Outcomes of Autologous Versus Irradiated Homologous Costal Cartilage Graft in Rhinoplasty.

Background: Autologous costal cartilage (ACC) and irradiated homologous costal cartilage (IHCC) are commonly used in septorhinoplasty when there is insufficient septal cartilage for grafting. Objective: To assess the surgical outcomes of patients who underwent septorhinoplasty with either ACC or IHCC as measured by rates of infection, resorption, warping, and revision rate. Methods: A retrospective analysis of patients who underwent rhinoplasty with ACC or IHCC at a single academic institution was performed. Demographic data, surgical details, antibiotic use, and outcomes, including surgical duration, infection, resorption, warping, and revision rate, were analyzed using Fisher's exact test, chi-squared test, and logistic regression. Results: One hundred forty-three patients were identified. The median age was 48 years (interquartile range: 35-57.5) and 62.2% (n = 89) were female, 61 patients (42.7%) underwent ACC, and 82 (57.3%) IHCC. Revision rate in both groups was similar (ACC = 14.8%, IHCC = 14.6%; p = 0.98). There was no difference in infection rate (ACC = 4.9%, IHCC = 3.7%; p = 0.71). Postoperative deformity and nasal obstruction were the most common indications for revision surgery. Surgical time was shorter with IHCC (p < 0.01). Mean follow-up time was 26.5 months (±25) for ACC, and 16 months (±12) for IHCC. Conclusions: ACC and IHCC are similar in terms of effectiveness and safety in septorhinoplasty.

Assessment of Artificial Intelligence Performance on the Otolaryngology Residency In-Service Exam.

Objectives: This study seeks to determine the potential use and reliability of a large language learning model for answering questions in a sub-specialized area of medicine, specifically practice exam questions in otolaryngology-head and neck surgery and assess its current efficacy for surgical trainees and learners. Study Design and Setting: All available questions from a public, paid-access question bank were manually input through ChatGPT. Methods: Outputs from ChatGPT were compared against the benchmark of the answers and explanations from the question bank. Questions were assessed in 2 domains: accuracy and comprehensiveness of explanations. Results: Overall, our study demonstrates a ChatGPT correct answer rate of 53% and a correct explanation rate of 54%. We find that with increasing difficulty of questions there is a decreasing rate of answer and explanation accuracy. Conclusion: Currently, artificial intelligence-driven learning platforms are not robust enough to be reliable medical education resources to assist learners in sub-specialty specific patient decision making scenarios.

Association of a Statewide Opioid Legislation with Opioid Prescribing Patterns in Facial Plastic and Reconstructive Procedures.

Background: The Michigan Opioid Laws are legislation enacted between 2017 and 2018 as a strategy to combat the growing opioid crisis. Objective: To compare opioid prescription rates and morphine milligram equivalents (MMEs) of opioid prescribed to patients undergoing various facial plastic and reconstructive surgery (FPRS) procedures before, during, and after legislation enactment. Materials and Methods: This is a cross-sectional retrospective review of subjects undergoing any of 10 FPRS procedures between July 2016 and November 2019 at a tertiary care hospital with analysis of demographic factors, opioid prescription rates, and MMEs over time. Results: Of 863 patients included, 107 and 575 patients were prescribed postoperative opioids before and after opiate legislation enactment, respectively, with no difference in baseline demographics between groups. Regression analysis showed no change in MME prescribing in the year before legislation (p = 0.70), followed by a decrease of 0.13 MME per day (p = 0.00), with a subsequent stabilization of MME at a reduced rate for the remainder of the study period (p = 0.74). Conclusion: Enactment of the Michigan Opioid Laws was temporally associated with a decrease in opioid prescriptions for common facial plastic surgery procedures.

Lip and Perioral Trauma: Principles of Aesthetic and Functional Reconstruction.

Successful management of lip and perioral trauma requires a nuanced understanding of anatomy and surgical techniques. Surgical correction is particularly challenging in instances of tissue loss, due to a narrow tolerance for aesthetic deformity and highly specialized functions of the perioral region, including facial expression, communication, and oral competence. Restoring continuity of the orbicularis oris musculature is critical for dynamic sphincter function of the upper and lower lips. Lip and perioral tissue symmetry are also critical for aesthetic balance, and failure to restore a natural appearance can adversely affect personal identity, with attendant psychological trauma. This discussion of lip and perioral trauma management encompasses lip and perioral anatomy, evaluation of injuries, reconstructive techniques, and prevention and management of complications. Perioral injuries are classified by size, depth, and extent of injury, and the corresponding reconstructive approaches are a function of complexity. These approaches proceed sequentially up rungs of the reconstructive ladder including primary repair, local flaps, grafting, regional flaps, as well as microvascular free tissue transfers. Procedures may be single stage or require multiple stages or subsequent refinement. Regardless of the defect size or location, the guiding principle of repair in the perioral region is restoring natural function and aesthetic appearance. This still-evolving area of facial plastic and reconstructive surgery lends itself to artistry and technical precision, offering opportunities for further innovation to improve the outcomes of patients with lip and perioral trauma.

Paramedian forehead flap pedicle division after 7 days using laser-assisted indocyanine green angiography.

The paramedian forehead flap is a major workhorse for reconstruction of medium- to large-sized nasal defects. The tissue bridge that results from the vascular pedicle results in significant cosmetic deformity, with associated social and occupational costs to the patient. This prospective cross-sectional study sought to assess efficacy and safety of takedown of the flap pedicle at 1 week using indocyanine green (ICG) angiography to assist in determining neovascularization of the flap. This study was performed at a tertiary care center from April 13, 2018 to March 22, 2019. Patients eligible for enrollment included those with defects appropriate for reconstruction with a paramedian forehead flap, partial-thickness defect, vascularized tissue in more than 50% of the recipient bed, and lack of nicotine use. Ten patients were included, and all underwent reconstructive surgery by a single surgeon. Laser-assisted ICG angiography was used during the first stage as well as at the second stage both immediately before and after flap division. Perfusion was in both time-independent and time-dependent analyses relative to a cheek reference point. Herein, we found successful 7-day flap takedown with no flap-related complications in all patients. There was an average of approximately 44% flap-to-cheek vascularity across all patients, and pre-division flap perfusion correlated well with post-division perfusion. In conclusion, in carefully selected patients with amenable defects, division of the pedicle at 1 week after initial flap transfer is safe and has the potential to limit the morbidity associated with the procedure.

Change in Postoperative Opioid Prescribing Patterns for Oculoplastic and Orbital Procedures Associated With State Opioid Legislation.

Importance: Understanding whether statewide legislation, such as the Michigan Opioid Laws, is associated with reduction in postoperative opioid prescriptions is informative in guiding future legislation. Objective: To identify changes in opioid prescribing patterns for oculoplastic and orbital procedures associated with the enactment of the Michigan Opioid Laws in 2017 and 2018. Design, Setting, and Participants: This cross-sectional study included 3781 patients who underwent any of 10 common oculoplastic and orbital procedures between June 1, 2016, and November 30, 2019, at a tertiary care institution. Exposures: From 2017 to 2018, Michigan enacted a series of laws to address the state's worsening opioid epidemic. Two major components of this legislation enacted on June 1, 2018, required prescribers to review a report of patients' opioid use history and obtain signed consent after educating patients on the use and disposal of opioids prior to prescribing. Main Outcomes and Measures: Demographic information, type of surgery, type and amount of opioid prescriptions, and morphine milligram equivalent (MME) were analyzed. MME was calculated as the product of dose, quantity, and opioid-specific conversion factor for each prescription. Linear interpolation spline regression was used to evaluate the association of prescription MME with time. Results: Of 3781 patients, 1614 (42.7%) were male. The mean (SD) age at the time of surgery was 63.3 (16.6) years. Of 2026 patients undergoing surgery before June 1, 2018, 1782 (88.0%) were prescribed postoperative opioids; of 1755 patients undergoing surgery after June 1, 2018, 878 (50.0%) were prescribed postoperative opioids (P < .001). There was no difference in age, sex, race/ethnicity, surgery type, or opioids prescribed between these 2 cohorts. Linear interpolation spline regression showed a decrease of 26.025 MMEs (equivalent to a 36.2% reduction of mean MME) between June 1, 2017, and September 30, 2018 (ß, -1.735; 95% CI, -0.088 to -0.024; P < .001), stabilizing at a persistently reduced rate of MME prescribed through the end of the study period (October 1, 2018, to November 30, 2019; ß, -0.005; 95% CI, -0.039 to 0.016; P = .42). Changes in MME in the 12 months before or 12 months after the period of legislation enactment were not identified. Conclusions and Relevance: In this cross-sectional study, reduction in opioid prescriptions for oculoplastic and orbital procedures was observed during the enactment period of the Michigan Opioid Laws and appeared to be sustained through the end of the study period. Similar statewide or national legislations aimed at increasing prescriber awareness and patient education on opioid use may help curtail the prescription opioid epidemic.

Effect of Nasal Steroids on Nasal Obstruction in Septal Deviation: A Double-Blind Randomized Controlled Trial.

Objective: This study sought to prospectively determine the effect of intranasal steroids versus placebo on nasal obstruction in septal deviation. Methods: This was a single-center randomized placebo-controlled double-blind trial with crossover in which all study participants received 6 weeks of therapy with Nasacort (Chattem, Inc.) and with Ayr saline spray (B.F. Ascher). Participants were randomized to one of two groups with a 2-week washout period between drugs. Nasal Obstruction Symptom Evaluation (NOSE) scores were collected at baseline and after each study drug. A subset of patients subsequently underwent surgical intervention after both drugs and additional NOSE scores were collected postoperatively. Results: Forty-two patients completed both study drugs with NOSE scores collected. Thirty-two patients underwent surgery and postoperative NOSE scores were collected. There was no significant difference in baseline demographics between the groups. There was no significant difference in mean NOSE scores in either group from baseline to the completion of the first and second study drugs. There was no difference in the change in mean NOSE score from baseline to postsaline (-3.9) versus baseline to poststeroid (-5.8, p = 0.60). Surgery resulted in a significant change in NOSE score at all postoperative time points (mean of -50, range of -47.2 to -53.6). Conclusions: We found no significant effect of intranasal steroids on nasal obstruction as compared with placebo. Surgery, however, was associated with significant sustained improvement in nasal obstruction. These data suggest that in patients with nasal obstruction due to a fixed cause, medical therapy with intranasal steroids is unlikely to be beneficial.

Nasal Obstruction after Mohs Surgery: Prevention and Correction.

As rates of Mohs micrographic surgery (MMS) have risen over recent decades in the setting of increased incidence of nonmelanoma skin cancer, so too has the need for post-Mohs reconstruction. The nose is one of the most common sites of post-MMS nasal reconstruction and presents unique challenges that often require expertise in facial plastic and reconstructive surgery. In addition to the aesthetic importance of the nose, preserving nasal function and preventing nasal obstruction are paramount to successful nasal reconstruction. This article will provide a brief review of nasal anatomy, with a focus on particular anatomic risk factors for post-MMS reconstruction nasal obstruction, strategies to prevent nasal obstruction, as well as techniques to correct the problem when it arises.

Evaluation of Antibiotic Prophylaxis in Rhinoplasty: A Systematic Review and Meta-analysis.

IMPORTANCE: Although antibiotic prophylaxis following rhinoplasty is widespread, the evidence on antibiotic prophylaxis effectiveness and the superiority of particular administration regimens is controversial. To date, a meta-analysis on the topic has not been performed. OBJECTIVE: To systematically review the association between use of preventive antibiotics and postoperative complications in patients undergoing rhinoplasty and quantify the review through meta-analysis. DATA SOURCES: MEDLINE, Embase, CINAHL, Central (Cochrane Controlled Register of Trials), Scopus, and Web of Science were searched with prospectively designed search phrases on February 16, 2018. All databases were searched from database inception. Key search terms included rhinoplasty, nasal valve repair, and antibacterial agent. STUDY SELECTION: Randomized clinical trials (RCTs) with adults (≥18 years) undergoing rhinoplasty and including systemic antibiotic medications administered in the absence of other reasons for use of an antibiotic (eg, localized or systemic infection), without restrictions on language or the time of publication, were included in the study. Interventions of interest were classified into 3 types: (1) single-dose systemic antibiotic administered within 24 hours before the first incision, (2) multidose systemic antibiotic treatment started within 24 hours before the first incision and continuing after the operation, and (3) systemic antibiotic therapy (single dose or multidose) started within 24 hours after the first incision. The following comparisons were made: for the interventions of type 1, no antibiotic; for the interventions of types 2 or 3, no antibiotic or an intervention of type 1. DATA EXTRACTION AND SYNTHESIS: Data extraction was compliant with PRISMA guidelines and Cochrane Handbook for Systematic Reviews of Interventions. Two independent reviewers assessed the relevance of the remaining records at abstract and full-text stages. Meta-analysis pooled with random-effects model. MAIN OUTCOMES AND MEASURES: Difference in infectious complication rate between groups. RESULTS: A total of 262 records were identified; of these, only 5 RCTs fulfilled predetermined population, intervention, comparison, and outcome criteria. The pooled study sample consisted of 589 participants. No significant differences in outcome of preventive antibiotic therapy given either preoperatively or postoperatively were found, with a pooled risk ratio of 0.92 (95% CI, 0.35-2.43; P = .86). CONCLUSIONS AND RELEVANCE: This study appears to be the first Cochrane-protocol systematic review and meta-analysis investigating preventive antibiotics in rhinoplasty. This study's results suggest that pooled evidence from the 5 RCTs does not support the use of preventive antibiotic therapy in rhinoplasty. LEVEL OF EVIDENCE: 1.

Risk of Venous Thromboembolism in Patients With Keratinocyte Carcinoma.

IMPORTANCE: Although malignancy is an established risk factor for venous thromboembolism (VTE), the risk of VTE specifically in patients with keratinocyte carcinoma (KC) has not been previously studied. OBJECTIVE: To determine the risk of VTE in patients with KC compared with patients not diagnosed with cancer and with patients diagnosed with common malignant neoplasms associated with VTE. DESIGN, SETTING, AND PARTICIPANTS: Population-based retrospective analysis of patient insurance claims made between January 1, 2007, and December 31, 2014, from the Truven MarketScan Commercial and Medicare Supplemental Databases. Patients treated across the United States were divided into 3 cohorts: patients with KC, patients with pancreatic cancer or acute myelogenous leukemia who are thus at high risk for VTE, and patients without a history of common malignant neoplasms. Patients were excluded from the KC cohort if they had a history of another type of cancer. Data were analyzed between April 1, 2017, and January 15, 2018. MAIN OUTCOMES AND MEASURES: Diagnosis of VTE within 1 year following the index date (for the KC and high-risk cohorts, the date of the initial diagnosis of cancer; for the control cohort, the date following 365 days of continuous insurance enrollment). Logistic regression was used to assess the risk of VTE in the KC cohort compared with the high-risk and control cohorts before and after matching across patient characteristics and known risk factors for VTE. RESULTS: Of 5 753 613 potentially eligible patients, the final sample consisted of 740 246 patients (12.8%) across 3 cohorts. Of the 740 246 study participants, 417 839 were in the KC cohort (223 986 [53.6%] men, mean [SD] age, 64.2 [13.6] years); 314 736 were in the control cohort (135 203 [43.0%] men, 42.9 [15.2] years); and 7671 were in the high-risk cohort (3502 [45.7%] men, 59.4 [14.4] years) The risk of VTE in the KC cohort was lower compared with the high-risk cohort in univariable analysis (odds ratio [OR], 0.22; 95% CI, 0.20-0.23; P < .001), multivariable analysis (OR, 0.29; 95% CI, 0.26-0.32; P < .001), and after matching across patient characteristics and known risk factors (OR, 0.52; 95% CI, 0.35-0.78; P = .001). The risk of VTE in the KC cohort was higher in the univariable analysis (OR, 2.31; 95% CI, 2.23-2.41; P < .001), lower in the multivariable analysis (OR, 0.85; 95% CI, 0.80-0.90; P < .001), and not different after matching of patient characteristics and risk factors (OR, 0.95; 95% CI, 0.89-1.01; P = .08) than that of the control cohort. CONCLUSIONS AND RELEVANCE: The results of this study provided no evidence supporting the increased risk of VTE in the KC cohort compared with the control cohort. Given the inherent risks of chemoprophylaxis, the need for prophylactic anticoagulation in patients with KC who are scheduled for surgery should be carefully considered. LEVEL OF EVIDENCE: NA.

Clinical characteristics of laryngeal versus nonlaryngeal amyloidosis.

OBJECTIVES/HYPOTHESIS: Amyloidosis represents a heterogeneous group of disorders marked by abnormal protein formation and deposition. Laryngeal amyloidosis is rare and classically thought to remain isolated with little risk of systemic involvement or associated malignancy. This study sought to further characterize differences in clinical characteristics between patients with laryngeal and nonlaryngeal amyloidosis. STUDY DESIGN: Retrospective case-control study. METHODS: The Stanford Translational Research Integrated Database Environment was searched to identify patients with biopsy-confirmed laryngeal amyloidosis and patients with amyloidosis without laryngeal involvement on endoscopy. Mann-Whitney U and χ2 tests were used for statistical analysis. RESULTS: Of 865 patients treated for amyloidosis between 1996 and 2016, 22 (2.5%) patients with biopsy-proven laryngeal amyloidosis were identified. An additional 22 patients with amyloidosis of a different organ and negative laryngoscopy-and therefore without laryngeal amyloidosis-were identified as controls. Compared to these controls with nonlaryngeal amyloidosis, patients with laryngeal amyloidosis were younger (mean age 52.8 years vs. 68.4 years, P < .0006), and 18% had additional organ involvement. Immunoglobulin light-chain amyloidosis was the most common subtype in both groups of patients. Eighty-six percent of patients with laryngeal amyloidosis required surgical excision, and of these patients, over 30% required multiple excisions. CONCLUSIONS: There is a significant rate (18%) of multiorgan involvement in patients with laryngeal amyloidosis, which contradicts conventional concepts that this is an isolated disorder. This finding could have a significant impact on the evaluation and management of patients with laryngeal amyloidosis. LEVEL OF EVIDENCE: 3b. Laryngoscope, 128:670-674, 2018.

Septoplasty: Basic and Advanced Techniques.

Nasal septal deviation is a prevalent problem that can have significant quality of life ramifications. Septoplasty is commonly performed to provide qualitative and quantitative benefit to those with nasal obstruction owing to septal deviation. Although a standard, basic technique is often adequate for individuals with mild to moderate mid to posterior septal deviation, unique challenges arise with caudal septal deviation. Herein, multiple strategies that attempt to address anterior septal deviation are discussed. Anterior septal reconstruction has been shown to be a safe and effective means by which to address severe caudal septal deviation and long-term reduction in preoperative symptoms.

In vivo Wnt pathway inhibition of human squamous cell carcinoma growth and metastasis in the chick chorioallantoic model.

BACKGROUND: Head and neck squamous cell carcinoma (HNSCC) is an aggressive cancer with poor overall survival. New therapeutic strategies that target specific molecular lesions driving advanced disease are needed. Herein we demonstrate the utility of the chicken chorioallantoic membrane (CAM) assay for in vivo human HNSCC tumor growth and metastasis and the tumor suppressive effects of a new chemotherapeutic agent. METHODS: We tested anti-metastatic effects of a WNT pathway inhibitor, WNT974 (also known as LGK974), which targets porcupine (PORCN) the palmityl-transferase that is essential for secretion of Wnt proteins. CAM assays were performed with 8 HNSCC cell lines: UM-SCC-1, UM-SCC-10A, UM-SCC-10B, UM-SCC-11A, UM-SCC-14A UM-SCC-17A, UM-SCC-17B, UM-SCC-25, and UM-SCC-34. RESULTS: UM-SCC-1 (University of Michigan Squamous Cell Carcinoma cell line) CAM xenografts contain CD44+ and ALDH+ cancer stem cell (CSC) proportions similar to UM-SCC-1 mouse xenografts supporting the applicability of the CAM assay for study of CSCs. Inhibition of WNT signaling by the PORCN inhibitor WNT974 reduced metastatic spread of UM-SCC cells, especially in UM-SCCs with Notch1 deficiency. CONCLUSIONS: Our data demonstrate decreased tumor growth and metastases in tumors from cell lines that showed in vitro responses to WNT974, providing evidence that this agent may have a role in future HNSCC therapy.