Postoperative Pain and Opioid Use after Facial Feminization Surgery.

The objective of this study is to characterize surgical pain after facial feminization surgery (FFS) and delineate postoperative opioid usage. It is a retrospective cohort study. It was performed in a multicenter integrated health care system. Electronic medical records were reviewed for patient demographic characteristics, medical history, pain medication prescriptions, and responses to a postoperative pain survey. Student's t-test and the Mann-Whitney U-test were used for bivariate analysis. Fisher's exact tests were used for categorical data. Seventy-four patients who underwent FFS were included. The mean (standard deviation) reported "average" postoperative pain score was 4.3 (2.3) out of 10. A total of 58% of patients reported pain lasting 5 or fewer days after surgery. The severity and duration of postoperative pain was similar between patients who underwent partial-FFS or full-FFS. A total of 68% of patients required fewer than 15 opioid tablets. There were no significant differences in the quantity of opioids prescribed or used between patients who underwent partial-FFS or full-FFS. Older age and premorbid mood disorder did not correlate with greater severity/duration of pain or number of opioids used after surgery. Most patients required fewer than 15 opioid tablets after surgery and experienced less than a week of postoperative pain. Patients undergoing full-FFS did not appear to experience significantly greater pain than those undergoing fewer procedures. Older age and premorbid mood disorder were not predictors of worse pain outcomes or greater opioid utilization.

Chondrolaryngoplasty.

Chondrolaryngoplasty is a well-described surgical procedure most commonly performed as part of facial feminization surgery for transgender patients with a diagnosis of gender dysphoria. A complete understanding of relevant neck anatomy and laryngeal function is critical to optimizing surgical outcomes. The overall goal of the procedure is to maximally reduce the thyroid cartilage prominence while preserving laryngeal integrity and minimizing the risk of external scarring. Among available approaches, the bronchoscopic-assisted technique with intraoperative needle localization has been demonstrated to reliably lead to safe and effective surgical outcomes while minimizing the risk of postoperative complications.

Quality of Life Outcomes After Facial Feminization Surgery.

Objective: Report a large single-institution cohort of quality of life (QOL) data before and after facial feminization surgery (FFS). Study Design: Case series. Methods: Patients who underwent FFS at our institution between 2017 and 2019 and completed a pre- and postoperative QOL survey were included in this study. Responses were scored on a 5-point scale with 1 corresponding to least agreement and 5 corresponding to most agreement. Paired t-test was used to compare pre- and postoperative mean scores for each response. Two-tailed t-test was used to compare the mean postoperative delta for each response by demographics. Results: One hundred seven of 341 patients completed a pre- and postoperative survey. The average age was 36 years (range 18-67). The mean time to postoperative survey completion was 96 days (interquartile range 43). Significant improvements in all aspects of QOL assessed on the survey were noted after surgery, including self-perceived facial femininity (2.1-3.8, p < 0.001) and publicly perceived facial femininity (2.0-3.6, p < 0.001). Patients also felt less limited in social activities (3.2-2.0, p < 0.001) and professional activities (2.7-1.7, p < 0.001). Conclusion: FFS improves self-perceived and externally perceived facial femininity and reduces limitations in social and professional activities.

Psychological Effect of the COVID-19 Pandemic Among Facial Feminization Surgery Patients.

BACKGROUND: The COVID-19 pandemic has disproportionately impacted mental health among the lesbian, gay, bisexual, transgender, queer community, with the delay of medical services as a factor. The pandemic's psychological effect on the transfeminine community pursuing facial feminization surgery remains unstudied. METHODS: Patients at our institution whose facial feminization surgeries were delayed due to the COVID-19 pandemic were included. A chart review collected validated, self-reported depression and psychological distress measures, as well as perceived facial femininity and desire for feminizing facial surgery prior to the pandemic. The data were compared to repeat measures during the pandemic (March-April 2020). RESULTS: Thirty patients were included in the study, 11 of whom had repeat data. Respondents during the pandemic (compared to prepandemic) felt their face was more feminine (p = 0.026) and more likely to be perceived as feminine by others (p = 0.026). They indicated a lower desire to alter their appearance with surgery (p = 0.041). Depression and distress indices were greater during the pandemic (p = 0.0018 and p = 0.026, respectively). CONCLUSION: This study is consistent with increasing depression and psychological distress among transfeminine individuals pursuing facial feminization surgery during the pandemic. The study revealed greater perceived facial femininity and a lower desire for surgery during the pandemic.

Initial Facial Feminization Surgery Experience in a Multicenter Integrated Health Care System.

OBJECTIVE: There are few large studies on facial feminization surgery (FFS). We provide the largest comprehensive report to date of an FFS cohort regarding the safety of multilevel surgery, patient-specific considerations with FFS procedures, and complications of surgery. STUDY DESIGN: Retrospective cohort study. SETTING: Multicenter integrated health care system. SUBJECTS AND METHODS: We examined all patients undergoing FFS within our institution from April 2016 to October 2018. Patients over the age of 18 with a diagnosis of gender dysphoria underwent any combination of scalp advancement, cranioplasty, brow lift, rhinoplasty, upper lip lift, mandibuloplasty, chondrolaryngoplasty, and/or additional cosmetic procedures. Medical records were reviewed for preoperative characteristics, FFS procedures undergone, and postoperative complications. RESULTS: In total, 121 patients underwent a total of 594 FFS procedures. Seventy-five percent of patients had only 1 or no comorbidities, and 90% of patients underwent cranioplasty, scalp advancement, and brow lift. African American patients (n = 5) less commonly underwent cranioplasty compared to those of other ethnicities (white, P < .001; Asian, P = .022; Hispanic, P = .014; multiracial, P = .006). Asian patients less commonly underwent rhinoplasty than white patients (38% vs 73%, P = .023). Only 8 (6.6%) patients experienced a significant complication after surgery. CONCLUSIONS: The population undergoing FFS is generally healthy, the upper third of the face is most commonly addressed, there are age and ethnic considerations in FFS, and major complications after multilevel surgery are uncommon.

Rapid risk stratification for obstructive sleep apnea, based on snoring severity and body mass index.

OBJECTIVE: It is unclear whether all snoring patients require polysomnography, and there are no highly sensitive clinical predictors of sleep apnea. Our objective was to develop a simple clinical screening test for OSA in snoring patients. STUDY DESIGN: Prospective, IRB-approved study at a university sleep disorders center. SUBJECTS AND METHODS: In 211 patients undergoing polysomnography, snoring severity, Epworth sleepiness scale, body mass index, demographic, and sleep study data were collected. Receiver operating characteristic (ROC) analysis and Pearson correlation were used to develop a sensitive screening test for OSA. RESULTS: Snoring severity score (SSS) and BMI were the two most accurate predictors of OSA on the ROC curve. A bipartite threshold of SSS = 4 or BMI = 26 carried sensitivity of 97.4%, specificity of 40%, positive predictive value of 82.3%, and negative predictive value of 84.2% for moderate/severe OSA. Patients at high risk were those with BMI > or =32 (89% PPV) or SSS > or =7 (92% PPV). CONCLUSIONS: The statistic most predictive of OSA was snoring severity. Combining this with BMI yielded a highly sensitive screening test for moderate/severe OSA. This clinical assessment may be useful in risk-stratifying patients for polysomnography and therapy, facilitating deferred work-up in low-risk patients and expedited therapy in high-risk patients.

Safety of modified coronal approach with dissection deep to temporalis fascia for facial nerve preservation.

OBJECTIVE: To evaluate the safety of a modified coronal approach to the upper craniofacial skeleton with dissection deep to the temporalis fascia for enhanced preservation of the frontal branch of the facial nerve. STUDY DESIGN: Case series with chart review. SETTING: Tertiary academic medical center. SUBJECTS AND METHODS: In total, 271 patients undergoing coronal flap approaches to the upper craniofacial skeleton by a single surgeon from January 2008 through December 2013 were included. Primary outcomes are temporary or permanent weakness of the frontal branch of the facial nerve as well as the incidence of temporal hollowing following surgery. Secondary outcomes include the presence of postoperative hematoma, seroma, infection, scarring, and alopecia. RESULTS: There were no cases involving either temporary or permanent facial nerve weakness. The incidence of other postoperative complications was also exceedingly low, including a hematoma rate of less than 1%, widened scarring in 2.6% of patients, and no cases of clinically significant temporal hollowing encountered during a mean follow-up period of 3 years. CONCLUSION: A modified coronal approach with dissection deep to the temporalis fascia offers a safe and reliable surgical technique for accessing the upper craniofacial skeleton. Observed complications were minimal, and despite this deeper plane of dissection, there were no cases of either temporary or permanent facial nerve weakness in a large retrospective series of patients from over the past 6 years. Consideration should be given for the routine use of this modified coronal approach for both reconstructive as well as cosmetic indications.

Fusobacterium necrophorum in a pediatric retropharyngeal abscess: A case report and review of the literature.

We present the case of a 17-year-old boy who developed a deep space neck infection following cervical trauma. He was initially managed conservatively with broad-spectrum antibiotics, but when he failed to improve clinically, he required surgical drainage. Wound cultures grew Fusobacterium necrophorum, an uncommon pathogen that can cause pediatric deep neck space infections, especially when it is not associated with Lemierre syndrome. The prognosis for this infection is favorable when it is identified early. Treatment with culture-directed antibiotics and surgical drainage as indicated is appropriate. When treating a pediatric deep neck space infection empirically, physicians should avoid treatment with a macrolide antibiotic, since Fusobacterium spp may be involved and they are often resistant to this class of drugs.

Don't hang your coat here.

Report 2 cases of coat hanger floor of mouth injuries in children. We describe 2 cases of children who presented with coat hanger impalement injuries of the floor of mouth and their management. Removal under anesthesia is safe with a period of observation postoperatively. Impalement injury with coat hangers in the head and neck is a rarely encountered or described mechanism of trauma. We report the first case series of coat hanger impalement injuries in the floor of mouth in two children. Plain film radiographs may be useful to determine the depth of injury and trajectory of the foreign body. Careful removal under anesthesia is safe. Little if any floor of mouth edema was encountered postoperatively, but close observation for potential critical floor of mouth hematoma or edema should be considered.

Tracheotomy timing and outcomes in the critically ill.

OBJECTIVE: To examine the impact of early tracheotomy in nontrauma patients on duration of mechanical ventilation (MV), intensive care unit (ICU) stay, and overall hospital stay. DESIGN: Case series with chart review. SETTING: Tertiary care medical center. METHODS: A retrospective study was performed for patients undergoing tracheotomy from 2005 to 2010. Demographics; survival; duration of endotracheal intubation, MV, ICU, and overall hospital stay; and incidence of ventilator-associated pneumonia (VAP) were assessed. Tracheotomy was considered early if it was performed by day 7 of MV and late thereafter. Nonparametric statistics were used to compare results from each group. RESULTS: Of the 592 patients included in the analysis, 128 received tracheotomy early and 464 late. Differences between age, sex, and overall survival were not statistically significant. Duration of MV was 45% less (mean ± standard error: 21.47 ± 1.86 days vs 39.33 ± 1.33 days; P < .001), total ICU stay was shortened by 33% (17.52 ± 1.38 days vs 26.27 ± 0.73 days; P < .001), and length of overall hospital course was reduced by 34% (35.85 ± 2.57 days vs 54.28 ± 1.60 days; P < .001) in the early tracheotomy group. Three patients (2.3%) from the early tracheotomy group developed VAP as compared with 15 (3.2%) from the late group. Duration from tracheotomy to ICU transfer and 30% overall mortality did not differ significantly between groups. CONCLUSION: Early tracheotomy in ICU patients is associated with earlier ICU discharge, shorter duration of mechanical ventilation, and decreased length of overall hospital stay without affecting mortality.

Bilateral central serous chorioretinopathy caused by intranasal corticosteroids: a case report and review of the literature.

The relationship between systemic corticosteroids and central serous chorioretinopathy (CSCR) has been well established; however, there also appears to be an association with intranasal corticosteroids. A search of the English literature revealed only three reported cases of CSCR linked to intranasal corticosteroid use, and in each, clinical improvement was observed after cessation of the steroid agent. We present an additional case of bilateral CSCR resulting from intranasal corticosteroid use and review the literature regarding this uncommon side effect. Otolaryngologists, as frequent prescribers of these medications, should be aware of their myriad side effects, including ophthalmologic conditions such as CSCR.

Cytosolic Ras supports eye development in Drosophila.

Ras proteins associate with cellular membranes as a consequence of a series of posttranslational modifications of a C-terminal CAAX sequence that include prenylation and are thought to be required for biological activity. In Drosophila melanogaster, Ras1 is required for eye development. We found that Drosophila Ras1 is inefficiently prenylated as a consequence of a lysine in the A(1) position of its CAAX sequence such that a significant pool remains soluble in the cytosol. We used mosaic analysis with a repressible cell marker (MARCM) to assess if various Ras1 transgenes could restore photoreceptor fate to eye disc cells that are null for Ras1. Surprisingly, we found that whereas Ras1 with an enhanced efficiency of membrane targeting could not rescue the Ras1 null phenotype, Ras1 that was not at all membrane targeted by virtue of a mutation of the CAAX cysteine was able to fully rescue eye development. In addition, constitutively active Ras1(12V,C186S) not targeted to membranes produced a hypermorphic phenotype and stimulated mitogen-activated protein kinase (MAPK) signaling in S2 cells. We conclude that the membrane association of Drosophila Ras1 is not required for eye development.