Long-Term Control of Nasal Tip Position: Quantitative Assessment of Caudal Septal Extension Graft.

BACKGROUND: Control of nasal tip position is critical to final rhinoplasty outcomes. Two frequent methods of exerting tip control are columellar strut and caudal septal extension graft (SEG). Past work has demonstrated that SEG are better able to preserve tip position. However, there is no quantitative data describing long-term projection and rotation. The purpose of this study was to analyze long-term maintenance of tip projection and rotation following SEG. METHODS: A retrospective study of adult patients undergoing open rhinoplasty was conducted. Three-dimensional photogrammetric evaluation of nasal tip position was performed. Anthropometric points were analyzed preoperatively and postoperatively. Outcome variables were tip projection, tip rotation, and nasal length. RESULTS: Twenty patients were included with an average follow-up time of 3.3 years (2.0 - 6.6 years). From postoperative week 1 to 6, there was a statistically significant decrease in rotation (-4.3%, p<0.01). There were no statistically significant decreases in projection, rotation, or nasal length from 6 weeks postoperative to 2 years postoperative, or from 6 weeks postoperative to final follow-up (2.0 - 6.6 years). CONCLUSIONS: Nasal tip projection and rotation appear to decrease from the immediate postoperative position, likely due to resolving edema. In this study, patients that underwent open rhinoplasty with SEG experienced modest loss of projection and rotation until 6 weeks postoperative, but projection and rotation were maintained from 6 weeks postoperative to 2 years and beyond. This study provides evidence that SEG maintains long-term changes in tip projection and rotation. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Wide Awake Trigger Finger Releases Performed in the United States: Trends in Volume, Operative Setting, and Reimbursement.

BACKGROUND: Trigger finger release (TFR) has traditionally been performed in outpatient operating rooms. More recently, TFR may be performed in the office setting to achieve greater efficiency and cost savings. METHODS: The 2010-2020 Q2 PearlDiver M91Ortho data set was analyzed for cases of TFR. Exclusion criteria were age less than 18 years, <30 days of postoperative records, concomitant hand surgery, monitored anesthesia use, and inpatient surgery. Age, sex, and Elixhauser comorbidity index were recorded. Operating room and office procedures were matched 4:1 based on patient characteristics. Total and physician reimbursement for the day of surgery, as well as 30-day narcotics prescriptions, emergency department (ED) visits, and surgical site infections (SSI) were determined. RESULTS: Before matching, TFRs were found to be increasingly performed in the office (from 7.9% in 2010 to 14.6% in 2020). Matched cohorts consisted of 63,951 operating room and 15,992 office procedures. Office procedures had lower mean total reimbursements ($435 vs $752, P < 0.001), slightly lower mean physician reimbursements ($420 vs $460, P < 0.001), and lower rates of narcotic prescriptions (30.5% vs 50.5%, P < 0.001) and 30-day ED visits (2.2% vs 2.9%, P < 0.05). There was no difference in 30-day SSI (0.5% vs 0.6%, P = 0.374). CONCLUSIONS: In-office TFR is becoming increasingly prevalent. After matching, in-office TFRs were associated with lesser costs to the system, lower narcotic prescriptions, and fewer postoperative ED visits, without increased SSI. Although it is important to perform procedures in the best location for the patient, physician, and system, the current study supports the increased value offered by in-office TFR.

How Does Reduction Mammaplasty Surgical Technique Impact Clinical, Aesthetic, and Patient-Reported Outcomes?: A Comparison of the Superomedial and Inferior Pedicle Techniques.

BACKGROUND: A comprehensive comparison of surgical, aesthetic, and quality of life outcomes by reduction mammaplasty technique does not exist. We sought to ascertain the effect of technique on clinical, aesthetic, and patient-reported outcomes. METHODS: Patients with symptomatic macromastia undergoing a superomedial or inferior pedicle reduction mammoplasty by a single surgeon were identified. BREAST-Q surveys were administered. Postoperative breast aesthetics were assessed in 50 matched-patients. Patient characteristics, complications, quality of life, and aesthetic scores were analyzed. RESULTS: Overall, 101 patients underwent reductions; 60.3% had a superomedial pedicle. Superomedial pedicle patients were more likely to have grade 3 ptosis (P < 0.01) and had significantly shorter procedure time (P < 0.01). Only the inferior pedicle technique resulted in wound dehiscence (P = 0.03) and reoperations from complications (P < 0.01). Those who underwent an inferior pedicle reduction were 4.3 times more likely to experience a postoperative complication (P = 0.03). No differences in quality of life existed between cohorts (P > 0.05). Superomedial pedicle patients received significantly better scarring scores (P = 0.03). CONCLUSIONS: The superomedial pedicle reduction mammoplasty technique provides clinical and aesthetic benefits compared with the inferior pedicle technique.

Quality and Readability of Accessible Facial Feminization Literature: Where Can We Improve?

BACKGROUND: Facial feminization surgery (FFS) consists of multiple, complex procedures. Well-informed patients have been shown to have better outcomes and expectations. However, there is limited data evaluating FFS patient-oriented material online. This study aims to evaluate the quality and readability of FFS literature online. METHODS: Facial feminization surgery-related terms were queried in Google with location, cookies, and user account information disabled. Websites were analyzed for readability using Flesch Reading Ease and Flesch-Kincaid Reading Grade Level, suitability using the suitability assessment of materials (SAM), and quality using the DISCERN scale. Unpaired t tests and χ2 tests were used to compare the websites of community-based and academic or public institutions. RESULTS: One hundred twenty websites met inclusion criteria (71 community-based and 49 academic). The average reading grade level was 11.68 ± 1.71. The average SAM score was 53.11 ± 11.75, denoting adequate readability. Only 16.67% of websites contained visual aids to assist in explaining procedures and benefits. Overall, 68.33% of websites' DISCERN score was rated very poor or poor, whereas only 8.33% were rated as good. The following DISCERN elements had the lowest scores across all graded websites: "clear source and date of information," "details of additional source of support," "refers to areas of uncertainty," and "describes risks of each treatment." Websites published by community-based institutions were significantly better in describing how FFS works and the benefits of each procedure. Academic sites overall were less biased (4.84 vs 4.62, P = 0.03) and provided additional sources of support (2.35 vs 1.32, P = <0.001). CONCLUSIONS: Online FFS patient resources should be written at a more inclusive reading level and should increase the use of pictorial aids to improve patient comprehension. Facial feminization surgery patient resources were significantly above the recommended sixth grade reading level for health literature. Academic and community-based institutions should include more information about procedural risks and limitations in surgical outcomes to ensure a broader scope of understanding.

Tranexamic Acid in Facial Feminization Surgery: Quantifying a High-risk Setting With Exogenous Estrogen Supplementation.

Tranexamic acid (TXA) has been increasingly utilized in orthognathic surgery, aesthetic surgery, and craniofacial surgery. However, the risk of increasing venous thromboembolic events (VTE) must be carefully considered as TXA is a prothrombotic agent. Our study aimed to investigate the safety of TXA in the setting of facial feminization surgery. These patients are at an elevated risk for VTE at baseline given their uniform history of exogenous estrogen supplementation. A retrospective review of all patients that underwent facial feminization surgery at our medical center between December 2015 and September of 2022 was performed. Demographic information, procedure type, Caprini scores, hematoma rate, VTE rate, estimated blood loss, and operative time were all studied. Unpaired t tests were used to compare patients that received TXA and those who did not. In total, there were 79 surgeries performed during our study period. There were 33 surgeries (41.77%) that used TXA intraoperatively. Ten patients (12.65%) received anticoagulation postoperatively, 5 of whom received TXA intraoperatively. Of the 33 patients who received TXA, 30 patients remained on estrogen therapy. There was no statistically significant difference in VTE rates in patients who received TXA (n=33, 41.77%) and those who did not (n=46, 58.23%). Bleeding events, Caprini scores, estimated blood loss, and operative time were also not found to be significantly different between the 2 cohorts. The authors found no significant increase in VTE in facial feminization patients undergoing estrogen supplementation when intraoperative TXA was utilized. This is the first known report investigating the safety of TXA in this higher risk patient population.

An update on long-term mental health in eight face transplant recipients - A single center experience.

OBJECTIVE: Face transplantation is a groundbreaking and complex surgical intervention offering profound physical and psychological benefits to patients with severe facial disfigurements. This report provides an update on the long-term psychosocial outcome of eight face transplant recipients. METHOD: All transplant recipients were initially transplanted at Brigham and Women´s Hospital (Boston, USA) between 2011 and 2020 and are seen as outpatient patients at Yale New Haven Hospital (New Haven, USA). A mixed-methods approach was used to assess the psychological well-being of these patients. The Short-Form 12, Brief-COPE, EQ-VAS and CES-D were administered between October 2022 and October 2023. RESULTS: Older age of face transplant recipients was significantly and positively associated with better mental health and increased use of both emotional and instrumental support (Brief-COPE). The initial enhancement in patients' self-reported quality of life, as assessed by the EQVAS, declined on the EQ-VAS score at the last follow-up period. Similarly, an increase in depression score was observed (CES-D score) up through the last follow-up assessment. Both of the latter results, however, did not reach statistical significance. CONCLUSIONS: These results underscore the importance of ongoing psychological support throughout the long-term journey of recovery for face transplant recipients. They emphasized the need for a comprehensive, patient-centered approach that also addresses the complex psychological dimensions and contributes to our understanding of the mental health dynamics involved in face transplantation, underscoring the need for guidelines and continued research in this evolving field.

Determining Morbidity of Adding Genioplasty to Bimaxillary Orthognathic Surgery.

BACKGROUND: Patients with dentofacial anomalies may undergo orthognathic surgery to address functional and aesthetic concerns. Past works have evaluated determinants affecting length of stay (LOS) in patients undergoing upper and/or lower jaw surgery alone. No studies have assessed the addition of genioplasty to double-jaw (Lefort I, bilateral sagittal split osteotomy (BSSO))) surgery and its effect on LOS and other outcomes. This study investigates whether the addition of genioplasty incurs additional morbidity to patients undergoing complex orthognathic surgery. METHODS: This was a retrospective cohort study of patients undergoing orthognathic surgery at Yale-New Haven Hospital. Clinical and demographic information were compared across the "double"- and "triple"-jaw cohorts with t tests and Chi-squared analyses. Multivariable linear and logistic regression analyses were utilized to assess the impact of genioplasty when controlling for baseline patient differences. RESULTS: A total of 27 patients received Lefort I and BSSO (double-jaw), and 224 received Lefort I, BSSO, and genioplasty (triple-jaw). Six (22.2%) double-jaw patients were segmental and fifty-eight (25.9%) triple-jaw patients were segmental (p > 0.05), during the study period. Triple-jaw surgery was associated with increased operative time (+ 41.1 min, p < 0.01). There was no increase in LOS, postoperative nausea and vomiting, opioid use, hematoma, or infection (p > 0.05). CONCLUSIONS: This study attempted to determine if triple-jaw surgery could influence patients' LOS and other surgical outcomes compared to double-jaw surgery. Only the operative time was significantly affected. This indicates that incorporation of a genioplasty can provide aesthetic benefit without incurring significant additional morbidity to the patient. LEVEL OF EVIDENCE III: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Postoperative Antibiotics Following Reduction Mammaplasty Does Not Reduce Rates of Surgical Site Infection.

BACKGROUND: The efficacy of antibiotic utilization following reduction mammaplasty has not been well studied. Furthermore, there is a lack of data describing subgroups who are historically at high risk for surgical site infection (SSI), specifically the obese population. OBJECTIVES: This study compares SSI rates in reduction mammaplasty patients who received postoperative courses of antibiotics with those who did not. Additional analysis was performed for the subgroup of patients with a body mass index (BMI) ≥30 kg/m2. METHODS: The 2010 to 2021 PearlDiver Mariner data set was reviewed to identify reduction mammaplasty patients. Patients were confirmed to have received perioperative antibiotics. Postoperative antibiotic use was determined based on the presence of postoperative prescriptions, and 1:1 matching was performed for those with and without postoperative antibiotics based on age and the Elixhauser Comorbidity Index. Rates of SSI, emergency department (ED) visits, and readmissions for the 90 days following surgery were recorded and compared. A subgroup analysis was performed on patients with a BMI of ≥30 kg/m2. RESULTS: Among patients who were confirmed to have received perioperative antibiotics, 2230 patients who also received postoperative antibiotics were identified and matched to 2230 patients who did not. Rates of SSI, ED visits, and readmission were not statistically different. A total of 218 obese patients were identified from this group and matched. Rates of SSI, ED visits, and readmission were not statistically different. CONCLUSIONS: In the current study, no difference in SSI rates between patients who received postoperative antibiotics and those who did not was found. These observations were corroborated in the obese population. These data may assist surgeons when considering postoperative antibiotics following reduction mammaplasty.

The Economic Impact of Extensor Tendon Lacerations of the Hand in the United States.

PURPOSE: Extensor tendon lacerations (ETLs) are a common and debilitating injury for thousands of Americans annually. No study has attempted to estimate their economic impact. The objective of this study was to estimate the economic impact of ETLs in America. METHODS: The cost of ETLs to society was estimated using a validated prevalence-based cost of illness model. The primary cohort was defined as all patients with complete ETLs in the United States undergoing surgical repair and, secondarily, the imputed number of patients requiring reoperation within 1 year. For these groups, both direct and indirect costs (lost income, missed workdays, and disability payments) were measured. RESULTS: The total annual direct medical costs amounted to $14,095.28 per injury and 100,000 population. The total annual indirect labor costs were found to range between $80,842.90 and $150,136.82 per injury and 100,000 population. Hence, the estimated total costs of ETLs are $307 million per year in the United States alone and could be as high as $531 million annually depending on the effects of worker absenteeism on the core production-based industries. CONCLUSIONS: Extensor tendon lacerations incur a significant economic burden to our health care system and are more costly when compared with many other common hand conditions. Specifically, indirect costs are the major contributor toward the total cost these injuries incur on society, accounting for an upward of 91% of the total cost. These results suggest efforts be focused on improving rehabilitation protocols and treatments. LEVEL OF EVIDENCE: Level II-economic and decision analyses.

The Economic Impact of Flexor Tendon Lacerations of the Hand in the United States.

PURPOSE: Flexor tendon lacerations are a common and debilitating injury for thousands of Americans annually. Despite this, no study has attempted to estimate the economic impact of these injuries. The objective of this study was to estimate the economic impact of flexor tendon lacerations in America. METHODS: The cost of flexor tendon lacerations to society was estimated using a validated prevalence-based cost of illness model. The primary cohort was defined as all patients in the United States presenting with complete flexor tendon lacerations who underwent surgical repair. The secondary cohort was defined by all patients who required reoperation within 1 year of their initial operation. For these groups, both direct and indirect costs (lost income, missed workdays, and disability payments) were measured. RESULTS: Flexor tendon lacerations incur an estimated cost of between US $240.8 and US $409.1 million annually to the American medical system. The total direct cost per injury is estimated to be US $13,725, whereas estimates to the indirect costs range from US $60,786 to US $112,888. CONCLUSIONS: Flexor tendon lacerations represent an important economic burden to our health care system, even when compared with other common hand conditions. Specifically, indirect costs, such as missed workdays, are the major contributor toward the total cost these injuries incur on society, accounting for upward of 89% of the total cost. This suggests that we should focus our efforts to improve treatments and rehabilitation protocols which decrease these indirect costs.

Racial disparities in surgical outcomes after mastectomy in 223 000 female breast cancer patients: a retrospective cohort study.

BACKGROUND: Breast cancer mortality and treatment differ across racial groups. It remains unclear whether such disparities are also reflected in perioperative outcomes of breast cancer patients undergoing mastectomy. STUDY DESIGN: The authors reviewed the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database (2008-2021) to identify female patients who underwent mastectomy for oncological purposes. The outcomes were stratified by five racial groups (white, Black/African American, Asian, American Indian/Alaska Native, and Native Hawaiian/Pacific Islander) and included 30-day mortality, reoperation, readmission, surgical and medical complications, and non-home discharge. RESULTS: The study population included 222 947 patients, 68% ( n =151 522) of whom were white, 11% ( n =23 987) Black/African American, 5% ( n =11 217) Asian, 0.5% ( n =1198) American Indian/Alaska Native, and 0.5% ( n =1018) Native Hawaiian/Pacific Islander. While 136 690 (61%) patients underwent partial mastectomy, 54 490 (24%) and 31 767 (14%) women received simple and radical mastectomy, respectively. Overall, adverse events occurred in 17 222 (7.7%) patients, the largest portion of which were surgical complications ( n =7246; 3.3%). Multivariable analysis revealed that being of Asian race was protective against perioperative complications [odds ratio (OR)=0.71; P <0.001], whereas American Indian/Alaska Native women were most vulnerable to the complication occurrence (OR=1.41; P <0.001). Black/African American patients had a significantly lower risk of medical (OR=0.59; P <0.001) and surgical complications (OR=0.60; P <0.001) after partial and radical mastectomy, respectively, their likelihood of readmission (OR=1.14; P =0.045) following partial mastectomy was significantly increased. CONCLUSION: The authors identified American Indian/Alaska Native women as particularly vulnerable to complications following mastectomy. Asian patients experienced the lowest rate of complications in the perioperative period. The authors' analyses revealed comparable confounder-adjusted outcomes following partial and complete mastectomy between Black and white races. Their findings call for care equalization in the field of breast cancer surgery.

Surgical management of breast fat necrosis: Multi-institutional data analysis of early outcomes and risk factors for complications.

BACKGROUND: Breast fat necrosis (BFN) is a non-cancerous condition affecting the adipose tissue. Despite incidence rates of up to 25% after breast surgery, little is known about risk factors and postoperative outcomes following the surgical treatment of BFN. METHODS: The National Surgical Quality Improvement Program of the American College of Surgeons (2008-2021) was queried to identify female patients diagnosed with and surgically treated for BFN. Outcomes of interest included 30-day surgical and medical complications, reoperation, and readmission. We performed confounder-adjusted multivariable analyses to determine risk factors. RESULTS: The study population included 1179 female patients (mean age: 55.8 ± 13.8 years), of whom 96% (n = 1130) underwent direct excision and 4.2% (n = 49) received debridement of necrotic tissue. The majority of cases were operated on by general surgeons (n = 867; 74%) in the outpatient setting (n = 1107; 94%). Overall, 74 patients (6.3%) experienced postoperative adverse events, most of which were surgical complications (n = 43; 3.7%). Twenty-one (1.8%) women had to return to operating room, while readmission was reported in 18 (1.5%) cases. Adverse events were significantly more likely to occur in patients with chronic heart failure (p = 0.002) and higher wound classes (p = 0.033). CONCLUSION: Complication rates following the surgical management of BFN were found to be relatively high and seen to correlate with the setting. We identified chronic heart failure and wound contamination as risk factors for complication occurrence. These evidence-based insights may sensitize surgeons to critically balance patients' eligibility for BFN surgery and refine perioperative algorithms.

Combined Tripier and V-Y Advancement Flaps for Reconstruction of Large Lid-cheek Junction Defects.

Reconstruction of lid-cheek junction defects has a known risk of ectropion. Cervicofacial flaps require significant dissection and can still be prone to ectropion. V-Y advancement flaps have been described as less morbid, but their use is limited to moderate-size defects that do not involve the lid margin. The authors present a technique of combined Tripier and V-Y advancement flaps for reconstruction of large defects of the lid-cheek junction involving the lower eyelid. A retrospective review of patients undergoing the authors' technique was performed. A facial artery perforator flap was designed in a V-Y fashion and advanced into the cheek. An orbicularis oculi myocutaneous flap (Tripier flap) was elevated from the upper eyelid and rotated into the lower eyelid/upper cheek to meet the superior edge of the V-Y flap. A separate review of patients undergoing cervicofacial flap reconstruction was also performed. Demographics, operative details, and complications were recorded and compared. This technique was applied to five patients with large-size (19.9 ± 5.6 cm2) defects of the lid-cheek. In all cases, healing was achieved without ectropion, hematoma, infection, dehiscence, flap necrosis, or facial nerve injury. Twenty-four patients separately underwent cervicofacial flap reconstruction for defects of comparable size (15.8 ± 10.7 cm2). Two patients developed ectropion, one patient developed a hematoma, and two patients developed an infection. Combined Tripier and V-Y advancement flaps is a useful technique to reconstruct lid-cheek junction defects. This method allows for the reconstruction of large lid-cheek junction defects that involve the lid margin.

"Advancing Face Transplantation: A Critical Analysis of Revisions and Long-Term Surgical Outcomes in Ten Cases".

BACKGROUND: Face transplantation has emerged as a viable solution for reconstructing the most complex facial injuries. Prior work has demonstrated that surgical revisions are necessary to optimize outcomes. The authors' group has updated the previous report of revisions in their cohort, quantified and described which revisions were performed for functional, aesthetic, or mixed indications, and described the rationale, safety, and long-term outcomes of these revisions. METHODS: A retrospective analysis of the authors' ten face transplants was performed from April 2009 to February 2023. The patients' medical records, preoperative facial defects, and operative reports (index and secondary revisions) were reviewed. RESULTS: Nine patients were included. One patient underwent irreversible acute on chronic allograft rejection and received a second face transplant. The average number of revisions was 5.2 per patient (range, 2 to 11 procedures). The median time interval from transplantation to first revision was 4 months (range, 1 to 21 months). Median follow-up was 106 months (range 39 to 142 months). Most interventions consisted of debulking the allograft or revising the periorbital tissues. CONCLUSIONS: In the current study, we report longer term data on revision surgeries needed in face transplant recipients. Patients should expect to undergo revisions for both functional and aesthetic considerations. Although the majority of revisions are performed within two years following transplantation, revisions can be safely performed at any time point. Shared decision-making between the patient and provider team is essential in deciding which revisions are performed and when.

Single Stitch Vicryl Mesh Wrap for Prepectoral Implant Breast Reconstruction.

Acellular dermal matrices are commonly used in prepectoral breast reconstruction for implant coverage and support, but they are associated with significant costs. The authors describe a technique for prepectoral breast reconstruction in which the implant is completely wrapped in a knitted Vicryl mesh and then positioned on the chest, without the need for any tacking sutures. A retrospective review was performed on all consecutive prepectoral breast reconstructions, using this technique at a single institution. A separate cohort undergoing prepectoral reconstruction with a conventional acellular dermal matrix technique was also reviewed for comparison. Patient demographics, oncologic and reconstruction characteristics, outcomes, complications, and materials cost were analyzed. Twelve patients (23 breasts) underwent prepectoral reconstruction with Vicryl mesh, and 34 patients (55 breasts) underwent prepectoral reconstruction with acellular dermal matrices. Overall complication rates in the Vicryl group were low (two infections, one case of skin necrosis, one hematoma) and did not differ statistically from the acellular dermal matrix group. Operative time per breast was nearly twice as fast (35.7 versus 68.0 min, P < 0.01). Calculated materials cost savings was $8273 per breast. Prepectoral breast reconstruction with Vicryl mesh only is a safe technique that is much faster and significantly cheaper compared with conventional reconstructive techniques utilizing acellular dermal matrices.

Wide-Awake Carpal Tunnel Release in the United States: Trends in Volume and Reimbursement by Operative Setting.

BACKGROUND: Office-based surgery can increase logistical and financial efficiency for patients and surgeons. The current study compares wide-awake office-based carpal tunnel release to wide-awake surgeries performed in the operating room (OR) in terms of volume, financial burden, narcotic prescriptions, and adverse events. METHODS: Surgeries performed under local-only anesthesia from 2010 to 2020 were identified in a national administrative database (PearlDiver™). Patients were grouped by surgical setting and matched based on age, sex, comorbidity burden, and geographic region. Primary endpoints included total disbursement and physician reimbursement, as well as 30-day narcotics prescriptions, emergency department (ED) visits, and surgical site infections (SSI). RESULTS: Before matching, there were 303,741 OR surgeries and 5,463 office surgeries. From 2010 to 2020, the percent of surgeries in the office increased from 1.2% to 3.4%. Matched cohorts included 21,835 OR surgeries and 5,459 office surgeries. Office surgery was associated with lower total disbursement and physician reimbursement for patients with commercial insurance, Medicaid, and Medicare. Linear regression modeling indicated that office-based surgery was significantly associated with lower total disbursement and physician reimbursement. Fewer office patients filled narcotic prescriptions and visited the ED, and there was no difference in SSI. CONCLUSION: Compared to OR surgery, office surgery was associated with lower financial burden, fewer narcotics prescriptions and ED visits, and similar incidence of SSI. These findings, together with literature showing greater efficiency in the office, suggest that office-based surgeries are safe and cost-effective and should continue to grow.

Quantitative Analysis of Morphometric Changes in Feminization Rhinoplasty Utilizing a Standardized Forehead-Rhinoplasty Technique.

Background: Rhinoplasty is one of the most commonly performed facial gender-affirming surgeries (FGASs) for transgender females, but well-established morphometric parameters describing feminizing nasal changes do not exist. Objectives: Describe the author's technique for feminization rhinoplasty, analyze the changes in 3-dimensional nasal anthropomorphic parameters, and describe patient-reported outcomes. Methods: Three-dimensional photogrammetric evaluation was performed both preoperatively and postoperatively in transgender female patients who underwent FGAS. Measurements assessed included the nasofrontal angle, nasolabial angle, dorsal height, mid-dorsal width, alar width, nasal tip width, and tip projection. Patients were surveyed preoperatively and postoperatively using the FACE-Q Nose module. Paired t-tests were utilized to assess changes in postoperative measurements and FACE-Q Nose satisfaction scores. Results: Twenty patients underwent FGAS during the study period. The average time between surgery and postoperative 3-dimensional images was 13.6 ± 6.8 months. The nasofrontal angle increased by 8.2° (148.0 ± 7.4° to 156.1 ± 6.7°, P < .001) and tip projection increased by 0.017 (0.58 ± 0.03 to 0.60 ± 0.04, P < .01). Dorsal height, mid-dorsal width, and tip width all decreased significantly (P < .05). There were significant improvements in patients' "Satisfaction with Nose," "Satisfaction with Facial Appearance Overall," "Psychological Function," and "Social Function" on FACE-Q. One revision rhinoplasty was performed, and no documented surgical complications were reported. Conclusions: There were statistically significant changes in the nasofrontal angle, tip projection, dorsal height, mid-dorsal width, and tip width in patients receiving feminization rhinoplasty. These data may help surgeons with preoperative planning and intraoperative decision making.

Ensuring Racial and Ethnic Inclusivity in Facial Vascularized Composite Allotransplantation.

Facial vascularized composite allotransplantation (fVCA) represents a valuable surgical option for reconstruction of the most devastating facial defects. There is a mounting body of evidence suggesting that healthcare disparities exist for a variety of other surgical and nonsurgical procedures. We aimed to investigate the potential existence of racial and ethnic disparities in the field of fVCA. Methods: A comprehensive literature review was conducted by the authors of this review on PubMed/MEDLINE, and Embase databases from database inception to December 1, 2022 for studies published in the English and French languages. The search terms were (1) "face" OR "facial" AND (2) "transplant" OR "VCA" OR "vascularized composite allotransplantation" OR "vascularized composite allograft" OR "graft." Results: Upon assessment of the racial and ethnic demographics of the 47 global cases of fVCA between 2005 and 2020, 36 were White, 10 were Asian, and one was Black. Sixteen of the 17 fVCA procedures performed in the United States involved White patients. The other patient self-identified as Black, equaling 6% of all US fVCA recipients. Conclusion: Our analysis showed that the ethnic and racial distribution of fVCA has not proportionally reflected the racial and ethnic demographics of the general US population, underscoring the risk of such healthcare imbalances. Although large-scale studies are needed before drawing definitive conclusions, leaders in the field should take preventive steps to avoid potential disparities. Further investigations into the factors that facilitate or prohibit access to fVCA referral and surgery will be necessary moving forward.

Cellular activation pathways and interaction networks in vascularized composite allotransplantation.

Vascularized composite allotransplantation (VCA) is an evolving field of reconstructive surgery that has revolutionized the treatment of patients with devastating injuries, including those with limb losses or facial disfigurement. The transplanted units are typically comprised of different tissue types, including skin, mucosa, blood and lymphatic vasculature, muscle, and bone. It is widely accepted that the antigenicity of some VCA components, such as skin, is particularly potent in eliciting a strong recipient rejection response following transplantation. The fine line between tolerance and rejection of the graft is orchestrated by different cell types, including both donor and recipient-derived lymphocytes, macrophages, and other immune and donor-derived tissue cells (e.g., endothelium). Here, we delineate the role of different cell and tissue types during VCA rejection. Rejection of VCA grafts and the necessity of life-long multidrug immunosuppression remains one of the major challenges in this field. This review sheds light on recent developments in decoding the cellular signature of graft rejection in VCA and how these may, ultimately, influence the clinical management of VCA patients by way of novel therapies that target specific cellular processes.