Augmented otorhinologic evaluation in telemedical visits.

PURPOSE: To determine if an endoscopic otologic and rhinologic examination performed by a patient and interpreted remotely by an otolaryngologist is non-inferior to in-person examination, and to assess the feasibility of this system for telemedical visits. MATERIALS AND METHODS: Twenty healthy subjects performed a self-examination of their ears and nose using a commercially available endoscope under remote guidance by an otolaryngology provider over Zoom. This same provider and another otolaryngologist also performed separate, in-person examinations of each subject and rated their findings. Finally, both providers blindly reviewed a video recording of each virtual exam four weeks later and rated their findings. Subjects were surveyed about their experience. Interrater reliability was calculated using Cohen's kappa coefficients and the ability to detect different anatomic structures and features by in-person vs. virtual examination was compared using Wilcoxon tests and Chi-squared proportion tests. RESULTS: The subjects' average age was 30 (SD 11.5) years. Interrater reliability was excellent; kappa coefficients were 0.72 and 0.81 (p < 0.001) for virtual and in-person exams, respectively. Of the 3 anatomic structures within the ear exam, none showed a difference in detectability between virtual and in-person exams. Of the 12 structures in the nasal exam, 3 were better visualized in-person and 9 showed no difference. Subject satisfaction was excellent; the average likelihood of recommending this virtual technology to peers (1-10) was 8.65 (SD 1.4). CONCLUSIONS: Patient self-examination of the ears and nose using a portable endoscope may be an effective strategy for obtaining valuable data during telemedical otolaryngology visits.

Applying Occam's Razor and Descending the Reconstructive Ladder: The Modified Cheek Advancement Flap for Reconstruction of Nasal Defects.

Nasal reconstruction has important functional and cosmetic considerations, as proper repair of nasal defects is necessary to maintain function of the nasal airway and to recreate the normal appearance of this central facial structure. Cheek advancement flaps provide matched, mobile, and highly vascularized tissue for the reconstruction of nasal defects, allowing for the concealment of incisions within natural creases in a one-stage approach. However, cheek advancement flaps are often underutilized for nasal reconstruction because of their difficulty in restoring nasal contour. We describe reconstruction of 19 nasal dorsal and sidewall defects 0.8 to 3 cm in size. We incorporated a periosteal anchoring suture to maintain/restore nasal contour and additionally removed a half standing cone inferior to the defect to prevent encroachment of the nasal ala or alar crease. All patients were evaluated at least 3 months postoperatively. In all patients, we were able to restore concavity of the nasofacial sulcus, preserve the biconvex nasal tips, prevent alar flaring and retraction, and conserve the alar groove. All patients had excellent functional and cosmetic outcomes. We believe this modified cheek advancement flap provides functionally and aesthetically superior results and can be considered as a first-line approach for repair of nasal dorsal and sidewall defects in subselected patients.

Critical Degree of Orbital Floor Displacement Drives Operative Repair of Zygomaticomaxillary Complex Fractures: Findings from a 10-Year Retrospective Study.

Among zygomaticomaxillary complex (ZMC) fractures presenting to a tertiary urban academic center, the authors hypothesized the presence of both clinical and radiographic predictors of operative management. The investigators conducted a retrospective cohort study of 1,914 patients with facial fractures managed at an academic medical center in New York City between 2008 and 2017. The predictor variables were based on both clinical data and features of pertinent imaging studies, and the outcome variable was an operative intervention. Descriptive and bivariate statistics were computed and the p-value was set at 0.05. In total, 196 patients sustained ZMC fractures (5.0%) and 121 (61.7%) ZMC fractures were treated surgically. All patients who presented with globe injury, blindness, retrobulbar injury, restricted gaze, or enophthalmos and a concurrent ZMC fracture were managed surgically. The most common surgical approach was the gingivobuccal corridor (31.9% of all approaches), and there were no significant immediate postoperative complications. Younger patients (38.9 ± 18 years vs. 56.1 ± 23.5 years, p < 0.0001) and patients with greater than or equal to 4 mm of orbital floor displacement were more likely to receive surgical treatment than observation (82 vs. 56%, p = 0.045), as were patients with comminuted orbital floor fractures (52 vs. 26%, p = 0.011). In this cohort, patients more likely to undergo surgical reduction were young patients with ophthalmologic symptoms on presentation and at least 4 mm displacement of the orbital floor. Low kinetic energy ZMC fractures may warrant surgical management as often as high-energy ZMC fractures. While orbital floor comminution has been shown to be a predictor for operative reduction, in this study we also demonstrated a difference in the rate of reduction based on the severity of orbital floor displacement. This may have significant implications in both the triage and selection of patients most suitable for operative repair.

Essential inpatient otolaryngology: what COVID-19 has revealed.

PURPOSE: To identify areas of critical otolaryngology contributions to inpatient care resistant to disruption by the COVID-19 pandemic. METHODS: Medical records of 614 otolaryngology consults seen between January and June of 2019 and 602 seen between January and June of 2020 were reviewed. Extracted data included patient demographics, SARS-CoV-2 status, medical comorbidities, consult location, consult category, reason for consult, procedures performed, and overall outcome. Prevalence of data items was compared using t tests and Chi-squared tests. RESULTS: The number of monthly consults to the otolaryngology service remained approximately stable after the onset of the COVID-19 pandemic. However, there was a substantial increase in ICU consults and a decrease in ER and floor consults. The proportion of otology, rhinology, and head and neck consults decreased while that of airway consults-most of which were tracheostomy-related-greatly increased. While the top ten reasons for consult remained essentially the same, they dramatically increased as a percentage of consults during COVID-19 (55-92%), whereas there was a dramatic decrease in the proportion of less frequent consults. CONCLUSION: The changes in otolaryngology consultation patterns seen after the onset of the pandemic are multifactorial, but may be attributed to novel pathologies, attitudes, and policies. Nonetheless, these patterns reveal that a set of core otolaryngologic issues, including acute airway issues, head and neck lesions, severe sinusitis and epistaxis, are essential and need to be addressed in the inpatient setting, whereas the significant drop in other consults suggests that they may be appropriately managed on an outpatient basis.

Telemedicine lessons learned during the COVID-19 pandemic: The augmented outpatient otolaryngology teleconsultation.

PURPOSE: Telemedicine use in otolaryngology waxed and waned during the COVID-19 pandemic outbreak in the U.S. Assessing the patterns of telemedicine use and its perceived limitations during the COVID-19 outbreak in 2020 allows identification and correction of impediments to consistent telemedicine use by otolaryngologists. MATERIALS AND METHODS: Full-time faculty of 2 academic otolaryngology departments in New York City were surveyed regarding their telemedicine use from March through August 2020 during the "first wave" of the COVID-19 pandemic. Based on these findings, a method of "augmented outpatient otolaryngology teleconsultation" designed to enhance the quality of the physical examination was developed and employed from August to December 2020. Patients receiving this augmented teleconsult were anonymously surveyed about their telemedical experience. RESULTS: Telemedicine use by faculty was minimal prior to the pandemic, but as total outpatient volume decreased 65-84% across subspecialties, it was used by all otolaryngologists during COVID-19. Physicians were less confident in making a telemedical diagnosis at all phases of the study in all subspecialties. Patients who had an augmented otolaryngology teleconsultation were satisfied with it, believed it facilitated earlier care, limited the time and cost of travel to the physician's office and felt their physician was able to perform a sufficient physical examination. CONCLUSIONS: During the COVID-19 crisis, physicians utilized teleotolaryngology to provide care but were less satisfied with their ability to make an accurate diagnosis. Inexpensive direct-to-consumer digital otoscopes can improve the quality of the physical examination provided and can address both patient and physician needs.

Theory and Evidence for Platelet Therapy of the Aging Face.

Platelet preparations are autologous blood concentrates with supraphysiologic concentrations of platelets with or without leukocytes used in various clinical applications including regenerative medicine, wound healing, and facial rejuvenation. Their use harnesses the important role of platelets and their secretory products in immunoregulation, wound healing, angiogenesis, and tissue remodeling. The use of platelet preparations has been long documented in orthopaedic surgery, maxillofacial surgery, and other fields, but over the years research has increased in their application to facial plastic surgical techniques. Here we review the various formulations of platelet rich concentrates, their applications to facial skin rejuvenation, wound healing, scar reduction, and tissue fill as documented in the literature since 2018.

Patient, Defect, and Surgical Factors Influencing Use of Ancillary Procedures after Facial Mohs Repairs.

This article determines if patient, defect, and repair factors can be used to predict the use of additional treatments to achieve optimal aesthetic results after repair of facial Mohs defects. An electronic chart review of patients undergoing Mohs excision and reconstruction of facial neoplasms from November 2005 to April 2017 was performed, reviewing patient demographics and history, tumor size, defect size and location, method and service of reconstruction, time between resection and repair, complications, and subsequent treatments. A total of 1,500 cases with basal cell and squamous cell carcinoma were analyzed. The average defect size was 3.09 ± 8.06 cm2; 81.9% of defects were less than 4 cm2 in size. Advancement flaps were used to repair 44.3% of defects. Complications and undesired sequelae (CUS) were noted in 15.9% of cases; scar hypertrophy or keloid (10.8%) was most common. Postoperative ancillary procedures were performed in less than one-quarter (23.4%) of patients to enhance the postrepair appearance; the most common procedures were intralesional corticosteroid injections and pulse dye laser treatments. CUS were more likely in females (19.6%), defects on the lips (28.7%) and on the nose (27.3%) (p < 0.001 for each). Females (22.7% vs. 12.7%), lip repairs (40.2% vs. 18.3%), transposition flaps (39.2% vs. 14.8%), and repairs performed by a dermatologist (17.9% vs. 11.2%) (p < 0.001 for each) were more likely to be treated with postoperative corticosteroid injections. Females (14.5% vs. 7.4%), patients under the age of 60 years (13.9% vs. 8.8%), and patients whose repair was performed by a dermatologist (11.9% vs. 2.9%) (p < 0.001 for each) were more likely to receive postoperative pulsed dye laser treatments. CUS and ancillary procedures after repair of facial Mohs defects are uncommon. Awareness of individual risk factors and defect characteristics allows the surgeon to choose the most appropriate repair technique while anticipating the potential need for ancillary procedures.

Injury Patterns in Pediatric Facial Fractures Unique to an Urban Environment.

This study aimed to define better the clinical presentation, fracture patterns, and features predictive of associated injuries and need for surgery in pediatric facial trauma patients in an urban setting. Charts of patients 18 years or younger with International Classification of Disease 9th and 10th revision (ICD-9/ICD-10) codes specific for facial fractures (excluding isolated nasal fractures) at NY-Presbyterian/Weill Cornell Medical Center between 2008 and 2017 were retrospectively reviewed. Of 204 patients, most were referred to the emergency department by a physician's office or self-presented. Children (age 0-6 years) were most likely to have been injured by falls, while more patients 7 to 12 years and 13 to 18 years were injured during sporting activities (p < 0.0001). Roughly half (50.5%) of the patients had a single fracture, and the likelihood of surgery increased with greater numbers of fractures. Older patients with either orbital or mandibular fractures were more likely to undergo surgery than younger ones (p = 0.0048 and p = 0.0053, respectively). Cranial bone fractures, CSF leaks, and intracranial injuries were more common in younger patients (p < 0.0001) than older patients and were more likely after high energy injuries; however, 16.2% of patients sustaining low energy injuries also sustained cranial bone, CSF leak, or intracranial injury. In an urban environment, significant pediatric facial fractures and associated injuries may occur after nonclassic low kinetic energy traumatic events. The age of the patient impacts both the injuries sustained and the treatment rendered. It is essential to maintain a high index of suspicion for associated injuries in all pediatric facial trauma patients.

Evolution of Blepharoplasty.

The eyes and periorbital region are central components of facial beauty and harmony, but the periorbital region is also one of the earliest to show signs of aging. Over the past few decades, significant progress has been made in our understanding of the anatomy in this area, as well as the deleterious effects of aging in this region. In turn, surgical philosophy and techniques have evolved to better combat changes in this area to achieve a more youthful, natural appearance.

Enhanced Contouring of Local Flaps.

Scars and flaps represent a disruption of the normal skin contour, shape, and texture. Successful reconstruction of facial defects with local flaps requires prior planning to choose the correct reconstructive method. However, thorough preoperative planning should include consideration of adjunctive procedures to improve expected postoperative results as well as potential procedures to improve less-than-ideal results. Approaching facial reconstruction holistically allows the surgeon to soberly assess his/her reconstructive results and attain outstanding appearance.

Trends in Nasal Subunit Reconstruction by Facial Plastic and Reconstructive Surgeons.

To determine if facial plastic and reconstructive surgeons still adhere to the classic nasal subunit principle as described by Burget and Menick. Observational survey. A Weill Cornell Medicine institutional review board approved electronic survey that was sent via e-mail to active members of the American Academy of Facial Plastic and Reconstructive Surgery (AAFPRS). The survey consisted of 32 multiple-choice questions pertaining to the operative management of small (22-30%), medium (50-58%), and large (75-81%) defects of each subunit of the nose, as well as demographic, provider, and practice characteristics. There were 111 responses to the survey (10.1% response rate). Ninety-eight percent of respondents reported familiarity with the subunit principle, and 59.6% considered the subunit principle in greater than 90% of cases. Almost three-quarters (70.4%) of respondents felt the subunit principle should be applied but could be modified based on the particular nasal defect, whereas 28.7% felt it was only sometimes helpful and was not mandatory for successful nasal reconstruction. Large defects of the tip and ala are generally treated by excision of the remaining subunit (79.4 and 80.6%, respectively). Fewer surgeons would excise the remaining subunit for large defects of the dorsum (39.8%), sidewall (38.8%), and soft tissue facet (18.4%). Simple repair without additional excision was the treatment of choice for small defects of the tip (58.2%), ala (59.2%), sidewall (65%), dorsum (68%), and soft tissue facet (71.8%). However, in many small- (up to 32%) and medium- (up to 51%) sized defects of the tip, ala, sidewall, and dorsum, respondents reported partial subunit excision. The majority of AAFPRS members abide to the classical subunit principle by completely excising the remaining subunit for large defects of the tip and ala. Many surgeons modify the subunit principle in small and medium defects.

Cutaneous Lymphadenoma: A Trichoblastoma with Regressive Inflammatory Changes.

The authors address the entity of cutaneous lymphadenoma. Although considered benign, cutaneous lymphadenoma can be easily misdiagnosed as basal cell carcinoma because of its close clinical and histological resemblance. This entity is rare and controversial both in terms of its histogenesis and the various diagnostic terms assigned to it throughout the literature. While rare, cutaneous lymphadenoma should be considered in the differential of any facial nodule or papule in addition to the more common basal cell carcinoma, nevi, cysts, and appendiceal tumors.

The Facial Adipose Tissue: A Revision.

Recent advantages in the anatomical understanding of the face have turned the focus toward the subcutaneous and deep facial fat compartments. During facial aging, these fat-filled compartments undergo substantial changes along with other structures in the face. Soft tissue filler and fat grafting are valid methods to fight the signs of facial aging, but little is known about their precise effect on the facial fat. This narrative review summarizes the current knowledge about the facial fat compartments in terms of anatomical location, histologic appearance, immune-histochemical characteristics, cellular interactions, and therapeutic options. Three different types of facial adipose tissue can be identified, which are located either superficially (dermal white adipose tissue) or deep (subcutaneous white adipose tissue): fibrous (perioral locations), structural (major parts of the midface), and deposit (buccal fat pad and deep temporal fat pad). These various fat types differ in the size of the adipocytes and the collagenous composition of their extracellular matrix and thus in their mechanical properties. Minimal invasive (e.g., soft tissue fillers or fat grafting) and surgical interventions aiming to restore the youthful face have to account for the different fat properties in various facial areas. However, little is known about the macro- and microscopic characteristics of the facial fat tissue in different compartments and future studies are needed to reveal new insights to better understand the process of aging and how to fight its signs best.

An Inferiorly Based Rotation Flap for Defects Involving the Lower Eyelid and Medial Cheek.

We report a series of 20 patients who underwent inferiorly based rotation flaps for reconstruction of defects of the medial and infraorbital cheek and lower eyelid following Mohs micrographic surgery for nonmelanoma skin cancer. Defects ranged from 1.2 to 3.2 cm in longest diameter and patients ranged from 27 to 91 years of age. All 20 patients had excellent functional and cosmetic outcome with up to 2-year follow-up and no subsequent surgical or laser revision. There were no instances of partial or complete flap necrosis, hematoma, or ectropion. Our series includes defects that originated on the cheek as far laterally as directly below the lateral canthus, and terminated as far medially as the nasal sidewall. An inferiorly based rotation flap is a viable alternative to a laterally based rotation flap and should be in the armamentarium of reconstructive dermatologic and facial plastic surgeons.