and methodologies has risen. These tools and methods are essential not only for the evaluation of aesthetic outcomes but also for the comprehensive assessment of inherent risks and the holistic enhancement of patients' quality of life.

Tranexamic acid (TXA) has been popularized as an adjunct to decrease the risk of bleeding and subsequent bruising and edema in aesthetic surgery. The most notable risks of TXA are thrombus and seizures, which are associated with higher plasma concentrations of the acid. In an effort to mitigate these risks, surgeons have begun using TXA locally, either as a topical irrigation or mixed into the local anesthetic. Although local use is thought to be safer from a side-effect standpoint, because… Show more

Tranexamic acid (TXA) has been popularized as an adjunct to decrease the risk of bleeding and subsequent bruising and edema in aesthetic surgery. The most notable risks of TXA are thrombus and seizures, which are associated with higher plasma concentrations of the acid. In an effort to mitigate these risks, surgeons have begun using TXA locally, either as a topical irrigation or mixed into the local anesthetic. Although local use is thought to be safer from a side-effect standpoint, because there is decreased systemic absorption, its use is not without risk. We present 4 patients who developed wound healing complications thought to be related to locally administered TXA. One patient had TXA delivered topically, and 3 patients had TXA mixed into their local anesthetic. These adverse events have not been published in the literature previously. This case report serves as a warning to other surgeons about using locally administered TXA. Show less

We highlight a management scheme subdivided into preoperative, intraoperative and postoperative timepoints for the comprehensive management of this patient population. Optimal results rely on an individualized medical and surgical treatment plan and regimen to achieve desired and realistic results.

This article takes a deep dive in to Aesthetic Rhinoplasty in Children and Adoles

Following incomplete facial nerve injury, patients may develop aberrant facial nerve reinnervation, which can result in facial synkinesis. The treatment goals for patients with postfacial paralysis synkinesis are to improve resting oral commissure position, oral competence, facial and cervical tightness, and smile symmetry and spontaneity. Modified selective neurectomy of the facial nerve as described by Azizzadeh and colleagues is a targeted surgical method that allows the surgeon to eliminate… Show more

Following incomplete facial nerve injury, patients may develop aberrant facial nerve reinnervation, which can result in facial synkinesis. The treatment goals for patients with postfacial paralysis synkinesis are to improve resting oral commissure position, oral competence, facial and cervical tightness, and smile symmetry and spontaneity. Modified selective neurectomy of the facial nerve as described by Azizzadeh and colleagues is a targeted surgical method that allows the surgeon to eliminate the antagonist movements of the face and allow the favorable movements of the face to predominate, resulting in a more natural smile. Show less

Moderate to high burnout has been reported in 35% to 86% of OTO-HNS residents. Among other surgical specialties, resident burnout ranges between 58% and 66% in plastics, 11% and 67% in neurosurgery, 38% and 68% in urology, and 31% and 56% in orthopedics. Highest burnout rates were seen in postgraduate year 2 residents. Factors significantly associated with burnout included hours worked (>80 h/wk), level of autonomy, exercise, and program support. Reported resident work hours have steadily… Show more

Moderate to high burnout has been reported in 35% to 86% of OTO-HNS residents. Among other surgical specialties, resident burnout ranges between 58% and 66% in plastics, 11% and 67% in neurosurgery, 38% and 68% in urology, and 31% and 56% in orthopedics. Highest burnout rates were seen in postgraduate year 2 residents. Factors significantly associated with burnout included hours worked (>80 h/wk), level of autonomy, exercise, and program support. Reported resident work hours have steadily increased: 8% of OTO-HNS residents in 2005 vs 26% in 2019 reported averaging >80 h/wk. Practical implications of resident burnout include decreased empathy, moral distress and injury, poor health, decreased quality of life, increased attrition, decreased desire to pursue fellowship, and increased likelihood of medical errors. Structured mentorship programs, wellness initiatives, and increased ancillary support have been associated with lower burnout rates and improvements in resident well-being across specialties.

Implications for practice: Addressing burnout, which is prevalent in OTO-HNS residents, is critical to improving patient care and physician well-being. Surgical specialties can share strategies to effectively address resident burnout through institutional interventions, which can be essential quality improvement initiatives, to promote well-being. Show less

Importance: The diagnosis and management of brow dysfunction in patients with postfacial paralysis with synkinesis can be perplexing and challenging for the treating physician. Objective: To describe a novel diagnostic and treatment algorithm for brow dysfunction in patients with postfacial paralysis with synkinesis. Design: Surgical pearls-description of novel surgical technique. Setting: A private practice. Participants: Patients who underwent the operation.

Between 2011 and 2021, the number of OHNS programs and positions expanded less than those of PS and General Surgery. The increase in the APP ratio was significantly greater for OHNS compared to those Dermatology, Orthopedic Surgery, General Surgery and all PGY1 residency positions for both US MD and all applicants (P < .01 for each). OHNS expansion of US MD (P = .046), but not all applicants (P = .169), outgrew that of Neurosurgery.

The 2020 to 2021 cycle affected by the COVID-19… Show more

Between 2011 and 2021, the number of OHNS programs and positions expanded less than those of PS and General Surgery. The increase in the APP ratio was significantly greater for OHNS compared to those Dermatology, Orthopedic Surgery, General Surgery and all PGY1 residency positions for both US MD and all applicants (P < .01 for each). OHNS expansion of US MD (P = .046), but not all applicants (P = .169), outgrew that of Neurosurgery.

The 2020 to 2021 cycle affected by the COVID-19 pandemic saw a continuation of the recent trend in the expanding OHNS applicant pool. OHNS remains one of the specialties with the highest APP ratio and has observed a significant growth compared to PS since 2018. Understanding and anticipating trends in residency application cycles is critical for designing processes to optimize the best fit between applicants and programs. Show less

Abstract

Objective: To examine functional outcomes following end-to-trunk masseteric to facial nerve transfer in patients with chronic flaccid facial paralysis.

Design: Retrospective chart review.

Setting: Tertiary-care private practice setting.

Participants: Patients with complete unilateral facial paralysis of less than 24 months duration.

Interventions: Direct end-to-trunk masseteric to facial nerve anastomosis.

Outcome measures: Outcome measures… Show more

Abstract

Objective: To examine functional outcomes following end-to-trunk masseteric to facial nerve transfer in patients with chronic flaccid facial paralysis.

Design: Retrospective chart review.

Setting: Tertiary-care private practice setting.

Participants: Patients with complete unilateral facial paralysis of less than 24 months duration.

Interventions: Direct end-to-trunk masseteric to facial nerve anastomosis.

Outcome measures: Outcome measures included time to first movement, development of synkinesis, and an objective assessment of the resting tone and dynamic movement that was achieved.

Results: Patient age at the time of transfer ranged from 6 to 61. Follow-up ranged from 12 to 24 months. No patients had any perioperative complications. No patient experienced significant mass movement or synkinetic facial movement with chewing. No patient had worsened chewing or swallowing. Patients have not yet recovered significant resting tone. All patients achieved smile activity when biting down with a median (interquartile range) oral commissure excursion of 7.57 mm (5.19-9.94 mm), starting 3 to 5 months after transfer.

Conclusions: End-to-trunk masseteric to facial nerve transfer is a safe and effective procedure. Patients had rapid reinnervation with good excursion and achieved a natural appearing smile. The rehabilitated smile appears better than that achieved with hypoglossal-facial nerve transfer. The procedure can be performed coincident with cross-facial nerve grafting, and in some cases may produce dynamic facial movement that obviates the need for free muscle transfer. Show less

In this article, my colleagues and I demonstrated how my recently described surgery commonly known as selective neurolysis can positively impact the quality of life for patients with facial paralysis with synkinesis

In this article, my coauthors and I review the currently available treatment options for Facial paralysis

In this article I describe a new classification for depressor labii inferioris and marginal mandibular facial nerve dysfunction and a surgical option to restore a natural appearing full dentition smile

I describe my approach to analyzing aging face using my innovative “subunits” and performing cutting edge facial rejuvenation and facelift procedures with this guidance

I discuss my viewpoint on how pandemics such as COVID can impact clinical practices of facial plastic surgeons

I discuss an innovative approach to managing facial paralysis and Bell’s palsy patients who develop synkinesis

I describe a simplified technique for harvesting nerves used in facial paralysis treatments

BACKGROUND: To address functional and smile dysfunction associated with post-facial paralysis synkinesis, the senior author (B.A.) has offered "modified selective neurectomy" of the lower division of the facial nerve as a long-term solution. This article examines technical considerations and outcomes of this procedure.

METHODS: A retrospective review was conducted of patients who underwent modified selective neurectomy of buccal and cervical branches of the facial nerve performed by a… Show more

BACKGROUND: To address functional and smile dysfunction associated with post-facial paralysis synkinesis, the senior author (B.A.) has offered "modified selective neurectomy" of the lower division of the facial nerve as a long-term solution. This article examines technical considerations and outcomes of this procedure.

METHODS: A retrospective review was conducted of patients who underwent modified selective neurectomy of buccal and cervical branches of the facial nerve performed by a single surgeon over a 4½-year period. House-Brackmann facial grading scores, electronic clinician-graded facial function scale, and onabotulinumtoxinA (botulinum toxin type A) dosages were examined before and after the procedure.

RESULTS: Sixty-three patients underwent modified selective neurectomy between June 20, 2013, and August 12, 2017. There were no serious complications. The revision rate was 17 percent. Temporary oral incompetence was reported in seven patients (11 percent) postoperatively. A statistically significant improvement was achieved in electronic clinician-graded facial function scale analysis of nasolabial fold depth at rest, oral commissure movement with smile, nasolabial fold orientation with smile, nasolabial depth with smile, depressor labii inferioris lower lip movement, midfacial synkinesis, mentalis synkinesis, platysmal synkinesis, static score, dynamic score, synkinesis score, periocular score, lower face and neck score, and midface and smile score. There was a significant decrease in botulinum toxin type A dosage and House-Brackmann score after surgery.

CONCLUSION: Modified selective neurectomy of the buccal and cervical divisions of the facial nerve is an effective long-term treatment for smile dysfunction in patients with post-facial paralysis synkinesis. Show less

I discuss my approach to managing patients with facial paralysis and synkinesis

I was lead editor on a book with the aim to have Comprehensive coverage, multidisciplinary guidance, and step-by-step instruction both in print and on video help surgeons choose the best approach and get the best results for any facial rejuvenation challenge. Master Techniques in Facial Rejuvenation presents multiple facial rejuvenation techniques by experts in the fields of plastic surgery, facial plastic surgery, otolaryngology, oculoplastic surgery and dermatology. Competing and… Show more

I was lead editor on a book with the aim to have Comprehensive coverage, multidisciplinary guidance, and step-by-step instruction both in print and on video help surgeons choose the best approach and get the best results for any facial rejuvenation challenge. Master Techniques in Facial Rejuvenation presents multiple facial rejuvenation techniques by experts in the fields of plastic surgery, facial plastic surgery, otolaryngology, oculoplastic surgery and dermatology. Competing and complementary techniques focus on all areas of the face, providing a balanced and systematic approach to this fast-growing field. Show less

I was part of panel of worldwide experts who were determining the validity of a new facial nerve grading scale for patients with facial paralysis

Importance Identifying a procedure to address lower eyelid retraction (LER) in the presence of an orbicularis deficit is a useful tool for aesthetic and reconstructive eyelid surgery.

Objective To describe and evaluate a surgical technique consisting of a closed canthal suspension and true lower eyelid retractor recession to address LER in the setting of orbicularis weakness.

Conclusions and Relevance Recent publications have demonstrated the utility of closed canthal… Show more

Importance Identifying a procedure to address lower eyelid retraction (LER) in the presence of an orbicularis deficit is a useful tool for aesthetic and reconstructive eyelid surgery.

Objective To describe and evaluate a surgical technique consisting of a closed canthal suspension and true lower eyelid retractor recession to address LER in the setting of orbicularis weakness.

Conclusions and Relevance Recent publications have demonstrated the utility of closed canthal suspension and true lower eyelid retractor recession as separate procedures. In the setting of LER with reduced orbicularis strength and/or tone, the techniques can be combined to recess the lower eyelid without disturbing the already compromised lower orbicularis muscle (minimally invasive, orbicularis-sparing, lower eyelid recession). The combination technique is safe and effective and yields excellent results. Show less

The Facial Nerve is a concise yet comprehensive guide to the pathology, diagnosis, and treatment of facial nerve disorders. Addressing important facial nerve problems such as congenital disorders and Bell's palsy, this text provides physicians with the most up-to-date medical and surgical treatment recommendations.

Master Techniques in Rhinoplasty is a concise yet comprehensive, multi-authored, multi-specialty surgical text and video atlas that provides all the guidance you need to get the best outcomes in rhinoplasty. Babak Azizzadeh, MD, FACS and other leading experts guide you through both open and endonasal primary and secondary rhinoplasty techniques with the use of step-by-step procedures, color line drawings, intraoperative photographs, and narrated videos on DVD.

The eyes are a central feature of facial appearance, expression and provide us the ability to see, our most important sensory function. For this reason, mastering the evaluation and execution of aesthetic rejuvenation of the eyelids and adjacent areas is critical to all surgeons who operate on these very delicate and interconnected structures. Master Techniques in Blepharoplasty and Periorbital Rejuvenation is a comprehensive, multi-specialty textbook on blepharoplasty and eyelid… Show more

The eyes are a central feature of facial appearance, expression and provide us the ability to see, our most important sensory function. For this reason, mastering the evaluation and execution of aesthetic rejuvenation of the eyelids and adjacent areas is critical to all surgeons who operate on these very delicate and interconnected structures. Master Techniques in Blepharoplasty and Periorbital Rejuvenation is a comprehensive, multi-specialty textbook on blepharoplasty and eyelid reconstruction. Show less

Master Techniques in Rhinoplasty is a concise yet comprehensive, multi-authored, multi-specialty surgical text and video atlas that provides all the guidance you need to get the best outcomes in rhinoplasty. Babak Azizzadeh, MD, FACS and other leading experts guide you through both open and endonasal primary and secondary rhinoplasty techniques with the use of step-by-step procedures, color line drawings, intraoperative photographs, and narrated videos on DVD.

This new resource helps you choose the best approach and get the best results for any facial rejuvenation challenge! Renowned facial plastic, plastic, and oculoplastic surgeons and dermatologists present multiple, competing and complementary, time-tested facial rejuvenation techniques. Each chapter is a step-by-step, illustrative depiction of the author's surgical techniques, with emphasis on minimally invasive surgery, recent trends, and adjunctive procedures. The book focuses on all areas of… Show more

This new resource helps you choose the best approach and get the best results for any facial rejuvenation challenge! Renowned facial plastic, plastic, and oculoplastic surgeons and dermatologists present multiple, competing and complementary, time-tested facial rejuvenation techniques. Each chapter is a step-by-step, illustrative depiction of the author's surgical techniques, with emphasis on minimally invasive surgery, recent trends, and adjunctive procedures. The book focuses on all areas of the face in order to produce a balanced and systematic approach for facial rejuvenation. An accompanying surgical atlas on 2 DVDs shows digitally videotaped procedures. Show less