Perceptions and Understanding of Transgender Patient Care: A Survey of Practicing Facial Plastic Surgeons.

Transgender individuals face significant health disparities including deficiencies in physician education, knowledge, and comfort with care. The objective of this study was to determine the perceptions, practice patterns, and familiarity of facial plastic surgeons with transgender health care. An anonymous questionnaire was sent to facial plastic surgeons within the American Academy of Facial Plastic and Reconstructive Surgery list-serve. Primary datapoints included participant characteristics, transgender-related experience, and educational goals. Of the 66 facial plastic surgeons surveyed, 49% had treated 1 to 10 transgender patients during their career, and 70% were actively treating at least 1 transgender patient. The number of patients treated and surgeries performed was significantly associated with self-perceived competence, comfort counseling on gender-affirming surgeries, discussing gender identity, asking preferred pronouns, and a desire to learn more about transgender care. Most participants (61%) obtained transgender care training through real-world experience, with only 18% receiving formal training in residency or fellowship. In total, 50% of respondents believe transgender care training among facial plastic surgeons is inadequate and 60% support its incorporation into residency/fellowship curricula. Increased awareness is needed to address the disparities experienced by transgender patients. Many facial plastic surgeons desire to learn more and support incorporating transgender care into training. Understanding the current state of transgender care can assist the facial plastic community in promoting education that strengthens physicians' ability to deliver competent care that addresses the inequities faced by this diverse group.

Hairline Restoration: Difference in Men and Woman-Length and Shape.

Hair restoration has become increasingly popular in recent years with both men and women. New technologies such as follicular unit extraction and grafting have made it possible for patients to get a natural looking result with minimal downtime. Men usually experience hairline recession as a result of androgenic alopecia, while women most commonly experience thinning of the crown and vertex, with the preservation of the hairline. However, there is a growing population of women who wish to advance their hairline forward because of congenital high hairline, traction alopecia, or previous facial cosmetic surgery. There are several key differences between the female and male hairline. Understanding such differences and following certain guidelines will help the facial plastic surgeon to obtain beautiful and natural appearing results.

Dorsal Augmentation with Homologous Rib.

Dorsal augmentation grafts are used to reconstruct and raise the nasal dorsum in patients with dorsal saddling due to trauma, infection, or previous nasal surgery, as well as in patients with a narrow, congenitally low, and/or wide dorsum. Alloplastic implants and various biomaterials are available for grafting, each with advantages and disadvantages. Although autologous septal cartilage is a preferable and often convenient source of cartilage, it is frequently not sufficient for large volume dorsal augmentation, nor is it available in patients who have had septoplasty, infection, previous rhinoplasty with grafting, or significant trauma. Ear cartilage may be used but it is difficult to make homogenous and smooth, and dorsal irregularities can be seen in the long term especially in thin-skinned patients. For these reasons, we frequently use irradiated costal cartilage from tissue banks as our grafting source, thereby eliminating the morbidity of harvesting the patient's own rib. Proper surgical techniques, the use of antibiotics, and proper sculpting and placement of the cartilage limits complications such as warping, resorption, infection, and extrusion. Irradiated homograft costal cartilage grafts have been used successfully in large numbers of patients with long-term follow-up with low complication rates and serve as a welcome alternative to harvesting a patient's rib cartilage.

Nonsurgical Rejuvenation of the Neck.

Nonsurgical skin tightening in the neck is an area of significant growth with seemingly countless devices. Optimal treatment choice depends on the patient's concerns, anatomy, and lifestyle. Patients with minimal skin laxity, but dynamic platysmal bands may benefit from botulinum toxin injections. Mild to moderately lax skin can be addressed with microfocused ultrasound or radiofrequency with microneedling. Significant sun damage and laxity can both be addressed with fractional ablative lasers. Options for submental preplatysmal fat include percutaneous radiofrequency, radiofrequency-helium plasma, deoxycholic acid injections, and cryolipolysis. Of these, percutaneous radiofrequency has the highest patient satisfaction and lowest complication rate.

Lip Lift.

The perioral area can be an important feature to convey femininity, particularly when speaking and smiling. A feminine lip has a shorter distance between the nasal sill and the vermillion border, fullness of the vermillion, and a few millimeters of tooth show with the mouth slightly open. The keys to a good outcome are incision design that respects the natural anatomy, placing the tension of the lift deep to the dermis to take tension off of the skin incision, determining the appropriate amount of lift for the patient's anatomy, and not violating the orbicularis oris.

Nonsurgical Rejuvenation of the Neck.

Nonsurgical skin tightening in the neck is an area of significant growth with seemingly countless devices. Optimal treatment choice depends on the patient's concerns, anatomy, and lifestyle. Patients with minimal skin laxity, but dynamic platysmal bands may benefit from botulinum toxin injections. Mild to moderately lax skin can be addressed with microfocused ultrasound or radiofrequency with microneedling. Significant sun damage and laxity can both be addressed with fractional ablative lasers. Options for submental preplatysmal fat include percutaneous radiofrequency, radiofrequency-helium plasma, deoxycholic acid injections, and cryolipolysis. Of these, percutaneous radiofrequency has the highest patient satisfaction and lowest complication rate.

Clinical Practice Guideline: Opioid Prescribing for Analgesia After Common Otolaryngology Operations.

OBJECTIVE: Opioid use disorder (OUD), which includes the morbidity of dependence and mortality of overdose, has reached epidemic proportions in the United States. Overprescription of opioids can lead to chronic use and misuse, and unused narcotics after surgery can lead to their diversion. Research supports that most patients do not take all the prescribed opioids after surgery and that surgeons are the second largest prescribers of opioids in the United States. The introduction of opioids in those with OUD often begins with prescription opioids. Reducing the number of extra opioids available after surgery through smaller prescriptions, safe storage, and disposal should reduce the risk of opioid use disorder in otolaryngology patients and their families. PURPOSE: The purpose of this specialty-specific guideline is to identify quality improvement opportunities in postoperative pain management of common otolaryngologic surgical procedures. These opportunities are communicated through clear actionable statements with explanation of the support in the literature, evaluation of the quality of the evidence, and recommendations on implementation. Employing these action statements should reduce the variation in care across the specialty and improve postoperative pain control while reducing risk of OUD. The target patients for the guideline are any patients treated for anticipated or reported pain within the first 30 days after undergoing common otolaryngologic procedures. The target audience of the guideline is otolaryngologists who perform surgery and clinicians who manage pain after surgical procedures. Outcomes to be considered include whether the patient has stopped using opioids, has disposed of unused opioids, and was satisfied with the pain management plan.The guideline addresses assessment of the patient for OUD risk factors, counseling on pain expectations, and identifying factors that can affect pain duration and/or severity. It also discusses the use of multimodal analgesia as first-line treatment and the responsible use of opioids. Last, safe disposal of unused opioids is discussed.This guideline is intended to focus on evidence-based quality improvement opportunities judged most important by the guideline development group. It is not a comprehensive guide on pain management in otolaryngologic procedures. The statements in this guideline are not intended to limit or restrict care provided by clinicians based on their experiences and assessments of individual patients. ACTION STATEMENTS: The guideline development group made strong recommendations for the following key action statements: (3A) prior to surgery, clinicians should identify risk factors for opioid use disorder when analgesia using opioids is anticipated; (6) clinicians should advocate for nonopioid medications as first-line management of pain after otolaryngologic surgery; (9) clinicians should recommend that patients (or their caregivers) store prescribed opioids securely and dispose of unused opioids through take-back programs or another accepted method.The guideline development group made recommendations for the following key action statements: (1) prior to surgery, clinicians should advise patients and others involved in the postoperative care about the expected duration and severity of pain; (2) prior to surgery, clinicians should gather information specific to the patient that modifies severity and/or duration of pain; (3B) in patients at risk for OUD, clinicians should evaluate the need to modify the analgesia plan; (4) clinicians should promote shared decision making by informing patients of the benefits and risks of postoperative pain treatments that include nonopioid analgesics, opioid analgesics, and nonpharmacologic interventions; (5) clinicians should develop a multimodal treatment plan for managing postoperative pain; (7) when treating postoperative pain with opioids, clinicians should limit therapy to the lowest effective dose and the shortest duration; (8A) clinicians should instruct patients and caregivers how to communicate if pain is not controlled or if medication side effects occur; (8B) clinicians should educate patients to stop opioids when pain is controlled with nonopioids and stop all analgesics when pain has resolved; (10) clinicians should inquire, within 30 days of surgery, whether the patient has stopped using opioids, has disposed of unused opioids, and was satisfied with the pain management plan.

Clinical Practice Guideline: Opioid Prescribing for Analgesia After Common Otolaryngology Operations Executive Summary.

OBJECTIVE: Opioid use disorder (OUD), which includes the morbidity of dependence and mortality of overdose, has reached epidemic proportions in the United States. Overprescription of opioids can lead to chronic use and misuse, and unused narcotics after surgery can lead to their diversion. Research supports that most patients do not take all the prescribed opioids after surgery and that surgeons are the second largest prescribers of opioids in the United States. The introduction of opioids in those with OUD often begins with prescription opioids. Reducing the number of extra opioids available after surgery through smaller prescriptions, safe storage, and disposal should reduce the risk of opioid use disorder in otolaryngology patients and their families. PURPOSE: The purpose of this specialty-specific guideline is to identify quality improvement opportunities in postoperative pain management of common otolaryngologic surgical procedures. These opportunities are communicated through clear actionable statements with explanation of the support in the literature, evaluation of the quality of the evidence, and recommendations on implementation. Employing these action statements should reduce the variation in care across the specialty and improve postoperative pain control while reducing risk of OUD. The target patients for the guideline are any patients treated for anticipated or reported pain within the first 30 days after undergoing common otolaryngologic procedures. The target audience of the guideline is otolaryngologists who perform surgery and clinicians who manage pain after surgical procedures. Outcomes to be considered include whether the patient has stopped using opioids, has disposed of unused opioids, and was satisfied with the pain management plan.The guideline addresses assessment of the patient for OUD risk factors, counseling on pain expectations, and identifying factors that can affect pain duration and/or severity. It also discusses the use of multimodal analgesia as first-line treatment and the responsible use of opioids. Last, safe disposal of unused opioids is discussed.This guideline is intended to focus on evidence-based quality improvement opportunities judged most important by the guideline development group. It is not a comprehensive guide on pain management in otolaryngologic procedures. The statements in this guideline are not intended to limit or restrict care provided by clinicians based on their experiences and assessments of individual patients. ACTION STATEMENTS: The guideline development group made strong recommendations for the following key action statements: (3A) prior to surgery, clinicians should identify risk factors for opioid use disorder when analgesia using opioids is anticipated; (6) clinicians should advocate for nonopioid medications as first-line management of pain after otolaryngologic surgery; (9) clinicians should recommend that patients (or their caregivers) store prescribed opioids securely and dispose of unused opioids through take-back programs or another accepted method.The guideline development group made recommendations for the following key action statements: (1) prior to surgery, clinicians should advise patients and others involved in the postoperative care about the expected duration and severity of pain; (2) prior to surgery, clinicians should gather information specific to the patient that modifies severity and/or duration of pain; (3B) in patients at risk for OUD, clinicians should evaluate the need to modify the analgesia plan; (4) clinicians should promote shared decision making by informing patients of the benefits and risks of postoperative pain treatments that include nonopioid analgesics, opioid analgesics, and nonpharmacologic interventions; (5) clinicians should develop a multimodal treatment plan for managing postoperative pain; (7) when treating postoperative pain with opioids, clinicians should limit therapy to the lowest effective dose and the shortest duration; (8A) clinicians should instruct patients and caregivers how to communicate if pain is not controlled or if medication side effects occur; (8B) clinicians should educate patients to stop opioids when pain is controlled with nonopioids and stop all analgesics when pain has resolved; (10) clinicians should inquire, within 30 days of surgery, whether the patient has stopped using opioids, has disposed of unused opioids, and was satisfied with the pain management plan.

Chondrolaryngoplasty-Thyroid Cartilage Reduction.

Chondrolaryngoplasty, also known as tracheal shave, is a surgical procedure performed for a prominent Adam's apple, usually in transfeminine patients with gender dysphoria to this marker of male sex. Although laryngeal anatomy is complex, knowledge of landmarks and techniques discussed in this article results in a safe procedure with rare complications and improvement in quality of life.

Opioid Use by Patients After Rhinoplasty.

IMPORTANCE: Given the increase in opioid addiction and overdose in the United States, reasoned opioid use after outpatient surgery may affect prescription medication abuse. OBJECTIVES: To examine patient use of opioids after rhinoplasty and establish an optimal postrhinoplasty pain management regimen. DESIGN, SETTING, AND PARTICIPANTS: In this case series, opioid use was evaluated in 62 patients who underwent rhinoplasty performed by 3 fellowship-trained facial plastic surgeons, 2 in private practice in Texas and 1 in an academic setting in Michigan, from February 2016 to September 2016. MAIN OUTCOMES AND MEASURES: Opioid use, pain control, and adverse effects were examined and opioid use was compared across patient demographic and surgical procedure characteristics, including rhinoplasty and septoplasty, open vs closed techniques, revision vs primary operations, reduction of turbinates, and use of osteotomies. Opioid use was self-reported as the number of prescribed tablets containing a combination of hydrocodone bitartrate (5 mg) and acetaminophen (325 mg) that were consumed. RESULTS: The mean (SEM) age of the patients was 38.7 (16.4) years and included 50 female patients (81%). Of the initially prescribed 20 to 30 hydrocodone-acetaminophen combination tablets, the 62 patients included in this study used a mean (SEM) of 8.7 (0.9) tablets, only 40% of those prescribed after rhinoplasty. In addition, 46 patients (74%) consumed 15 or fewer tablets, whereas only 3 patients (5%) required refills of pain medication. Sex, age, concurrent septoplasty or turbinate reduction, use of osteotomy, and history of a rhinoplasty were not associated with the number of tablets used. The most common adverse effects included drowsiness in 22 patients (35%), nausea in 7 (11%), light-headedness in 3 (5%), and constipation in 3 (5%). CONCLUSIONS AND RELEVANCE: To mitigate the misuse or diversion of physician-prescribed opioid medications, surgeons must be steadfast in prescribing an appropriate amount of pain medication after surgery. A multifaceted pain control program is proposed to manage postoperative pain and ascertain the balance between controlling pain and avoiding overprescribing narcotics. LEVEL OF EVIDENCE: NA.

The Otolaryngologist's Role in Providing Gender-Affirming Care: An Opportunity for Improved Education and Training.

Currently, there are limited resources and training available for otolaryngologists and otolaryngology practice personnel to provide gender-affirming care for transgender or gender nonconforming patients. This unique patient population may present to our offices for gender-specific care or with complaints of the ear, nose, and throat unrelated to gender identity. Our current practice has unintentional but direct consequences on our patients care, as transgender patients often report negative experiences in the healthcare setting related to their gender identity. The absence of resources and training is also seen in other specialties. Physicians who create an environment where patients of all gender identities feel welcome can better meet their patients' health care needs. In addition, otolaryngologists can play a role in easing the gender dysphoria experienced by transgender patients. We suggest educational content should be created for and made available to otolaryngologists and office staff to provide gender-affirming care.

Functional expression and microdomain localization of prestin in cultured cells.

INTRODUCTION: Prestin is an essential component of the molecular motor of cochlear outer hair cells that contribute to frequency selectivity and sensitivity of mammalian hearing. A model system to study prestin employs its transfection into cultured HEK 293 cells. Our goal was to characterize prestin's trafficking pathway and localization in the plasma membrane. METHODS: We used immuno-colocalization of prestin with intracellular and plasma membrane markers and sucrose density fractionation to analyze prestin in membrane compartments. Voltage clamping was used to measure nonlinear capacitance (NLC), prestin's electrical signature. RESULTS & DISCUSSION: Prestin targets to the membrane by 24 hours post-transfection when NLC is measurable. Prestin then concentrates into membrane foci that colocalize and fractionate with membrane microdomains. Depleting membrane cholesterol content altered prestin localization and NLC. CONCLUSION: Prestin activity in HEK 293 cells results from expression in the plasma membrane and altering membrane lipid content affects prestin localization and activity.

Tuning of the outer hair cell motor by membrane cholesterol.

Cholesterol affects diverse biological processes, in many cases by modulating the function of integral membrane proteins. We observed that alterations of cochlear cholesterol modulate hearing in mice. Mammalian hearing is powered by outer hair cell (OHC) electromotility, a membrane-based motor mechanism that resides in the OHC lateral wall. We show that membrane cholesterol decreases during maturation of OHCs. To study the effects of cholesterol on hearing at the molecular level, we altered cholesterol levels in the OHC wall, which contains the membrane protein prestin. We show a dynamic and reversible relationship between membrane cholesterol levels and voltage dependence of prestin-associated charge movement in both OHCs and prestin-transfected HEK 293 cells. Cholesterol levels also modulate the distribution of prestin within plasma membrane microdomains and affect prestin self-association in HEK 293 cells. These findings indicate that alterations in membrane cholesterol affect prestin function and functionally tune the outer hair cell.