Bony Dorsal Preservation.

Rhinoplasty is undergoing a transformation with the re-emergence of Dorsal Preservation Rhinoplasty (DPR) techniques. This article introduces a novel addition to the DPR repertoire, "Bony Dorsal Preservation" (BDP), which has particular application for the correction of crooked noses. In this comprehensive overview, we summarize current DPR concepts and techniques, the intricate considerations that go into the dorsal osseocartilaginous vault and septal management, and how these are modified to treat the crooked nose. However, current DPR techniques, particularly the Low Septal Strip (LSS), have drawbacks, and the desire to address such issues led to the development of BDP. BDP is ideal for cases where there is no septal base pathology. It maintains the core principle of DPR by lowering dorsal humps without creating open roof deformities. Its unique feature lies in the temporary separation of the upper lateral cartilages from the septum while leaving the septal base attachment intact, thus allowing the entire osseocartilaginous vault to be adjusted independently before reconnecting the preserved upper lateral cartilages. This technique offers direct visualization during septal excision and fixation and enables cartilaginous vault movement without sacrificing stability. Compared to LSS, there is more septal cartilage available for harvesting, the risks of a single point of septal fixation are eliminated, and there is the potential to transition to component reduction techniques if needed. With shared indications and contraindications with other DPR methods, BDP emerges as a valuable addition to the evolving field of rhinoplasty, particularly in addressing the challenges of the crooked nose.

The Future of Microsurgery: Vascularized Composite Allotransplantation and Engineering Vascularized Tissue.

Background: Microsurgical techniques have revolutionized the field of reconstructive surgery and are the mainstay for complex soft tissue reconstruction. However, their limitations have promoted the development of viable alternatives. This article seeks to explore technologies that have the potential of revolutionizing microsurgical reconstruction as it is currently known, reflect on current and future vascularized composite allotransplantation (VCA) practices, as well as describe the basic science within emerging technologies and their potential translational applications. Methods: A literature review was performed of the technologies that may represent the future of microsurgery: vascularized tissue engineering (VCA) and flap-specific tissue engineering. Results: VCA has shown great promise and has already been employed in the clinical setting (especially in face and limb transplantation). Immunosuppression, logistics, cost, and regulatory pathways remain barriers to overcome to make it freely available. Vascularized and flap-specific tissue engineering remain a laboratory reality but have the potential to supersede VCA. The capability of creating an off-the-shelf free flap matching the required tissue, size, and shape is a significant advantage. However, these technologies are still at the early stage and require significant advancement before they can be translated into the clinical setting. Conclusion: VCA, vascularized tissue engineering, and flap-specific bioengineering represent possible avenues for the evolution of current microsurgical techniques. The next decade will elucidate which of these three strategies will evolve into a tangible translational option and hopefully bring a paradigm shift of reconstructive surgery.

Turn Your Vision into Reality-AI-Powered Pre-operative Outcome Simulation in Rhinoplasty Surgery.

BACKGROUND: The increasing demand and changing trends in rhinoplasty surgery emphasize the need for effective doctor-patient communication, for which Artificial Intelligence (AI) could be a valuable tool in managing patient expectations during pre-operative consultations. OBJECTIVE: To develop an AI-based model to simulate realistic postoperative rhinoplasty outcomes. METHODS: We trained a Generative Adversarial Network (GAN) using 3,030 rhinoplasty patients' pre- and postoperative images. One-hundred-one study participants were presented with 30 pre-rhinoplasty patient photographs followed by an image set consisting of the real postoperative versus the GAN-generated image and asked to identify the GAN-generated image. RESULTS: The study sample (48 males, 53 females, mean age of 31.6 ± 9.0 years) correctly identified the GAN-generated images with an accuracy of 52.5 ± 14.3%. Male study participants were more likely to identify the AI-generated images compared with female study participants (55.4% versus 49.6%; p = 0.042). CONCLUSION: We presented a GAN-based simulator for rhinoplasty outcomes which used pre-operative patient images to predict accurate representations that were not perceived as different from real postoperative outcomes. 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 .

Face the Future-Artificial Intelligence in Oral and Maxillofacial Surgery.

Artificial intelligence (AI) has emerged as a versatile health-technology tool revolutionizing medical services through the implementation of predictive, preventative, individualized, and participatory approaches. AI encompasses different computational concepts such as machine learning, deep learning techniques, and neural networks. AI also presents a broad platform for improving preoperative planning, intraoperative workflow, and postoperative patient outcomes in the field of oral and maxillofacial surgery (OMFS). The purpose of this review is to present a comprehensive summary of the existing scientific knowledge. The authors thoroughly reviewed English-language PubMed/MEDLINE and Embase papers from their establishment to 1 December 2022. The search terms were (1) "OMFS" OR "oral and maxillofacial" OR "oral and maxillofacial surgery" OR "oral surgery" AND (2) "AI" OR "artificial intelligence". The search format was tailored to each database's syntax. To find pertinent material, each retrieved article and systematic review's reference list was thoroughly examined. According to the literature, AI is already being used in certain areas of OMFS, such as radiographic image quality improvement, diagnosis of cysts and tumors, and localization of cephalometric landmarks. Through additional research, it may be possible to provide practitioners in numerous disciplines with additional assistance to enhance preoperative planning, intraoperative screening, and postoperative monitoring. Overall, AI carries promising potential to advance the field of OMFS and generate novel solution possibilities for persisting clinical challenges. Herein, this review provides a comprehensive summary of AI in OMFS and sheds light on future research efforts. Further, the advanced analysis of complex medical imaging data can support surgeons in preoperative assessments, virtual surgical simulations, and individualized treatment strategies. AI also assists surgeons during intraoperative decision-making by offering immediate feedback and guidance to enhance surgical accuracy and reduce complication rates, for instance by predicting the risk of bleeding.

Beyond the Operating Room: Exploring Gender Bias in Leadership Positions in German Plastic Surgery.

Background: Despite efforts to promote gender equity in medicine, gender disparities persist in various medical specialties, including plastic surgery. This study aimed to investigate the representation of female physicians in leadership positions in German plastic surgery departments. Methods: This cross-sectional study collected data about the physician workforce in the German plastic surgery field. The primary outcome was the proportion of female physicians in plastic surgery departments. Data were collected from 94 departments. The physician workforce was stratified based on gender and leadership. Results: We included 812 physicians working in different German plastic surgery departments. Of those, 76.8% were in leadership positions, and 35.1% were women. There was a significant association between being male sex and holding a leadership position (n = 158/188, 84% versus n = 30/188, 16%, P < 0.0001). This association persisted even after accounting for the academic grade of each physician in a multivariable regression model (OR 2.565; 95% confidence interval, 1.628-4.041). Conclusions: Women are significantly underrepresented in leadership positions in German plastic surgery, with only 16% of female physicians holding such positions. Furthermore, being male sex was significantly associated with holding a leadership position, even after adjusting for the academic grade. These findings emphasize the existence of gender bias in the selection process for leadership positions in plastic surgery.

Gender distribution and women leadership in German Otolaryngology, Head and Neck Surgery.

Objective: To determine the distribution of female physicians throughout the rank from resident to leadership positions in German Otolaryngology-Head and Neck Surgery (OHNS) departments. Methods: This cross-sectional study collected data about the physician workforce in the German OHNS.The primary outcome was the proportion of female physicians. Data were collected from 165 departments from January 2022 to February 2022. The physician workforce was stratified based on gender and leadership. Results: We included 2089 physicians from 165 departments of OHNS in German hospitals. Female residents and specialists outnumbered male peers (484/872 [55.5%] vs. 388/872 [44.5%] and 224/363 [61.71%] vs. 139/363 [38.29%], respectively). However, the women proportion decreased gradually with elevated hierarchical rank starting at the attending physician level to reaching its lowest extreme (14/165 [7.23%]) at the head of the department level. Holding a leadership position was associated with being male (n = 282 [85.2%] vs. n = 49 [14.8%], p < .0001). This persisted even after controlling the academic rank in a multivariable regression model (OR: 5.027, 95% CI: 3.536-7.146). The gap between the two genders in favor of men regarding leadership persisted in all kinds of hospitals. However, this disparity was lowest in university hospitals, (male: n = 83 [78.3%] vs. female: n = 23, [21.7%], p < .0001). Conclusions: Even though women outnumbered men in resident and specialist positions, they are still underrepresented in leadership positions in OHNS. Continuous surveillance is needed to watch the dynamic changes in the gap between the two genders and address it with more sex equality-supporting policies. Level of Evidence: IV.

Venous Thromboembolism Rates After Free Flap Reconstruction of the Head and Neck Region.

BACKGROUND: Venous thromboembolism (VTE) is a major concern for the postoperative hospitalized patient, especially after long and complex procedures. Cancer itself also contributes to the hypercoagulable state, further complicating the management of patients. Despite prophylaxis, breakthrough events can occur. We aimed to assess our institutional VTE and bleeding rates after free flap reconstruction of the head and neck (H&N) region and the factors associated with VTE events. METHODS: A retrospective review of the patients who underwent H&N free flap reconstruction at an academic center from 2012 to 2021 was performed from a prospectively maintained database. Data regarding patient demographics, medical history, surgical details, and overall outcomes were collected. Outcomes studied included postoperative 30-day VTE rates and major bleeding events. Patients who had a VTE event were compared with the rest of the cohort to identify factors associated with VTE. RESULTS: Free flap reconstruction of the H&N region was performed in 949 patients. Reconstruction after cancer extirpation for squamous cell carcinoma was the most common etiology (79%). The most common flap was thigh based (50%), followed by the fibula (29%). The most common postoperative VTE chemoprophylaxis regimen was enoxaparin 30 mg twice daily (83%). The VTE and bleeding rates over the 10-year period were 4.6% (n = 44) and 8.7% (n = 83), respectively. Body mass index (28.7 ± 5.8 vs 26.2 ± 6.6, P = 0.013) and pulmonary comorbidities were found to be significantly higher in patients who had a VTE event (43% vs 27%, P = 0.017). Patients with a VTE event had a prolonged hospital stay of 8 more days (19.2 ± 17.4 vs 11 ± 7, P = 0.003) and a higher incidence of bleeding events (27% vs 8%, P < 0.001). CONCLUSIONS: Postoperative VTE is a significant complication associated with increased length of hospitalization in patients undergoing free flap reconstruction of the H&N region. Institutional measures should be implemented on an individualized basis based on patient comorbidities to improve the postoperative VTE rates, while balancing the bleeding events.

Association between venous thromboembolism rates and different prophylactic anticoagulation regimens in patients undergoing free flap reconstruction of the head and neck region.

BACKGROUND: Venous Thromboembolism (VTE) is a serious complication after free tissue transfer to the head and neck (H&N). However, an optimal antithrombotic prophylaxis protocol is not defined in the literature. Enoxaparin 30 mg twice daily (BID) and heparin 5000 IU three times daily (TID) are among the most commonly used regimens for chemoprophylaxis. However, no studies compare these two agents in the H&N population. METHODS: A cohort study of patients who underwent free tissue transfer to H&N from 2012 to 2021 and received either enoxaparin 30 mg BID or Heparin 5000 IU TID postoperatively. Postoperative VTE and hematoma events were recorded within 30 days of index surgery. The cohort was divided into two groups based on chemoprophylaxis. VTE and hematoma rates were compared between the groups. RESULTS: Out of 895 patients, 737 met the inclusion criteria. The mean age and Caprini score were 60.6 [SD 12.5] years and 6.5 [SD 1.7], respectively. 234 [31.88%] were female. VTE and hematoma rates among all patients were 4.47% and 5.56%, respectively. The mean Caprini score between the enoxaparin (n = 664) and heparin (n = 73) groups was not statistically significant (6.5 ± 1.7 vs.6.3 ± 1.3, p = 0.457). The VTE rate in the enoxaparin group was significantly lower than in the heparin group (3.9% vs. 9.6%; OR: 2.602, 95% CI: 1.087-6.225). Hematoma rates were similar between the two groups (5.5% vs. 5.6%; OR: 0.982, 95% CI: 0.339-2.838). CONCLUSIONS: Enoxaparin 30 mg BID was associated with a lower VTE rate while maintaining a similar hematoma rate compared to heparin 5000 units TID. This association may support the use of enoxaparin over heparin for VTE chemoprophylaxis in H&N reconstruction.

Outcomes of KTP Laser Ablation in Glottic Neoplasms: A Systematic Review and Meta-Analysis.

OBJECTIVES: To evaluate the safety and clinical effectiveness of transoral laser microsurgery (TLM) with potassium-titanyl-phosphate (KTP) laser ablation for glottic neoplasms. DATA SOURCE: MEDLINE via PubMed, SCOPUS, Web of Science, and Cochrane Library. REVIEW METHODS: A systematic review and meta-analysis of studies assessing the safety and efficacy of KTP laser therapy in patients with early-stage glottic neoplasms. RESULTS: Eight studies were included. After an average follow-up of 3.3 years, the overall survival and disease-free survival for patients who underwent KTP were 90.7% (95% CI 85%-96.5%) and 98.5% (95% CI 97.3%-99.8%), respectively. In the single-arm meta-analysis, the pooled estimate of recurrence was 7.7% (95% CI 3.4%-12%). The overall voice handicap index (VHI) estimate attributed to KTP in the single-arm meta-analysis was 6.76 (95% CI [3.05, 10.48]) and 5.21 (95% CI [2.86, 7.56]) within 6 months and after a one-year follow-up, respectively. CONCLUSION: KTP laser ablation is a safe and effective method for treating patients with early glottic neoplasms. Laryngoscope, 133:1806-1814, 2023.

Deep Learning Applications in Surgery: Current Uses and Future Directions.

Deep learning (DL) is a subset of machine learning that is rapidly gaining traction in surgical fields. Its tremendous capacity for powerful data-driven problem-solving has generated computational breakthroughs in many realms, with the fields of medicine and surgery becoming increasingly prominent avenues. Through its multi-layer architecture of interconnected neural networks, DL enables feature extraction and pattern recognition of highly complex and large-volume data. Across various surgical specialties, DL is being applied to optimize both preoperative planning and intraoperative performance in new and innovative ways. Surgeons are now able to integrate deep learning tools into their practice to improve patient safety and outcomes. Through this review, we explore the applications of deep learning in surgery and related subspecialties with an aim to shed light on the practical utilization of this technology in the present and near future.