Anesthesia considerations of magnetic resonance imaging-guided focused ultrasound thalamotomy for essential tremor: a case series.

PURPOSE: Essential tremor (ET) is a common movement disorder with disability in voluntary actions such as eating and writing. First-line treatment involves pharmacological agents, although efficacy is limited by side effects. In these patients, functional neurosurgery can be considered. Magnetic resonance imaging-guided focused ultrasound (MRgFUS) thalamotomy offers a non-invasive solution for treatment. This paper examines an original cohort of ET patients undergoing MRgFUS thalamotomy and discusses the anesthetic management of these cases. METHODS: We retrospectively reviewed the anesthetic records of all MRgFUS thalamotomy cases from 15 May 2012 to 16 July 2015 at our centre (Sunnybrook Health Sciences Centre, Toronto, Canada) to expand a data set provided by the focused ultrasound system manufacturer (Insightec, Tirat Carmel, Israel) from a prior phase-II regulatory approval study. Specific drug and procedural details were listed including aspects of the patients' experience. RESULTS: A total of 82 patients were included in the analysis, 78 from a phase-II trial (16 were from the local site) and four local non-trial cases. No patient required general anesthesia and only 29% of cases required sedation to tolerate the procedure. The most frequent medications required were antiemetics and analgesics. Headache (31%) was the most frequent perioperative symptom. Transient intra-procedural paresthesia symptoms were a common occurrence (32%). CONCLUSIONS: The use of MRgFUS for thalamotomy provides a non-invasive and well-tolerated method for treating ET, which usually only requires monitored anesthesia care sedation. Nevertheless, there are several predictable side effects that require contingency planning including the personnel and means to resolve them.

RéSUMé: OBJECTIF: Le tremblement essentiel (TE) est un trouble moteur courant qui affecte les mouvements volontaires tels que se nourrir ou écrire. Le traitement de première ligne est basé sur des agents pharmacologiques, mais son efficacité est limitée par les effets secondaires. Chez de tels patients, une neurochirurgie fonctionnelle peut être envisagée. La thalamotomie par ultrasons focalisés guidés par imagerie de résonance magnétique (ou MRgFUS) offre une solution de traitement non invasive. Cet article examine une cohorte initiale de patients souffrant de TE et subissant une thalamotomie par MRgFUS et discute de la prise en charge anesthésique de ces cas. MéTHODE: Nous avons évalué de manière rétrospective les dossiers anesthésiques de toutes les interventions de thalamotomie par MRgFUS réalisées entre le 15 mai 2012 et le 16 juillet 2015 dans notre centre (Sunnybrook Health Sciences Centre, Toronto, Canada) afin d'élargir un ensemble de données fourni par le fabricant de systèmes d'ultrasons focalisés (Insightec, Tirat Carmel, Israël) basé sur une étude d'approbation règlementaire de phase II. Les médicaments spécifiques et détails procéduraux ont été enregistrés, y compris divers aspects de l'expérience des patients. RéSULTATS: Un total de 82 patients ont été inclus dans l'analyse, dont 78 participants de l'étude de phase II (16 au site local) et quatre cas locaux non inclus dans l'étude. Aucun patient n'a nécessité d'anesthésie générale et seulement 29 % des cas ont nécessité une sédation pour tolérer l'intervention. Les médicaments les plus fréquemment requis étaient les antiémétiques et analgésiques. Les céphalées (31 %) constituaient le symptôme périopératoire le plus fréquent. Des symptômes de paresthésie intra-procédurale transitoire étaient fréquents (32 %). CONCLUSION: L'utilisation de la MRgFUS pour la thalamotomie offre une méthode non invasive et bien tolérée pour le traitement du tremblement essentiel, qui ne nécessite habituellement qu'une sédation sous surveillance comme soin anesthésique. Toutefois, cette intervention a plusieurs effets secondaires prévisibles qui nécessitent un plan de contingence incluant le personnel et les moyens pour les traiter.

Effect on laryngeal adductor function of vincristine block of posterior cricoarytenoid muscle 3 to 5 months after recurrent laryngeal nerve injury.

OBJECTIVES: It has been shown in a canine model that a single injection of vincristine into the posterior cricoarytenoid (PCA) muscle at the time of recurrent laryngeal nerve (RLN) injury effectively blocks its reinnervation and results in improved adductor strength. But clinically, such injuries are usually diagnosed weeks or months after onset. Vincristine injection does not affect a muscle that is already innervated; thus, there is a limited time frame following RLN injury during which a vincristine injection could effectively improve ultimate laryngeal adductor functional recovery. A series of delayed injections was performed in a canine model and results assessed. STUDY DESIGN: Animal (canine) experiment. METHODS: The RLN was transected and repaired, and vincristine (0.4 mg) was injected into the PCA muscle at the time of injury (n=12) or 3, 4, and 5 months later (n=8 each study group). Six months after RLN injury, laryngeal adductor function was measured. Results of vincristine injection without RLN injury (n=6) and longer-term (12 months) follow-up for time zero injections (n=4) are also reported. RESULTS: The animals injected at time zero had better adductor function than non-injected controls, as reported previously, and this result was further increased at 12 months. The 3-month delay gave results similar to the time zero group. The 5-month delay group showed no vincristine benefit, and the 4-month delay group gave an intermediate result. Vincristine to the PCA had no effect on adductor function when the RLN was left intact. Plasma levels showed 19% of injected vincristine reached systemic circulation, which was cleared within 69 hours. CONCLUSIONS: Vincristine injection of the PCA muscle after RLN injury, which blocks this antagonist muscle from synkinetic reinnervation, leads to improved laryngeal adductor functional recovery. The window of opportunity to apply this treatment closes by 4 months after RLN injury in the canine model. Human RLN recovery follows a similar time course and can reasonably be expected to have a similar therapeutic window.

Through a New Lens: Skin-Grafted Free Flaps and Objective Facial Skin Color Matching.

Background: Head and neck ablative surgery can impose aesthetic disfigurement, particularly when severe color mismatch exists between native and reconstructed facial skin. To date, the accuracy, objectivity, and modifiability of facial skin color matching remains poorly understood. Objective: To measure skin color match outcomes after head and neck reconstruction using handheld colorimetry. Methods: Patients undergoing complex head and neck reconstruction involving facial skin were included. A variety of skin paddle donor sites were studied, including split-thickness skin graft (STSG) placement over myocutaneous or adipofasciocutaneous free flaps after de-epithelization. Skin color match (deltaE) was measured during follow-up using a handheld colorimeter. Results: Forty-seven patients were included, with median age 69. The most common flap type was the anterolateral thigh (n = 31, 66%). Twenty patients underwent STSG to the skin paddle. DeltaE measurements among the patients with STSGs demonstrated better color match (lowest deltaE), compared with patients with unaltered skin paddles (3.4 ± 1.0 vs. 6.5 ± 2.5, p < 0.0001). Conclusion: We found the use of STSGs over de-epithelialized myogenous or adipofasciocutaneous flaps improves color match, as measured by handheld colorimetry.

Assessment of Variability in Free Flap Color Match to Facial Skin by Donor Site and Race.

OBJECTIVES: To use portable colorimetry to quantify color differences between facial skin and potential three head and neck microvascular free tissue transfer (MFTT) donor sites-radial forearm (RF), anterolateral thigh (ALT), and fibula (FF)-and compare these differences by pigmentation of the donor site skin and self-identified race. METHODS: In this cross-sectional cohort study, healthy volunteers consented to handheld colorimeter measurements at the three potential MFTT donor sites (RF, ALT, FF) to quantify color match to the facial skin using the CIE color space (DeltaE). The comparison of ipsilateral to contralateral cheek served as control for measurements. Cross-sectional measurements in healthy volunteers were then compared to measurements obtained in postoperative head and neck MFTT patients. RESULTS: DeltaE measurements were obtained for 128 healthy controls and 24 postoperative patients (N = 152). With increasing lightness (decreased pigmentation) of the skin at the donor site, the color match significantly worsened (higher DeltaE) across all potential MFTT donor sites (all p < 0.05). DeltaE from healthy controls closely approximated postoperative color match measurements in patients who underwent cervicofacial MFTT (DeltaE RF: 5.3 vs. 6.0, p = 0.432; DeltaE ALT: 6.2 vs. 6.4, p = 0.822; DeltaE FF: 6.0 vs. 6.4, p = 0.806). CONCLUSION: Patients with decreased skin pigmentation who are undergoing head and neck MFTT may experience worse color discrepancy between cervicofacial skin and the transferred skin paddle than those with more pigmented skin. Portable colorimetry may identify patients who could benefit from interventions such as dermis-resected free tissue reconstruction with skin grafting to improve postoperative appearance. LEVEL OF EVIDENCE: 3 Laryngoscope, 134:3581-3586, 2024.

Increasing Pedicle Reach with Musculocutaneous Perforator Dissection in Anterolateral Thigh Free Flaps.

OBJECTIVE: To measure the increase in effective pedicle reach with microdissection of musculocutaneous perforators during anterolateral thigh (ALT) free tissue harvest. METHODS: A review of our institution's free flap database was performed to identify ALT free tissue transfers. The distance from pedicle vessel origin to its perforator's insertion at the fascia lata (effective pedicle length [EPL]) was measured prior to and following intramuscular dissection of musculocutaneous perforators. Pertinent clinicopathologic variables were abstracted from the electronic medical record. RESULTS: A total of 314 ALT free flaps were performed between February 2017 and August 2022. Of these, 85 had documentation of EPL before and after musculocutaneous perforator dissection. ALT reconstruction was primarily performed for reconstruction of oncologic ablative defects (66, 78%). The mean EPL prior to perforator microdissection was 8.8 cm (standard deviation, SD 2.8 cm; range 3-15 cm). Following perforator dissection, mean EPL significantly increased to 14.0 cm (SD 3.0 cm; range 7-22 cm) with a mean net gain of 5.2 cm in distance (95% confidence interval 4.8-5.6 cm; p < 0.001). Nine patients (11%) required operating room take-back for anastomosis revision (3, 3.5%), recipient site hematoma evacuation (4, 4.7%), and wound dehiscence (2, 2.3%); one complete flap loss due to venous thrombosis was observed. CONCLUSION: Dissection of musculocutaneous perforators during ALT free flap harvest can increase effective pedicle reach by 5.2 cm or nearly 60%. This harvest technique can facilitate the performance of tension-free anastomoses when substantial vascular pedicle length or vascular pedicle tunneling is required. LEVEL OF EVIDENCE: 4 Laryngoscope, 134:666-670, 2024.

The Impact of Venous Anastomosis Technique on Outcomes of Free Tissue Transfer to the Head and Neck.

Objectives: To evaluate the impact of different techniques of microvascular venous anastomosis on the outcome of free tissue transfer to the head and neck. Methods: Retrospective case series of patients undergoing microvascular free tissue transfer (MFTT) from January 2006 to September 2021. Chi-square tests and t-tests were utilized to identify differences in flap outcomes by technique, and log-binomial regression analyses were utilized to identify differences in flap outcomes by technique. Results: A total of 1055 consecutive MFTTs were analyzed. One hundred four cases required a return to the operating room for any reason, and 19 were attributed to venous compromise (18.0%). Ultimately, there were 22 FTT failures requiring complete revision (2.1%). In total, 1055 MFTTs involved 1352 venous anastomoses, ranging from 1 to 3 anastomoses in each case. End-to-end (ETE) was used 1040 times (76.9%) and end-to-side (ETS) 204 times (15.0%). The calculated risk ratio for venous complication for ETS compared with ETE was 1.17 (0.34-3.98). A microvascular coupler was used in 355 cases (33.6%). The calculated risk ratio for coupler compared with suture anastomoses was 0.92 (0.35-2.39). Conclusions: There were no significant difference in regard to outcomes of MFTT when comparing ETE with ETS, nor when comparing coupler with suture anastomoses.

Objective Photoanalysis of Feminizing Frontal Cranioplasty Outcomes.

Study Design: Retrospective analysis at a tertiary care center. Objective: This study describes a method of analyzing postoperative results using lateral view clinical photographs to create normalized projection ratios of the glabella and radix. Methods: We reviewed preoperative and postoperative photographs of 15 patients. All photographs were in the lateral view Frankfort horizontal plane. We calculated the distances between the (a) tragus and cornea, (b) cornea and radix, (c) cornea and glabella, and the (θ) nasofrontal angle. Results: Fifteen sets of patient photographs were analyzed and found that there was a favorable 14% reduction at the radix and an even greater reduction (78.9%) at the glabella. The nasofrontal angle was improved to a more feminine range from 131.84° preoperatively to 145.86° postoperatively. Conclusions: Normalized projection ratios of the glabella and radix, along with the nasofrontal angle, can be used to objectively measure outcomes of frontal feminizing cranioplasty.

Postoperative inpatient surgical complications following head and neck microvascular free tissue transfer.

BACKGROUND: Complications following head and neck microvascular free tissue transfer (MFTT) are common. Less is known about when they occur. METHOD: Retrospective study of patients with primary or recurrent head and neck cancer undergoing MFTT reconstruction at a tertiary care institution. MFTT reconstructions with inpatient postoperative complications were included. The Kruskal-Wallis test was used to compare median postoperative day (POD) onset of complication by flap type. RESULTS: Of 1090 patients undergoing MFTT reconstruction, 126 (11.6%) patients experienced inpatient complications including fibula (n = 35), anterolateral thigh (n = 60), or radial forearm (n = 31) MFTTs. POD onset was shortest for surgical site hematoma (median = 1 [IQR 1-5]), and longest for donor site infection (median = 11.5 [IQR 8-15]). There was no significant difference between flap types and POD onset of complications (p > 0.05). CONCLUSION: Hematoma formation and flap failure occur earliest during hospitalization, while dehiscence, infection, and fistula occur later. There is no difference in complication timing between flap types.

Ergonomic Assessment of Septorhinoplasty Maneuvers During Simulated Pregnancy.

Objective: Women represent an increasing proportion of the otolaryngology workforce. Work-related musculoskeletal disorders (WRMSD) are a little-studied yet important impediment to career completion. Scant attention has been directed to study the impact of pregnancy on surgeon posture and ergonomics. We piloted the use of a pregnancy simulation suit (Empathy Belly) to assess the risk of ergonomic compromise when performing open septorhinoplasty. Study Design: Surgical simulation. Setting: Single session, training simulation lab at academic medical center. Methods: Medical students and surgical residents performed the initial steps of a rhinoplasty procedure without and with a pregnancy simulation suit and were filmed with an artificial intelligence-based video analysis app from Kinetica Labs that calculates joint angles and categorizes the ergonomic risk factors. Still images from videos were taken and analyzed using validated posture-based analysis rubrics. Participants were asked to complete a qualitative questionnaire after the session. Results: Twelve medical students and surgical residents participated in the study. Posture-based analysis indicated increased ergonomics risk factors among trainees when performing a rhinoplasty while wearing the pregnancy suit. Video analysis indicated trends of worsening back angle and shoulder postures. Trainees reported experiencing pain in the neck, suprapubic area, and lower back. They acknowledged the importance of ergonomics in otolaryngology and desired further education about workplace injury risk mitigation. Conclusion: Pregnancy impacts the ergonomics of performing septorhinoplasty and further investigation is required into interventions to reduce risk of WRMSDs.

Outcomes Associated with Multiple Free Tissue Transfers Performed in a Single Day.

Background: Although microvascular free tissue transfer (MFTT) remains technically challenging, surgeons may need to perform >1 MFTT operations in a given day. Objective: To compare MFTT outcomes in cases where surgeons completed one versus two flaps per day by measuring flap viability and complication rates. Methods: A retrospective review was conducted of MFTT cases from January 2011 to February 2022 with >30-day follow-up. Outcomes, including flap survival and operating room takeback, were compared using multivariate logistic regression analysis. Results: Of 1096 patients meeting inclusion criteria (1105 flaps), there was a male predominance (n = 721, 66%). Mean age was 63.0 ± 14.4 years. Complications requiring takeback were identified in 108 flaps (9.8%) and were greatest for double flaps in the same patient (SP) (27.8%, p = 0.06). Flap failure occurred in 23 (2.1%) cases and was also greatest for double flaps in the SP (16.7%, p = 0.001). Takeback (p = 0.06) and failure (p = 0.70) rates were not different between days with one versus two unique patient flaps. Conclusions: Among patients undergoing MFTT, those treated on days in which surgeons perform two unique cases compared with single cases will demonstrate no difference in outcomes, as measured by flap survival and takeback, whereas patients with defects requiring multiple flaps will experience greater takeback and failure rates.

Anterolateral Thigh Free Flap Versus Thigh Split Thickness Skin Graft: Comparison of Morbidity in the First 30 Days.

Background: An anterior thigh split thickness skin graft (AT-STSG) is frequently needed to close the radial forearm free flap (RFFF) donor site, conferring morbidity to two extremities. The anterolateral thigh (ALT) free flap is virtually always closed primarily. Objective: To compare donor site pain, sensation, motor function, and cosmesis associated with the AT-STSG and the ALT. Methods: Patients undergoing an ALT or an RFFF with AT-STSG were enrolled in a prospective observational cohort study. Pain, tingling, numbness, lower extremity function, and subjective donor site cosmetic satisfaction were measured at 1 week and 1 month postoperation using validated instruments. Results: Forty-eight patients were included, with a mean age of 64.2 years (female 31.2%). There were no differences in age or medical comorbidities between the two groups. The average donor defect was 50 and 180 cm2 for the AT-STSG and ALT cohorts, respectively. At 1 week and 1 month postoperatively, we did not detect a difference in donor site pain, pruritus, numbness or tingling, lower extremity function, or subjective cosmetic satisfaction between the two cohorts. Conclusion: ALT primary donor site morbidity, including pain, sensory function, motor function, and cosmesis, is equivalent to RFFF secondary donor site morbidity at 1 week and 1 month postoperatively.

Assessing the Prevalence of Burnout Among Female Microvascular Head and Neck Surgeons.

Background: Research has not explicitly explored differences between male and female microvascular head and neck (MHN) surgeon burnout, which should be identified and addressed to ensure career satisfaction and longevity. Objective: To measure and compare the prevalence of burnout among male versus female MHN surgeons. Methods: A prospective questionnaire based on the Maslach Burnout Inventory (MBI) was distributed through a web-based survey to the American Association of Facial Plastic and Reconstructive Surgeons and American Head and Neck Society in 2021 and 2022. Additional variables collected included demographics, relationship and parental status, academic rank, annual salary, and COVID-19-related questions. Results: One hundred thirteen surveys were collected. Twenty-nine (25.7%) were women and all completed MHN surgery fellowships. Women trended toward more emotional exhaustion than men (2.8 mean MBI vs. 2.3 mean MBI) but reported similar personal achievement (4.8 mean MBI vs. 4.9 mean MBI). Men experienced less workplace sexual harassment (p < 0.001). Women experienced more burnout (69% vs. 39%, p = 0.006) during the COVID-19 pandemic. Conclusion: Female MHN surgeons reported in this survey to experience more workplace sexual harassment and higher COVID-19-related burnout than their male counterparts.

Outcomes of Vascularized Versus Nonvascularized Adipofascial Grafts for Parotidectomy Reconstruction.

Objectives: Parotidectomy defects can leave patients with considerable functional and cosmetic deformities. We aim to compare the success rates and complications associated with vascularized versus nonvascularized adipofascial grafts for reconstruction, including flap failure, return to surgery, infection, and delay to adjuvant treatment. Methods: Retrospective case series of patients undergoing either adipofascial anterolateral thigh (AFALT) free tissue transfer or free fat transfer (FFT) after parotidectomy from January 2010 to January 2020. Group comparisons and logistic regression were used to determine predictors of outcome measures. Results: Seventy-six patients underwent AFALT reconstruction, and 73 patients underwent FFT reconstruction. Patients treated with AFALT reconstruction had more aggressive tumor characteristics and underwent more complex resections, most commonly radical parotidectomy (n = 55, 72.4%). Postoperative complications at both the donor and recipient sites were more common in the FFT group (N = 20, 27.4% in FFT vs. N = 11, 14.5% in AFALT, odds ratio = 0.45, 95% confidence interval = 0.20-1.02, p = 0.052). Conclusions: Although used in more advanced disease and in a more heavily treated wound bed, the AFALT free flap was safe and associated with fewer infectious complications than that offered by FFT.

Restarting Therapeutic Antibiotics Following Postoperative Prophylaxis in Head and Neck Microvascular Free Tissue Transfer.

OBJECTIVE: To determine factors associated with restarting therapeutic antibiotics within 30 days of head and neck microvascular free tissue transfer (HN-MFTT). STUDY DESIGN: Retrospective study of consecutive HN-MFTTs performed from January 2015 to July 2020. SETTING: Tertiary academic medical center. METHODS: Thirty-day postoperative antibiotic use and post-HN-MFTT surgical and medical complications were assessed. Univariable analyses and multivariable logistic regression were used to evaluate risk factors associated with restarting antibiotics. RESULTS: overall 482 patients with 501 HN-MFTTs were stratified by duration of prophylaxis: ≤24 hours (n = 136, 27.1%), 25-72 hours (n = 54, 10.8%), and >72 hours (n = 311, 62.1%). Antibiotics were restarted in 199 patients (209 procedures, 42%). The most common indications for antibiotic reinitiation were flap recipient site infection (n = 59, 28%); hospital-acquired pneumonia (n = 44, 21%); and wound dehiscence, fluctuance, or change in quality of drain output (n = 44, 21%). Shorter antibiotic prophylaxis (≤24 hours) (odds ratio [OR], 1.95; 95% CI, 1.2-3.0; P = .003), osteocutaneous flaps (OR, 2.15; 95% CI, 1.3-3.4; P = .001), and prior immunotherapy/chemotherapy (OR, 2.29; 95% CI, 1.2-4.3; P = .01) were associated with reinitiation of antibiotics for surgical infections. Restarting antimicrobials for nosocomial infections was associated with aerodigestive defects (OR, 2.45; 95% CI, 1.1-5.2; P = .019), cardiovascular disease (OR, 3.00; 95% CI, 1.5-5.9; P = .001), and medical comorbidities approximated by American Society of Anesthesiologists class 3 or 4 (OR, 2.83; 95% CI, 1.5-5.4; P = .002). CONCLUSION: Aerodigestive reconstruction, 24-hour postoperative antimicrobial prophylaxis, American Society of Anesthesiologists class 3 and 4, prior chemotherapy/immunotherapy, cardiovascular disease, and osteocutaneous flaps are associated with reinitiation of antibiotics within 30 days of HN-MFTT.

Long-Term Appearance-Related Outcomes of Facial Reconstruction After Skin Cancer Resection.

Background: Aesthetic outcomes of facial reconstruction after skin cancer resection (RSCR) may affect long-term quality of life. Objective: To evaluate postoperative patient perceptions of skin cancer defect reconstruction using patient-reported outcome measures. Methods: Patients who underwent RSCR from 2016 to 2021 completed validated FACE-Q scales, including Satisfaction with Facial Appearance (SFA), Scar Appearance, and Appearance-Related Distress (ARD). Scores were scaled 0-100 and compared. Results: Sixty-one respondents completed the survey at a median of 3.0 (interquartile range: 1.6-4.1) years post-treatment. The majority had basal cell carcinomas (n = 41, 67%) and nasal defects (n = 40, 66%). Patients who received either revision surgery or office-based procedures to improve scarring reported lower satisfaction with scar appearance (65.8 ± 31.8 vs. 80.1 ± 20.8, p = 0.048). Dissatisfaction with scar appearance was correlated with decreased SFA (mean score: 76.6 ± 24.5; r = 0.44, p = 0.0004) and greater ARD (mean score: 23.8 ± 24.3; r = -0.66, p < 0.0001). Younger patients were also more likely to experience ARD (ß = -0.54, 95% confidence interval: [-0.96, -0.12, p = 0.014). SFA and ARD did not differ by operative factors, including reconstruction type, or single- versus multistage reconstruction. Conclusion: Although overall SFA after RSCR is high, regardless of reconstruction type, decreased satisfaction is correlated to poorer psychosocial function. Younger patients and those requiring revision procedures may be at greatest risk.

Patterns of Postoperative Trismus Following Mandibulectomy and Fibula Free Flap Reconstruction.

The factors that contribute to postoperative trismus after mandibulectomy and fibula free flap reconstruction (FFFR) are undefined. We retrospectively assessed postoperative trismus (defined as a maximum interincisal opening ≤35 mm) in 106 patients undergoing mandibulectomy with FFFR, employing logistic regression to identify risk factors associated with this sequela. The surgical indication was primary ablation in 64%, salvage for recurrence in 24%, and osteonecrosis in 12%. Forty-five percent of patients had existing preoperative trismus, and 58% of patients received adjuvant radiation/chemoradiation following surgery. The overall rates of postoperative trismus were 76% in the early postoperative period (≤3 months after surgery) and 67% in the late postoperative period (>6 months after surgery). Late postoperative trismus occurred more frequently in patients with ramus-involving vs. ramus-preserving posterior mandibulotomies (82% vs. 46%, p = 0.004). A ramus-involving mandibulotomy was the only variable significantly associated with trismus >6 months postoperatively on multivariable logistic regression (OR, 7.94; 95% CI, 1.85−33.97; p = 0.005). This work demonstrates that trismus is common after mandibulectomy and FFFR, and suggests that posterior mandibulotomies that involve or remove the ramus may predispose to a higher risk of persistent postoperative trismus.

Objective Outcomes of Trichophytic Brow Lift and Hairline Advancement in Facial Feminization Surgery.

Importance: The upper facial third is an important area to address in facial feminization surgery (FFS). Objective: This study seeks to quantify the changes in eyebrow, hairline, and forehead heights associated with brow lift and hairline advancement surgery in the transgender patient population. Design, Setting, and Participants: A cohort study performed at an academic medical center. Main Outcomes and Measures: Pre- and postoperative frontal view photographs underwent computer-aided photograph analysis. Brow position, hairline position, and forehead height were measured. Patient self-identified race, ethnicity, as well as other demographic factors were also collected. Results: Forty-six patients underwent FFS with brow lift and hairline advancement with photographs permitting measurement. Eyebrow analysis was performed in 33 patients. Hairline and forehead analyses were accomplished in 30 patients. The mean brow elevation was 4.6 mm across all locations. The forehead reduction achieved was 9.8-11.3 mm. Conclusion and Relevance: Trichophytic brow lifting with hairline advancement outcomes was able to be reliably quantified from standardized clinical photographs. On average, 4-5 mm of brow lift, 6-7 mm of hairline lowering, and 10-11 mm of forehead reduction were achieved, contributing to a more feminine appearance of the upper facial third.

Hepatitis C as a Potential Risk Factor for Adverse Surgical Outcomes in Head and Neck Free Tissue Transfer Reconstruction.

Background: Infection with hepatitis C virus (HCV) is associated with an increased risk of developing head and neck cancer (HNC), and negatively impacts cancer-specific survival. Objective: To measure the impact of HCV status on free tissue transfer failure, flap takeback, and length of stay in HNC patients undergoing reconstruction. Methods: We retrospectively reviewed patients who underwent head and neck free tissue transfer reconstruction at a single academic institution between August 2011 and June 2020. Results: In the HCV-infected group, total flap failure rate was 2.9% versus 1.3% in the control group and the takeback rate was 11.1% versus 9.6%. On multivariate analysis, HCV status was not associated with flap failure, flap takeback, or total length of hospital stay >7 days. Conclusion: In this study, HCV status was not associated with differences in postoperative complications or length of stay. Future research with greater numbers of HCV-positive study subjects is required to elucidate the effect of HCV infection in this patient population.

Smile Outcomes of an Externally Scarless, Intraoral Orthodromic Temporalis Tendon Transfer.

Background: Temporalis tendon transfer (TTT) often relies on external incisions in the nasolabial fold, temporal region, or both. Herein, we studied smile outcomes of a TTT technique via a single intraoral incision without external skin incisions. Objective: To measure the difference in static perioral positions before and after intraoral TTT. Methods: Five patients underwent an externally scarless TTT technique via an intraoral approach. Iris measurements were used to estimate pixel-to-millimeter conversion for facial analysis of vertical and horizontal oral commissure excursion vectors using the JAVA-based program Facegram version 1.0 (Massachusetts Eye & Ear Infirmary). Results: After surgery, mean vertical height on the affected side significantly increased from 3.4 mm to a postoperative value of 20.6 mm, p = 0.016. There was no difference in horizontal smile excursion after surgery (35.7 mm vs. 32.2 mm, p = 0.37). Smile angle difference between affected and healthy smile (Δα) reduced from 27.0° preoperative to 3.5°, representing a decrease in facial asymmetry (p = 0.002). Conclusion: Intraoral, externally scarless TTT is an effective option for dynamic facial reanimation, obviating external incisions in select patients.

Effect of microporous polysaccharide hemospheres on anterolateral thigh free flap donor site complications.

Background: Postoperative seroma is the most common donor site complication following anterolateral thigh (ALT) free flap harvest for head and neck reconstruction. The utility of novel microporous polysaccharide hemospheres (MPH) has not been studied as a hemostatic agent in this setting. Methods: Prospective, single-blind, randomized controlled trial of patients undergoing fasciocutaneous ALT harvest for head and neck reconstruction at a tertiary academic medical center between April 2018 and February 2020. The intervention (MPH) group received 3 g of topical MPH to the ALT donor site prior to closure whereas the control group did not receive application of MPH. Outcomes included total drain output (ml), drain output during postoperative days (POD) 1-3 alone, drain duration (days), and incidence of donor site hematoma, seroma, or infection. Results: Twenty-nine patients were randomized to the MPH group and 26 to the control group. For MPH and control groups, mean total drain output was 284.7 ± 153.0 ml versus 317.9 ± 177.6 ml (p = .527), mean POD 1-3 drain output alone was 169.3 ± 88.8 ml versus 157.9 ± 78.7 ml (p = .749), and drain duration was 5.9 ± 1.5 days versus 6.5 ± 1.6 days (p = .144), respectively. There was no significant difference in seroma (p = .733), hematoma (p = .492), or infection (p = 1.000). Drain output was not significantly influenced by gender, age, body weight, or smoking habits. Conclusion: MPH administration to ALT free flap donor sites did not significantly improve drain output, hematoma formation, or seroma formation.Level of Evidence 2.