Nasal Analysis of Classic Animated Movie Villains versus Hero Counterparts.

Opposing facial features between animated villains and heroes have historically been used to demonstrate contrasting morality between characters, and this could have an impact on how humans view someone as good or evil in everyday life. Studies have been done investigating classic dermatologic features of villainous characters. This principle can be applied to nasal features as well. A search for "top animated characters" was performed. Characters were chosen from American Film Institute's "The Top Tens," Rolling Stone's "25 Best Pixar Movie Characters," and Screenrant's "The 30 Best Animated Movie Characters of All Time." Twenty villains and twenty hero counterparts from respective films were chosen. Classic nasal features were analyzed. Twenty villains (14 male, 6 female) and 20 heroes (12 male, 8 female) were analyzed. Sixteen villains (80%) had greater than normal nasal frontal angle versus 18 heroes (90%). Thirteen villains (65%) had an acute nasolabial angle versus two heroes (10%). Two villains (10%) had excess columellar show versus seven heroes (35%). Seven villains (35%) and one hero (5%) had a dorsal hump. Twelve villains (60%) had an overprojected chin versus three heroes (15%). Villains in pre-2000s films more frequently had a dorsal hump, overprojected chin, ptotic tip, pollybeak deformity, and bulbous tip. Heroes in pre-2000s films more frequently had an overrotated tip. Villains and heroes commonly have a greater than normal nasofrontal angle. Villains more commonly have an acute nasolabial angle, underrotated tip, overprojected chin, dorsal hump, and pollybeak deformity. Heroes more commonly have a large nasolabial angle and overrotated tip. Further research in conjunction with psychologists is required to obtain concrete data on how this affects whether an individual in real life is seen as good or evil, and the impact this has on interactions in society, including in the medical field.

Rattled: Analysis of Facial Trauma Among Toddlers.

OBJECTIVE: The aim of this study was to determine the national incidence of facial trauma among toddlers and delineate patterns of injury and their causes. METHODS: A retrospective review was designed to explore patterns of maxillofacial trauma within toddler-aged children using the National Electronic Injury Surveillance System from the Consumer Product Safety Commission. The database was searched for emergency department visits involving facial trauma sustained by children 12 months through 3 years of age from 2010 through 2014 and analyzed for patient demographics, primary diagnosis, and associated products/activities. Subset analyses were performed between age groups to determine the relationship between causes of injury and age using extrapolated national incidences. RESULTS: A sample of 45,249 patients extrapolated to an estimated 1.3 million emergency department visits for facial trauma in toddlers from 2010 to 2014, averaging 260,000 annually. Injuries involving foreign bodies and fractures had a higher incidence in toddlers 2 years or older, and fractures comprised fewer than 1% of facial injuries in any age group. Furniture was the most common source of trauma overall, with a higher frequency among toddlers aged 12 to 17 months. Trauma in the setting of sports was more common in toddlers aged 3 years. CONCLUSIONS: The low incidence of facial fractures further supports recommendations against routine imaging in toddler facial trauma and suggests that more focus should be placed on investigating for concurrent traumas and soft tissue injuries where fractures are involved. Our findings highlight prevention opportunities, particularly in furniture-related injuries for toddlers aged 12 to 17 months and sports-related traumas in toddlers aged 3 years. Our study also suggests restricting certain toys from 3-year-old toddlers to decrease the risk of aspiration.

Public Perception of Facial Fillers.

There has been widespread coverage of cosmetic procedures, particularly facial fillers, as minimally invasive options for facial rejuvenation. The authors' objective was to characterize news media's coverage of facial fillers and its role in shaping public perception of these products over the past decade. Public view plays a significant role in policymaking, assisting patient communication, and addressing preconceived notions. Google News was searched for online news coverage related to "facial fillers" from 2008 to 2017. News articles from various sources were reviewed and analyzed with multiple objectives including complications listed, advantages, disadvantages, physician specialties, overall theme of the articles as positive, negative, or neutral and other parametrics. A chi-square test was used for statistical analysis. Of 426 articles meeting inclusion criteria, international news (20.4%), tabloids (18.8%), online health sites (18.3%), and national news (16.9%) were represented. Of articles containing adequate information, coverage was 44.7% positive, 29.9% neutral, and 26.1% negative with no significant change from 2008 to 2017. In addition, 46.0% of papers discussed complications including vascular injury and blindness associated with fillers, with significant increase by 2017 (p < 0.05). Facial fillers media coverage was overall positive, with broad coverage at both national and international levels. Complications were discussed often, and although vascular injury and vision damage are rare complications of fillers, they were frequently cited, potentially leading the public to believe they occur frequently. There were also significant concerns in the news media about greater regulation of products used as facial fillers, and practitioners administrating them. Altogether, these findings provide a comprehensive overview of patient perception and expectations of an increasingly popular and expanding cosmetic procedure.

Economic Analysis of Using Free Fat Graft or Acellular Dermis to Prevent Post-parotidectomy Frey Syndrome.

A decision tree was constructed to determine the incremental cost-effectiveness ratio (ICER) of grafting techniques used to prevent Frey Syndrome. The authors performed a sensitivity analysis to calculate what the probability of preventing Frey Syndrome would have to be and maximum costs associated with using grafting techniques to warrant their use as more "cost-effective" choice than using neither. Decision pathways utilized were uses of (1) free fat graft (FFG), (2) acellular dermis, and (3) no grafting. The probability of developing Frey syndrome and costs were extracted from previous studies to construct the decision tree. The primary effectiveness was the ICER of FFG or acellular dermis to prevent Frey syndrome. The initial outcomes included preventing Frey syndrome (effectiveness = 1) or developing Frey syndrome (effectiveness = 0). Compared with not using a graft, the ICER of using FFG and acellular dermis were $10,628 and $50,813, respectively. Frey syndrome was found in 2.6% of patients postoperatively in FFG group, 9.8% of patients in acellular dermis group, and 30.7% of patients who did not have a graft. The ICER shows absolute dominance of FFG with lower cost and high effectiveness over acellular dermis. This economic evaluation strongly supports the use of FFG over acellular dermis as cost-effective approach for prevention of postparotidectomy Frey syndrome.

Impact of Postreconstitution Room Temperature Storage on the Efficacy of IncobotulinumtoxinA Treatment of Dynamic Lateral Canthus Lines.

BACKGROUND: The efficacy of botulinum neurotoxin type A after prolonged storage at room temperature is currently unknown. This randomized, double-blinded, split-face study investigated the impact of postreconstitution 25°C storage for 1 week on the clinical efficacy of incobotulinumtoxinA in the treatment of lateral canthus lines. PATIENTS AND METHODS: Twenty-one participants with at least mild to moderate crow's feet at maximum contraction on the Crow's Feet Grading Scale (CFGS) underwent injection to each lateral canthus area with 10 U of freshly reconstituted and room temperature-stored product and followed for 4 months. Responders were defined as those demonstrating at least a 1-point improvement on their CFGS score. RESULTS: At each visit (2 weeks and 1, 2, 3, and 4 months), there was no statistical difference in the rate of responders between the fresh and the stored products. In addition, the percentage of responders displaying a 2-point versus a 1-point improvement and response longevity did not statistically differ between both products for the entire 4-month study duration. CONCLUSION: Prolonged storage of incobotulinumtoxinA at room temperature does not appear to significantly alter its efficacy or longevity in the treatment of dynamic lateral canthus lines.

Craniofacial Surgery and Adverse Outcomes: An Inquiry Into Medical Negligence.

OBJECTIVE: This study aimed to evaluate factors contributing to medical negligence relevant to craniofacial surgery. METHODS: Retrospective analysis of verdict and settlement reports on the Westlaw legal database for outcome, awards, physician defendants, and other specific factors raised in malpractice litigation. RESULTS: Of 42 verdicts and settlement reports included, 52.4% were resolved with either an out-of-court settlement or plaintiff verdict, with aggregate payments totaling $50.1M (in 2013 dollars). Median settlements and jury-awarded damages were $988,000 and $555,000, respectively. Payments in pediatric cases ($1.2M) were significantly higher. Plastic surgeons, oral surgeons, and otolaryngologists were the most commonly named defendants. The most common alleged factors included intraoperative negligence (69.0%), permanent deficits (54.8%), requiring additional surgery (52.4%), missed/delayed diagnosis of a complication (42.9%), disfigurement/scarring (28.6%), postoperative negligence (28.6%), and inadequate informed consent (20.6% of surgical cases). Failure to diagnose a fracture (19.0%) and cleft-reparative procedures (14.3%) were the most frequently litigated entities. CONCLUSION: Medical negligence related to craniofacial surgery involves plaintiffs in a wide age range as well as physician defendants in numerous specialties, and proceedings resolved with settlement and plaintiff verdict involve substantial payments. Cases with death, allegedly permanent injuries, and pediatric plaintiffs had significantly higher payments.

Voicing an impact: who does the National Institutes of Health support for voice disorder research?

PURPOSE: Interest in a variety of neoplastic, functional, neurological, and age-related laryngeal disorders has contributed to the development of laryngology as an established subspecialty. Funding support plays a critical role in facilitating scholarship within the field. Our objectives were to evaluate who is receiving funding from the NIH for topics relevant to voice disorders, and further describe temporal trends in grants awarded. METHODS: The NIH RePORTER database was searched for grants relevant to voice disorders. Data were further organized by PI specialty, academic department, and funding totals. Furthermore, PI scholarly impact, as measured by the h-index, was calculated. RESULTS: A total of 830 funded fiscal years (for 232 unique projects) totaling $203 million have supported projects examining voice disorders. A plurality of projects (32.8%) was awarded to PIs in otolaryngology departments, followed by 17.2% to speech pathology/communication sciences departments. Although year-to-year variation was noted, otolaryngology departments received approximately 15% of funding annually. Funded otolaryngologists had similar scholarly impact values to individuals in other specialties. CONCLUSIONS: The study of voice disorders involves an interdisciplinary approach, as PIs in numerous specialties receive NIH funding support. As they receive a considerable proportion of this funding and had similar h-indices compared to other specialties involved, otolaryngologists have just as much scholarly impact despite being a smaller specialty. As speech and language pathologists also comprised a significant proportion of individuals in this analysis, enhanced cooperation and encouragement of interdisciplinary scholarly initiatives may be beneficial.

Unattractive consequences: litigation from facial dermabrasion and chemical peels.

BACKGROUND: Facial dermabrasion and chemical peel are common cosmetic procedures that are generally safe yet do possess inherent risks. The patient's expectations, formed well in advance of treatment, strongly correlate with overall satisfaction. OBJECTIVES: The authors reviewed and analyzed litigation related to the performance of facial dermabrasion and chemical peel. METHODS: The authors searched the WestlawNext legal database for relevant litigation and examined factors such as allegations raised, patient demographics, defendant specialties, final outcomes, and payments. RESULTS: Proceedings from 25 cases were analyzed, involving 22 female and 2 male plaintiffs; in 1 case, sex was not specified. Sixteen cases (64%) resulted in a decision for the defendant and 9 (36%) were resolved with payments. The median difference between out-of-court settlements (median, $940 000) and jury-awarded damages (median, $535 000) was not statistically significant. Factors raised in litigation included poor cosmetic outcome (80%), alleged intratreatment negligence (68%), permanent injury (64%), informed-consent deficits (60%), emotional/psychological injury (44%), posttreatment negligence (32%), and the need for additional treatment/surgery (32%). CONCLUSIONS: Out-of-court settlements and jury-awarded damages were considerable in cases where physicians practicing various (or multiple) specialties were named as defendants. These findings emphasize the need for physicians to thoroughly document potential complications prior to treatment, during the informed-consent process. Additionally, general considerations should be taken into account, such as patient expectations and the potential need for other procedures, which may enhance pretreatment communication and ultimately minimize liability. Finally, it is important to stress that physicians may be held liable for procedures performed by nonphysician ancillary staff.

Patterns of Filler-Induced Facial Skin Ischemia: A Systematic Review of 243 Cases and Introduction of the FOEM Scoring System and Grading Scale.

BACKGROUND: The incidence of facial skin necrosis has increased considerably because of the growth in the popularity of dermal fillers. This study describes the patterns and severity of facial skin ischemia, along with associated neuro-ophthalmologic injuries, in the published literature through the introduction of the facial artery, ophthalmic artery, distal external carotid artery, internal maxillary artery (FOEM) facial angiosome scoring system and grading scale. METHODS: A systematic review of all photographic cases of facial skin ischemia attributable to vascular occlusion with dermal fillers and injectable materials was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. RESULTS: A total of 243 cases were identified, with 738 digital clinical photographs retrieved. The facial artery (58% of cases) and ophthalmic artery (48% of cases) angiosomes were most commonly affected. The frontonasal and angulonasal territories were the most common facial skin segments injured by filler-induced vascular occlusion. Cutaneous involvement of the ophthalmic angiosome was significantly associated with neuro-ophthalmologic complications [vision loss, 39% versus 0.8% ( P = 0.00001); stroke, 8% versus 0.8% ( P = 0.0085)]. Injuries with greater cutaneous surface area or cross-angiosome involvement were associated with a higher incidence of severe visual deficits and bilateral stroke. CONCLUSIONS: Facial skin necrosis attributable to vascular occlusion is a rapidly growing problem that has remained poorly characterized in the literature. This study provides the largest descriptive analysis of published photographic reports of skin ischemia to date and proposes a novel scoring system and grading classification to aid in future reporting.

Orbital post-septal hyaluronic acid: An iatrogenic etiology compounding lower eyelid steatoblepharon.

The stark rise in the incidence of dermal filler-related adverse sequelae has given rise to a variety of cosmetic distortions related to improper filler placement that include dynamic and static contour deformities of the face. In this article, we describe two instances of post-septal hyaluronic acid filler aggravating existing steatoblepharon and outline potential causative mechanisms responsible for this condition.

RealSelf Social Media Analysis of Rhinoplasty Patient Reviews.

BACKGROUND: Social media has become increasingly important for patients when deciding whether they should undergo rhinoplasty. The purpose of this study is to analyze patient satisfaction of rhinoplasty procedures through RealSelf social media reviews. METHODS: We collected data from 583 rhinoplasty reviews published on the RealSelf portal. In posts dated between 2016 and 2020, we included those which were labeled as "Worth It" and "Not Worth It." Posts that were labeled as "Unsure" or were left unlabeled were excluded from the study. In addition, posts not including the cost of their rhinoplasty were excluded. Taking into account patient demographics and cost of the procedure, we analyzed reasons for choosing to undergo surgery, reasons for choosing surgeons, and reasons for liking or disliking their procedure. RESULTS: Of the 583 reviews analyzed, most (45.4%) were categorized from the 18-24 years age group and there was an overall 93.8% satisfaction rate. While there was no statistically significant difference in the cost of rhinoplasty surgeries between "Worth It" and "Not Worth It" groups, the average cost of recorded rhinoplasties was US$ 8043 with a standard deviation ± $3296. According to our analysis, younger patients aged 18-24 years relied more on social media to choose their surgeons and desired a more natural appearance to their nose while older ones preferred compatible physician personalities and increased self-esteem for rhinoplasty. CONCLUSION: This study offers a unique perspective into the distinguishing characteristics of different age groups and the values they place in pursuing rhinoplasty, choosing their surgeons, and why they like/dislike their surgical outcomes.

Acute Pain Management Following Facial Plastic Surgery.

Facial plastic surgery, including septorhinoplasty, aging face procedures, otoplasty, and oculoplastic procedures, has varying levels of evidence for the management of acute pain after surgery. This article discusses the available evidence in these procedures and discusses the authors' recommendations for the treatment of postoperative pain, with a focus on decreasing the reliance on opioid pain medication.

Fellow Selection Protocols in Facial Plastic Surgery: A National Survey of Facial Plastic Surgery Program Directors.

Background: Despite its popularity among otolaryngology residents, there is currently a paucity of knowledge on the match in facial plastics surgery fellowships and the selection criteria that drive the match process. To increase the understanding of this process and to improve the manner in which candidates are vetted, a survey study was designed. Methods: A 24-question online survey was designed to discern desired qualities regarding fellow selection, interview processes, fellow participation, and program director satisfaction with the current process. This survey was sent to all American Academy of Facial Plastic and Reconstructive Surgery fellowship program directors in the United States. Results: Overall, 40 of the 64 fellowship directors responded to the survey for a total response rate of 62.5%. Most fellowship directors reported that the reputation of an applicant's residency was an important component of the selection criteria with 34 of 40 of those who responded rating it at least "somewhat important." With regard to the otolaryngology trainee examination, nearly all fellowship directors (39/40) reported that there was no minimum cutoff score to be offered an interview. When fellowship directors were asked to rank the academic components of an application that they viewed as most important, they most commonly reported that the strength of an applicant's letters of recommendation were most important. Conclusions: With the increasing popularity of fellowships within the field of otolaryngology, having an understanding of which components of the application process are viewed as most important by fellowship directors is crucial in applicants matching into the fellowship of their choice.

Functional and Aesthetic Outcomes of Extracorporeal Septoplasty: A Systematic Review and Meta-Analyses.

OBJECTIVE: The safety and efficacy of extracorporeal septoplasty (ECS) has long been debated. Our objective was to determine this technique's functional and aesthetic outcomes and complications through a systematic review of the literature. DATA SOURCES: PubMed/MEDLINE, Embase, Cochrane Library, and Web of Science databases were evaluated for studies detailing functional or aesthetic outcomes of ECS. REVIEW METHODS: Bias was evaluated using the Cochrane Risk of Bias Tool and the Methodological Index for Non-randomized Studies (MINORS) score. Aesthetic and functional outcomes in addition to complications were evaluated using subjective and objective measures. Meta-analyses were performed when appropriate. RESULTS: Seventeen studies encompassing 1418 patients were included. The average MINORS score for observational studies was 9.2. Overall there was a significant improvement in subjective nasal function with a preoperative average Nasal Obstruction Symptom Evaluation (NOSE) score of 75 (±16) decreasing to 19.5 (±16.5) postoperatively for a mean difference (MD) of -55 (95% confidence interval (CI): -60 to -49.5). In terms of objective nasal function, at 6 months postoperatively, there was an improvement of nasal flow measured by rhinometry ranging from 70 to 71% across studies. Anthropometric measurements were utilized for objective aesthetic outcomes. There was a significant improvement in I-shaped deviations (MD: -2.7°, 95% CI: -5.6 to -0.16) and C-shaped deviations improved by 11.9° (95% CI +2.8-+21.2). Complication rates ranged from 0 to 18%. CONCLUSION: ECS can achieve significant improvements in the subjective and objective function of the nose. The associated complication rate is low but variable between surgeons.

Biofilm density in the pediatric nasopharynx: recurrent acute otitis media versus obstructive sleep apnea.

OBJECTIVES: We compared the biofilm surface density of adenoids removed from children with recurrent acute otitis media (RAOM) to that of adenoids removed from children with a diagnosis of obstructive sleep apnea (OSA). METHODS: We performed a comparative microanatomic study of adenoid mucosa using scanning electron microscopy in patients with diagnoses of RAOM and OSA (27 female and 41 male; age range, 3 months to 15 years). RESULTS: The adenoids removed from patients with RAOM had dense, mature biofilms covering nearly their entire mucosal surfaces. More specifically, the adenoids removed from patients with RAOM had an average of 93.53% of their mucosal surface covered, versus an average of 1.01% coverage on the adenoids removed from patients with OSA. These differences were statistically significant (p < 0.0001). CONCLUSIONS: The adenoids removed from patients with RAOM had almost their entire mucosal surface covered with biofilms, versus scant coverage for patients with OSA. Recurrent acute otitis media is notoriously resistant to antibiotic treatment, and aspirates of middle ear fluid repeatedly yield negative cultures. It is these properties that have led biofilms to become increasingly implicated in the pathogenesis of RAOM. Thus, the resistance of biofilms to antimicrobials, together with their planktonic shedding of organisms, may be an important mechanism in the development of RAOM.

Management of the overprojected nose and ptotic nasal tip.

Ensuring consistent and reproducible results during cosmetic tip rhinoplasty can be extremely difficult. The unpredictable forces of wound contracture and scarring have humbled even the most experienced rhinoplasty surgeons in various cases throughout their careers. Armed with a knowledge of tip dynamics, however, one can combat the various nasal tip deformities with reasonable accuracy. In this article, we present techniques that are specifically used to correct tip overprojection and tip ptosis. The medial crural tuck-up is a procedure that can be used to deproject the nose while maintaining an overall harmonious tip aesthetic. The lower to upper lateral cartilage suspension has been used in our practice to specifically modify the droopy nasal tip. Both procedures have produced excellent long-term results.

Negative Pressure Wound Therapy in the Head and Neck: An Evidence-Based Approach.

OBJECTIVE: To perform an evidence-based review with recommendations that evaluates the indications and utility of negative pressure wound therapy (NPWT) in the head and neck. METHODS: The authors searched the PubMed, Medline, Embase, Web of Science, and Cochrane Library databases for relevant literature. The primary outcome was successful intended use of NPWT, be it for granulation tissue formation, infection control, or complete wound closure. Patient demographics, etiology, and other clinical characteristics were explored. Meta-analysis of observational studies was used to examine response rates and wound sizes. RESULTS: Fifty-seven articles encompassing 522 patients were included. The most common etiologies reported included: neoplasm (343 patients [65.7%]), oro-/pharyngocutaneous fistula (9.8%), infection (10.5%), and trauma (9.6%). The majority of wounds treated were in the neck (61.6%). Potential risk factors that may compromise wound healing were noted in 217 of 522 patients (41.6%). Of these 217 patients, 135 had properly documented risk factors, with the most common being prior irradiation (63%). The overall mean response across studies was 85.7% (95% confidence interval: 0.806-0.896, P < 0.001, I2 = 0 %). CONCLUSION: Negative pressure wound therapy is useful for the management of head and neck wounds and should be considered for patients in whom wound healing is progressing insufficiently, including those with a history of head and neck cancer, oro-/pharyngocutaenous fistula, and trauma. Randomized controlled trials further comparing NPWT versus other modalities may be invaluable in further delineating its appropriate role. Laryngoscope, 129:671-683, 2019.

Perioperative Analgesia for Patients Undergoing Septoplasty and Rhinoplasty: An Evidence-Based Review.

OBJECTIVES/HYPOTHESIS: Opioid misuse and diversion is a pressing topic in today's healthcare environment. The objective of this study was to conduct a review of non-opioid perioperative analgesic regimens following septoplasty, rhinoplasty, and septorhinoplasty. STUDY DESIGN: Evidence-based systematic review. METHODS: PubMed, MEDLINE, Cochrane Library, and Embase databases were reviewed for articles related to perioperative analgesic use in septoplasty, rhinoplasty, and septorhinoplasty. Quality of studies were assessed via the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) criteria, Jadad scores, and the Cochrane bias tool. Patient demographic data and clinical outcomes, including medication type, dose, administration time, pain scores, and adverse events, were obtained from included studies. Summary tables detailing the benefits and harms of each investigated regimen are included. RESULTS: Thirty-seven studies met inclusion criteria for this evidence-based review. The quality of the studies was determined to be of moderate quality based off of GRADE standardized criteria with a mean Jadad score of 3.1. A preponderance of evidence showed reduced perioperative pain scores and rescue analgesic requirements, supporting the use of local anesthetics for analgesic control. Nonsteroidal anti-inflammatory drugs (NSAIDs) demonstrated similar decreased visual analog scores and postoperative analgesic demand; however, increased adverse events in this class warrant caution. CONCLUSIONS: Contemporary literature supports the use of NSAIDs, gabapentin, local anesthetics, and α-agonists as effective perioperative analgesic opioid alternatives for septoplasty and septorhinoplasty. Local anesthetic use is a cost-effective option resulting in decreased postoperative pain scores and rescue analgesic requirements. Further large-scale, multi-institutional, controlled studies are needed to provide definitive recommendations. LEVEL OF EVIDENCE: NA Laryngoscope, 129:E200-E212, 2019.