Histological assessment of microtia cartilage, a potential source of autograft tissue in ear reconstruction.

Cartilage is a strong and flexible connective tissue that has many forms and functions in our body. While cartilage exhibits some forms of limited repair, for the most part, it is not particularly regenerative. Thus, in situations where patients require cartilage reconstruction, surgeons may use autografts to replace missing or damaged tissue. Cartilage tissues from different regions of the body exhibit histological differences and are in limited supply. Thus, it is important to characterize these differences to determine the most appropriate autograft source. In the case of microtia, a congenital deformity where the pinna is underdeveloped, reconstruction commonly utilizes cartilage sourced from a patient's own costal cartilage. This presents a potential morbidity risk. In this study, we evaluate the histological characteristics of microtia cartilage compared with normal auricular and costal cartilage obtained from human patients undergoing surgical resection. Histochemistry was used to evaluate cellularity, lipid content, and ECM content. Using a Bayesian statistical approach, we determined that while costal cartilage is the standard tissue donor, the microanatomy of microtia cartilage more closely reflects normal auricular cartilage than costal cartilage. Therefore, microtia cartilage may serve as an additional reservoir for cartilage during reconstruction.

A descriptive study of mental health and wellbeing of doctors and medical students in the UK.

Doctors and medical students are working in a system which is affecting their mental wellbeing and their ability to provide the best possible care for patients. The British Medical Association conducted an online survey of doctors and medical students in October 2018. In total, 4347 responses were received and analysed. Doctors working the longest hours appear to be most vulnerable to psychological and emotional disturbance. Older and more senior doctors are most likely to report that their working environment has impacted on their condition. Medical students and junior doctors report the highest rate of having a formally diagnosed mental health condition in the last 12 months. This may be because they are in the vulnerable age group when psychiatric disorders start. Junior doctors were least likely to be aware of how to access help or support. Older doctors, those working as SAS (Staff, Associate Specialists and Specialty) doctors and overseas qualified doctors are most likely to say they have asked for support in managing a problem from their employer but that no support was provided. It is important to recognize that doctors, in spite of stress and poor wellbeing, continue to work hard, which has both advantages and disadvantages. These findings highlight that the environment in which doctors work, train, and study affects their mental health, and for this reason careful consideration needs to be given to the type and level of support provision available to them, as well as the ease of access and awareness of such support.

White adipose tissue inflammation and cancer-specific survival in patients with squamous cell carcinoma of the oral tongue.

BACKGROUND: Obesity is associated with increased adipose tissue in the tongue. Chronic white adipose tissue (WAT) inflammation commonly occurs in the obese. We investigated whether WAT inflammation in the tongue impacts survival in patients with squamous cell carcinoma (SCC) of the oral tongue. METHODS: In a retrospective cohort study, patients with T1 and T2 SCC of the oral tongue who underwent curative-intent resection were included. Tongue WAT inflammation was defined by the presence of dead or dying adipocytes surrounded by macrophages forming crown-like structures. The primary and secondary endpoints were disease-specific survival (DSS) and overall survival (OS), respectively. Subgroup analyses were carried out in patients without lymph node involvement for whom adjuvant therapies were not indicated. RESULTS: Archived tissue was available from 125 patients. The median follow-up was 55 months (range, 3-156 months). Overall, 49 of 125 patients (39%) had tongue WAT inflammation, which was associated with higher body mass index, increased tumor thickness, and vascular invasion (P < .05). The 3-year DSS rate for patients with tongue WAT inflammation was 59% (95% confidence interval [CI], 46%-76%) versus 82% (95% CI, 73%-92%) for those without inflammation. For patients without lymph node involvement for whom adjuvant therapy was not indicated (N = 70), tongue WAT inflammation was associated with shortened DSS and OS (P < .05). When adjusted for body mass index and potential prognostic covariates, the hazard ratio for DSS and OS was 5.40 (95% CI, 1.20-24.26) and 2.97 (95% CI, 1.02-8.65), respectively. CONCLUSIONS: Tongue WAT inflammation is associated with worse DSS and OS in patients who have early stage SCC of the oral tongue. Cancer 2016;122:3794-3802. © 2016 American Cancer Society.

Impact of obesity on the survival of patients with early-stage squamous cell carcinoma of the oral tongue.

BACKGROUND: Although obesity increases risk and negatively affects survival for many malignancies, the prognostic implications in squamous cell carcinoma (SCC) of the oral tongue, a disease often associated with prediagnosis weight loss, are unknown. METHODS: Patients with T1-T2 oral tongue SCC underwent curative-intent resection in this single-institution study. All patients underwent nutritional assessment prior to surgery. Body mass index (BMI) was calculated from measured height and weight and categorized as obese (≥ 30 kg/m(2) ), overweight (25-29.9 kg/m(2) ), or normal (18.5-24.9 kg/m(2) ). Clinical outcomes, including disease-specific survival, recurrence-free survival, and overall survival, were compared by BMI group using Cox regression. RESULTS: From 2000 to 2009, 155 patients (90 men, 65 women) of median age 57 years (range, 18-86 years) were included. Baseline characteristics were similar by BMI group. Obesity was significantly associated with adverse disease-specific survival compared with normal weight in univariable (hazard ratio [HR] = 2.65, 95% confidence interval [CI] = 1.07-6.59; P = .04) and multivariable analyses (HR = 5.01; 95% CI = 1.69-14.81; P = .004). A consistent association was seen between obesity and worse recurrence-free survival (HR = 1.87; 95% CI = 0.90-3.88) and between obesity and worse overall survival (HR = 2.03; 95% CI = 0.88-4.65) though without reaching statistical significance (P = .09 and P = .10, respectively) in multivariable analyses. CONCLUSIONS: In this retrospective study, obesity was an adverse independent prognostic variable. This association may not have been previously appreciated due to confounding by multiple factors including prediagnosis weight loss.

Salvage of Infected Alloplastic Ear Reconstructions via Negative Pressure Wound Therapy.

This is the first description of Negative Pressure Wound Therapy (NPWT) use in rescuing alloplastic ear reconstructions. Previously considered a sign of certain impending failure, severe infections with frank purulence can be salvaged. As a more recently developed technique, porous polyethylene (PPE) ear reconstruction provides benefits when compared to rib techniques. Increasing surgeon awareness of complication management may lead to further adoption of the technique and improve reconstructive results. Described herein are two cases of draining infections following PPE ear reconstruction that were salvaged with satisfactory results. Laryngoscope, 2024.

Minimally Invasive Techniques for Facial Rejuvenation Utilizing Polydioxanone Threads.

Cosmetic procedures to combat the effects of aging are increasing in demand. Surgical interventions, such as rhytidectomy, have long been the standard method of providing a more youthful appearance. However, these procedures are costly, often require general anesthesia, and have potential risks such as scarring and prolonged recovery. A safe, effective, alternative to surgery is the nonsurgical thread-lift. Nevertheless, proper patient selection is critical for optimal outcomes and for patient and provider satisfaction. Over the past decade, these treatments have gained significant popularity for patients to achieve a more rejuvenated appearance with less complications and minimal downtime.

Endoscopic-Indocyanine Green Angiography Assisted Microtia Reconstruction.

Described herein is an innovative, minimally-invasive technique to harvest temporoparietal fascia flap used in implant-based ear reconstruction for children with microtia. This technique utilizes a never previously described application of intra-operative Indocyanine Green Angiography to optimize flap viability and minimizing the risk of facial nerve injury. Laryngoscope, 133:3615-3618, 2023.

Dual Option Microtia Clinic: A Comparison of Outcomes in Microtia Reconstruction Using Autologous Rib or Porous Polyethylene Implant.

Introduction: Auricular reconstruction techniques most frequently utilize either autologous costal cartilage or alloplastic porous polyethylene (PPE) implant. Objectives: To compare the aesthetic outcomes, number of surgeries, and complications in children who underwent microtia reconstruction with either rib or PPE implant by blinded photograph review. Methods: This retrospective cohort study included consecutive pediatric patients who underwent auricular reconstruction with either autologous cartilage or PPE between November 2017 and February 2022. Blinded observers rated each postoperative ear through a web-based survey. Data on patient characteristics, operative time, length of admission, and complications were collected, bivariate analyses were performed using chi-square or Fisher's exact tests for categorical variables and Wilcoxon rank-sum test for continuous variables. Results: Forty-four ears were included, 28 of which (63.6%) were reconstructed with cartilage. Median patient age was 8 years (range 4-18 years) and 29 (65.9%) were male. The cartilage group had more surgeries (median 2.5 vs. 1.0, p < 0.001), and total operating time across all surgeries did not differ significantly. Conclusion: The two groups in our study had similar rates of complications and aesthetic scores, and aesthetic scores were worse for ears with wound complications requiring unplanned revisions.

Patient Perception of Education, Care Coordination, and Psychological Distress After Developing Facial Paralysis: A Qualitative Study.

Importance: The management of vestibular schwannoma may include observation, microsurgical resection, or radiation of a tumor near the facial nerve. Injury to the facial nerve can result in facial paralysis with major functional, social, and psychological sequelae, and the experiences of patients after paralysis are not well studied. Objective: To (1) identify patient preparedness for developing facial paralysis and how well their care is coordinated following its development and (2) present in their own words outcomes of facial paralysis in terms of physical health, emotional health, self-perception, and social interactions. Design, Setting, and Participants: A qualitative observational study was performed using semistructured interviews at a tertiary care academic medical center. Semistructured interviews were conducted between January 1, 2018, and June 30, 2019, with adults aged 25 to 70 years who developed facial paralysis after treatment for vestibular schwannoma. Data were analyzed from July 2019 to June 2020. Main Outcomes and Measures: Perceptions of the educational and emotional experiences of individuals who developed complete facial paralysis after surgical treatment of vestibular schwannoma. Results: Overall, 12 participants were interviewed (median age, 54 years [range, 25-70 years]; 11 were female). Saturation was achieved after 12 interviews, indicating that no further information could be elicited from additional interviews. Four major themes were identified: (1) lack of sufficient patient education about the diagnosis of facial paralysis; (2) lack of appropriate care coordination related to facial paralysis; (3) changes in physical and emotional health following facial paralysis; and (4) changes in social interactions and external support following facial paralysis. Conclusions and Relevance: It is well-known that patients with facial paralysis have reduced quality of life, severe psychological and emotional sequelae. However, little is currently done to help prepare patients for this undesirable outcome. In this qualitative study of facial paralysis, patients express, in their own words, their feeling that the education and management of facial paralysis by their clinicians was inadequate. Before patients undergo surgery, and certainly after injury to the facial nerve, clinicians should consider the patient's goals, preferences, and values to ensure that a comprehensive educational program and psychosocial support system are implemented. Facial reanimation research has not adequately captured these key patient factors associated with the quality of communication.

Accelerating surgical training and reducing the burden of surgical disease in Haiti before and after the earthquake.

In general, university-based global health initiatives have tended to focus on expanding access to primary care. In the past, surgical programs may have been characterized by sporadic participation with little educational focus. However, there have been some notable exceptions with plastic surgery volunteer missions. We offer another model of regularly scheduled surgical trips to rural Haiti in plastic and general surgery. The goal of these trips is to reduce the burden of surgical disease and ultimately repair every cleft lip/palate in Haiti. Another principal objective is to accelerate the training of American residents through increased case load and personal interaction with attending surgeons in a concentrated period. Diversity of the case load and the overall number of surgeries performed by residents in a typical surgical trip outpaces the experiences available during a typical week in an American hospital setting. More importantly, we continue to provide ongoing training to Haitian nurses and surgeons in surgical techniques and postoperative care. Our postoperative complication rate has been relatively low. Our follow-up rates have been lower than 70% despite intensive attempts to maintain continued communication with our patients. Through our experiences in surgical care in rural Haiti, we were able to quickly ramp up our trauma and orthopedic surgical care immediately after the earthquake. Project Medishare and the University of Miami continue to operate a trauma and acute care hospital in Port au Prince. The hospital provides ongoing orthopedic, trauma, and neurosurgical expertise from the rotating teams of American surgeons and training of Haitian surgeons in modern surgical techniques. We believe that surgical residencies in the United States can improve their training programs and reduce global surgical burden of disease through consistent trips and working closely with country partners.

Minimally Invasive Techniques for Facial Rejuvenation Utilizing Polydioxanone Threads.

Cosmetic procedures to combat the effects of aging are increasing in demand. Surgical interventions, such as rhytidectomy, have long been the standard method of providing a more youthful appearance. However, these procedures are costly, often require general anesthesia, and have potential risks such as scarring and prolonged recovery. A safe, effective, alternative to surgery is the nonsurgical thread-lift. Nevertheless, proper patient selection is critical for optimal outcomes and for patient and provider satisfaction. Over the past decade, these treatments have gained significant popularity for patients to achieve a more rejuvenated appearance with less complications and minimal downtime.

The Role of Subcutaneous Radiofrequency-Assisted Liposculpture in the Facial Plastic Surgeon's Practice.

Importance: Percutaneous radiofrequency-based skin tightening procedures can offer patients an option to undergo a potential treatment for skin laxity and excess adipose of the face and neck with less downtime, lower cost, and decreased risk of complications compared with more aggressive open procedures such as neck lift, face and neck lift, and platysmaplasty. Observations: FaceTite and AccuTite can safely yet effectively deliver energy into the subdermal space, targeting the dermal collagen network and deeper fascial layer. Ideal candidates have early jowl formation, mild to moderate skin laxity, and submental adiposity. Relevance & Conclusions: From the perspective of facial plastic surgeons, these procedures can enhance the volume of an aesthetic practice by welcoming patients who may not otherwise present for face and neck rejuvenation out of fear from surgery. Furthermore, many of these minimally invasive patients will ultimately return for surgical rejuvenation later in life.

Transcutaneous Radiofrequency Microneedling in the Facial Plastic Surgeon's Practice: A Review.

Importance: Minimally invasive methods for skin rejuvenation are in high demand. A diverse array of minimally invasive devices has been developed for aesthetical purposes and should be considered to help patients achieve their goals. Observations: Radiofrequency (RF) microneedling is a safe and effective intervention for treatment of various aesthetical and dermatological conditions in all skin types. This review highlights Morpheus8 (InMode, Inc., Irvine, CA) and what differentiates it from other similar devices. Conclusions and Relevance: RF microneedling addresses aesthetical and dermatological concerns for a diverse variety of patients in whom surgical intervention may not be desired. Morpheus8 has unique technological properties and advances that make it the preferred device for many practices.

Microtia Reconstruction and Erector Spinae Block in Children: A Case Series With Chart Review.

OBJECTIVES: Autologous reconstruction of microtia is advantageous due to its inherent biocompatibility and long-term stability, but postoperative pain associated with costal harvest is a significant issue. A well-planned pain management approach is imperative. Our objective is to introduce the novel application of erector spinae block anesthesia in pediatric microtia reconstruction and evaluate its impact on pain scores, use of opioids, and hospital length of stay. STUDY DESIGN: Case series with chart review. SETTING: Patients undergoing stage 1 microtia reconstruction at a tertiary pediatric hospital. METHODS: Data collected included demographics, opioid amounts, Wong-Baker FACES Pain Rating Scale scores, opioid-related side effects, and hospital length of stay. We used generalized estimating equations to examine the effect of erector spinae block use on total opioid use and pain scores and a linear regression model to assess the effect on hospital stay. RESULTS: Forty-seven patients were included: 14 in the erector spinae block group and 33 in the continuous wound pump group. The mean age was 8.3 years (SD, 2; range, 6-13), and 13 (32%) were female. Patients in the erector spinae block group had a 65.44% decrease in adjusted total opioid use (95% CI, -79.72% to -41.10%; P < .0001), a decrease in length of hospital stay (ß = -1.69 [95% CI, -2.11 to -1.26], P < .0001), and no difference in reported pain scores when compared with patients in the continuous wound pump group. CONCLUSIONS: This study demonstrates that early experience with an erector spinae block resulted in decreased opioid use and shorter hospital stay as compared with continuous wound infiltration with local anesthetic.

Trends in Operative Complex Middle and Upper Maxillofacial Trauma: A 17-Year Study.

OBJECTIVES/HYPOTHESIS: Over 3 million incidents of facial trauma occur each year in the United States. This study aims to determine trends in operative middle and upper maxillofacial trauma in one of the largest US cities. STUDY DESIGN: Retrospective case-control study. METHODS: Retrospective chart review of all operative middle and upper maxillofacial trauma from July 1993 to July 2010 presenting to Los Angeles County Hospital, a Level I Trauma Center. Data included demographics, mechanism of injury, and fracture characteristics. RESULTS: Analysis was performed for a total of 4,299 patients and 5,549 facial fractures. Mean patient age was 34.6, and most patients were male (88%). Between the two time periods (1993-2001 and 2002-2010), there was a 42% reduction in operative maxillofacial trauma (3,510 to 2,039). Orbital floor and zygomaticomaxillary complex fractures were the most prevalent types of fractures. Panfacial fractures demonstrated the largest reduction in number of fractures (325 to 5, P<0.01). Assault and motor vehicle accidents (MVA) were the two most common mechanisms of injury. Operative fractures due to MVAs decreased (390 to 214, P = .74), whereas fractures due to assault increased (749 to 800, P<0.01). Compared to adults, pediatric facial trauma (age < 18) were caused by a higher percentage of MVAs (27% vs. 13%), auto versus pedestrian (9% vs. 5%), and gunshot wounds (8% vs. 4%) (P<0.01). CONCLUSIONS: Operative middle and upper maxillofacial trauma decreased over a 17-year period. Assault was the most significant mechanism of trauma overall. These trends suggest that focusing future prevention strategies on curtailing interpersonal violence may more effectively address the burden of facial trauma. LEVEL OF EVIDENCE: 3 Laryngoscope, 131:1985-1989, 2021.

ERAS for Head and Neck Tissue Transfer Reduces Opioid Usage, Peak Pain Scores, and Blood Utilization.

OBJECTIVES: We implement a novel enhanced recovery after surgery (ERAS) protocol with pre-operative non-opioid loading, total intravenous anesthesia, multimodal peri-operative analgesia, and restricted red blood cell (pRBC) transfusions. 1) Compare differences in mean postoperative peak pain scores, opioid usage, and pRBC transfusions. 2) Examine changes in overall length of stay (LOS), intensive care unit LOS, complications, and 30-day readmissions. METHODS: Retrospective cohort study comparing 132 ERAS vs. 66 non-ERAS patients after HNC tissue transfer reconstruction. Data was collected in a double-blind fashion by two teams. RESULTS: Mean postoperative peak pain scores were lower in the ERAS group up to postoperative day (POD) 2. POD0: 4.6 ± 3.6 vs. 6.5 ± 3.5; P = .004) (POD1: 5.2 ± 3.5 vs. 7.3 ± 2.3; P = .002) (POD2: 4.1 ± 3.5 vs. 6.6 ± 2.8; P = .000). Opioid utilization, converted into morphine milligram equivalents, was decreased in the ERAS group (POD0: 6.0 ± 9.8 vs. 10.3 ± 10.8; P = .010) (POD1: 14.1 ± 22.1 vs. 34.2 ± 23.2; P = .000) (POD2: 11.4 ± 19.7 vs. 37.6 ± 31.7; P = .000) (POD3: 13.7 ± 20.5 vs. 37.9 ± 42.3; P = .000) (POD4: 11.7 ± 17.9 vs. 36.2 ± 39.2; P = .000) (POD5: 10.3 ± 17.9 vs. 35.4 ± 45.6; P = .000). Mean pRBC transfusion rate was lower in ERAS patients (2.1 vs. 3.1 units, P = .017). There were no differences between ERAS and non-ERAS patients in hospital LOS, ICU LOS, complication rates, and 30-day readmissions. CONCLUSION: Our ERAS pathway reduced postoperative pain, opioid usage, and pRBC transfusions after HNC reconstruction. These benefits were obtained without an increase in hospital or ICU LOS, complications, or readmission rates. LEVEL OF EVIDENCE: 3 Laryngoscope, 131:E792-E799, 2021.

Physiology and Medical Treatments for Alopecia.

Androgenetic alopecia (AGA) is the most common hair loss disorder in men and women. The characteristic and reproducible balding pattern in AGA negatively affects self-image and the external perceptions of the balding patient. The phenotypical changes are driven by dihydrotestosterone (DHT) and its precursor testosterone. DHT induces follicle miniaturization and hair cycle changes until resulting hairs no longer extrude through the skin surface. AGA is inherited in a polygenetic pattern and is susceptible to epigenetic and environmental factors. Currently, minoxidil, finasteride, and photolaser therapy are the only Food and Drug Administration-approved medical treatments for AGA.

Analysis of the operative utilization of concurrent rhinoplasty and endoscopic sinus surgery.

OBJECTIVES/HYPOTHESIS: To quantify and analyze the concurrent performance of rhinoplasty (RP) (with or without septoplasty) and functional endoscopic sinus surgery (FESS). STUDY DESIGN: Cross-sectional analysis. METHODS: Current Procedural Terminology codes were used to extract cases of RP (n = 22,360), FESS (n = 99,173), and concurrent RP with FESS (RP + FESS) (n = 1,321) within the State Ambulatory Surgery Databases of California, Florida, Maryland, and New York from 2009 to 2011. Patient demographics, surgeon volume, charge, concurrent nasal procedures, and operating room (OR) time were compared. RESULTS: Among the 1,321 RP + FESS combination cases, a majority involved primary rhinoplasty (n = 697, 52.8%), followed by nasal valve repair (n = 563, 42.6%) and revision rhinoplasty (n = 61, 4.6%). High-volume (n > 30), medium-volume (n = 10-30), and low-volume rhinoplasty surgeons (n ≤ 9) were observed to perform a similar number of FESS + RP combination surgeries (153, 152, and 155, respectively). A majority of RP + FESS involved two or fewer sinuses (65%). Mean OR time for RP + FESS was 189.4 ± 4.2 minutes, approximately 50 minutes shorter than the sum of standalone RP performed individually (138.8 ± 1.0 minutes) and standalone FESS (102.9 ± 0.4 minutes). CONCLUSIONS: RP + FESS more frequently involved fewer sinuses (compared with FESS alone) and was also less likely to involve revision rhinoplasty (compared with rhinoplasty alone); therefore, these cases may be selected for lower sinus disease burden and less complex rhinoplasty compared to standalone procedures. Procedures combining rhinoplasty and sinus surgery had a reduction in OR time compared to the hypothetical sum of two standalone procedures. LEVEL OF EVIDENCE: NA Laryngoscope, 130:E311-E319, 2020.

Emerging Trends in Nasal Surgery: What Is the Impact of a Bioabsorbable Nasal Implant?

BACKGROUND: A bioabsorbable nasal valve implant (NVI) was introduced in 2016 as a minimally invasive solution to nasal valve collapse. Historically the introduction of less invasive procedures performable in-office has resulted in an increase in volume. Our objective is to evaluate this trend as it relates to nasal vestibular repair, and its impact on healthcare utilization. METHODS: We interrogated the Medicare Part B national database for nasal vestibular repair (CPT code: 30465), Unlisted nasal procedure (30999) and septoplasty (30520) from 2010 to 2017. Septoplasty was used as a surrogate for overall nasal procedural rate. Linear regression modeling was used to examine the changes in reported vestibular repair rate adjusting for septoplasty rate. RESULTS: In the Medicare population, the rate of septoplasty was stable from 2010 to 2017, increasing from 26,962 to 30,194 at an annual rate of 1.5%. Coding for unlisted nasal procedure increased from 272 to 333 at an adjusted annual rate of 1.1% over this time period. Coding for nasal vestibular repair increased from 2026 to 5331 over this interval at an adjusted annual rate of 0.9% from 2010 to 2016 but significantly increased to 5% between 2016 to 2017 (P < .0001). CONCLUSION: The reported volume of nasal vestibular repair increased significantly in the year following Food and Drug Administration approval of NVIs. In the absence of a corresponding increase in septoplasty, this temporal relationship suggests that the introduction of NVIs impacted the utilization of this procedural code. LEVEL OF EVIDENCE: N/A Laryngoscope, 2020.