Artificial intelligence for objectively measuring years regained after facial rejuvenation surgery.

BACKGROUND: Few objective measures are available for assessing the success of facial rejuvenation after face lift surgery. Convolutional neural networks (CNNs) may be used for this type of measurement. The purpose of this investigation is to use artificial intelligence (AI) via CNNs to objectively classify patient photos by age before and after aesthetic surgery. Uniquely, men and patients undergoing deep plane face lifts were included. METHODS: A CNN (FaceX) was used for facial age recognition and age estimation. Patient photos were analyzed preoperatively, and at three (PO1) and 12 months (PO2) postoperatively. The study population included male and female patients who underwent facial rejuvenation at our institution from 2017 to 2021. Patient photos were collected with the same camera, distance, and lighting. RESULTS: 226 patients were analyzed with a mean true age of 62.2 (SD 6.7) years. The AI estimated the mean preoperative age to be 64.7 (SD 10.4) years. The AI was 96.0 % accurate. Across all subjects, a 3.5-year, 5 % reduction in age (p ≤ 0.001) was attributed at PO1, and a 1.7 year, 3 % age reduction (p = 0.034) at PO2. No single ancillary procedure or technique conferred more benefit than others. The 15 males had a 2.0 year, 4 % age reduction (p = 0.06) at PO1. CONCLUSION: AI can be used to objectively measure the success of facelift surgery and compare outcomes among rhytidectomy techniques. Additionally, multiple, different approaches were effective with no single approach being superior. As AI continues to rapidly advance, more accurate models may be developed for multiple applications in facial plastic surgery.

Predictors of opioid requirement among patients receiving free flap reconstruction to the head and neck.

BACKGROUND: Opioids are a part of standard of care treatment of acute, severe postoperative pain. However, increased opioid requirements have been shown to be associated with increased postoperative complications, morbidity, and mortality. The aim of this study was to identify potential predictive factors associated with increased or decreased opioid requirements after free tissue transfer (FTT) to the head and neck. MATERIALS/METHODS: A retrospective review was conducted on subjects who underwent head and neck reconstruction (HNR) from 2015 to 2021 at a single tertiary care center. Patients with inpatient stay over 10 days and those receiving fentanyl for sedation purposes were excluded due to EMR limitations and confounding, respectively. The total dose of opioid medication each patient received was calculated and summed using morphine milligram equivalents (MME). Statistical analysis was conducted using poisson regression and multivariable regression models. RESULTS: Two hundred and ninety-one patients were included. The mean opioid requirement for all subjects was 228.6 (SD 250.0) MMEs during their entire postoperative stay and the mean length of stay was 6.0 (SD 1.7) days. An established opioid prescription prior to surgical resection was the greatest predictor of increased risk for opioid requirement according univariate and multivariate analysis 2.356 (2.321-2.392), p ≤ 0.0001 and 1.833 (1.802-1.863), p ≤ 0.0001, respectively. Fibula transfers were associated with higher opioid requirements while scapula transfers were associated with decreased opioid requirements compared to other free tissue transfer types. CONCLUSION: Preoperative opioid use was associated with higher postoperative opioid requirements. Multimodal pain management (MMPM) was not associated with a decreased opioid requirement; however, further studies are needed to investigate the hierarchy, dosing, and timing of MMPM in relation to opioid requirements and pain control.

A novel simulation module for segmental mandibulectomy and mandible reconstruction using 3D models.

INTRODUCTION: Mandibular resection and reconstruction are common but complex procedures in head and neck surgery. Resection with adequate margins is critical to the success of the procedure but technical training is restricted to real case experience. Here we describe our experience in the development and evaluation of a mandibular resection and reconstruction simulation module. METHODS: 3D printed (3DP) models of a mandible with a pathologic lesion were developed from imaging data from a patient with an ameloblastoma. During an educational conference, otolaryngology trainees participated in a simulation in which they reviewed a CT scan of the pathologic mandible and then planned their osteotomies before and after handling a 3DP model demonstrating the lesion. The adequacy of the osteotomy margins was assessed and components of the simulation were rated by participants with pre- and post-training surveys. RESULTS: 52 participants met criteria. After reviewing the CT scan, 34 participants (65.3 %) proposed osteotomies clear of the lesion. This proportion improved to 48 (92.3 %, p = 0.001) after handling the 3D model. Among those with initially adequate margins (n = 33), 45.5 % decreased their margins closer to the ideal, 27.2 % made no revision, 21.2 % widened their margins. 92 % of participants found the simulation beneficial for surgical planning and technical training. After the exercise, the majority of participants had increased confidence in conceptualizing the boundaries of the lesion (69.2 %) and their abilities to ablate (76.5 %). CONCLUSIONS: The structured mandibulectomy simulation using 3DP models was useful in the development of trainee experience in segmental mandible resection. LAY SUMMARY: This study presents the first mandibulectomy simulation module for trainees with the use of 3DP models. The use of a 3DP model was also shown to improve the quality of surgical training.

Characteristics and Outcomes of Patients Discharged Directly Home From a Medical Intensive Care Unit: A Retrospective Cohort Study.

OBJECTIVE: To evaluate the safety of directly discharging patients home from the medical intensive care unit (MICU). MATERIALS AND METHODS: Single-center retrospective observational study of consecutive MICU direct discharges to home from an urban university hospital between June, 1, 2017, and June 30, 2019. RESULTS: Of 1061 MICU discharges, 331 (31.2%) patients were eligible for analysis. Patients were divided into 2 groups based on duration of wait-time (< or ≥24 hours) between ward transfer order and ultimate hospital discharge. Most patients (68.2%) were discharged in <24 hours. Patients who waited for a floor bed for ≥24 hours prior to discharge had longer hospital length-of-stay (LOS, median 3.83 versus 2.00 days) and ICU LOS (median 3.51 versus 1.74 days). Overall, 44 (13.3%) direct MICU discharges were readmitted to the hospital within 30-days, but there was no difference in this outcome or in 30-day mortality when comparing the 2 wait-time groups. CONCLUSIONS: The practice of directly discharging MICU patients home does not negatively influence patient outcomes. Patients who overstay in the ICU after being deemed transfer-ready are unlikely to be benefiting from critical care, but impact hospital throughput and resource utilization. Prospective investigation into this practice may provide further confirmation of its feasibility and safety.

Complications and Functional Outcomes After Esophageal Reconstruction with an Intact Larynx.

BACKGROUND: Esophageal defects can result from primary pathologies such as malignancy or stricture, or secondary ones such as perforation due to trauma or iatrogenic injury. Techniques, management, and outcomes of reconstruction in this setting are poorly understood. Herein, we aim to highlight surgical outcomes in patients undergoing local and free flap reconstruction of esophageal defects in the setting of an intact larynx. METHODS: Retrospective review of patients who underwent esophageal reconstruction with an intact larynx between 2009 and 2022 at our institution was performed. RESULTS: Ten patients met inclusion criteria. Esophageal reconstruction was performed for extruded spinal hardware (n = 8), and esophageal stricture (n = 2). Four patients underwent reconstruction with free tissue transfer, and six with local pedicled flaps. There were no cases of flap failure, esophageal fistula, hematoma, or wound dehiscence. One patient had post-operative bleeding requiring return to the operating room. Three patients had a postoperative wound infection, two of whom required washout. There were no unplanned 30-day readmissions. At three months after operation, all patients who were not tube feed-dependent prior to surgery returned to oral intake. Of the four patients who were tube feed-dependent preoperatively, three were tolerating oral intake at nine months postoperatively. Nine patients (90%) had stable flexible laryngoscopy exams pre- and postoperatively with no voice changes. CONCLUSIONS: Reconstruction of esophageal defects in the setting of an intact larynx can be challenging. In this series, surgical intervention with free tissue transfer and local pedicled flaps was effective in returning patients to oral intake with low long-term morbidity. LEVEL OF EVIDENCE: 4 Laryngoscope, 134:1227-1233, 2024.

Comparison of CPAP and Expansion Sphincter Pharyngoplasty using the Mean Disease Alleviation Concept.

OBJECTIVE: Continuous Positive Airway Pressure (CPAP) is the typical first treatment for Obstructive Sleep Apnea (OSA); however, patient adherence is often suboptimal. Expansion Sphincter Pharyngoplasty (ESP) is an alternative treatment option for patients with OSA who demonstrate signs of palatal and lateral pharyngeal collapse. The aim of this study is to compare therapeutic outcomes, using the mean disease alleviation concept, for patients who underwent ESP to patients undergoing CPAP therapy. DATA SOURCES: Single-institution retrospective cohort study. METHODS: All patients who underwent ESP from 2018 to 2021 or were prescribed CPAP from December to June 2021 at our institution were assessed for inclusion. ESP patients who had pre- and post-operative sleep studies available and CPAP patients who followed up at our institution's sleep clinic were included for analysis. Charts were reviewed for demographic information and sleep study results, and treatment outcomes were measured by calculating mean disease alleviation. RESULTS: There were 77 patients in the ESP group and 107 patients in the CPAP group. AHI reduction was greater in the CPAP group (p = 0.016); however, mean disease alleviation was similar between groups (p = 0.076). One-way ANCOVA demonstrated similar MDA between groups when controlling for patient age, BMI, gender, and pre-operative AHI (F [1,177] = 2,931.6, p = 0.104). CONCLUSION: CPAP therapy provided superior reduction in AHI compared to ESP; however, overall treatment efficacy as measured by mean disease alleviation was similar for both groups. LEVEL OF EVIDENCE: 3 Laryngoscope, 133:1513-1517, 2023.

Retrograde Cricopharyngeus Dysfunction: The Jefferson Experience.

OBJECTIVES: To describe our center's experience with the identification and treatment of retrograde cricopharyngeus dysfunction (R-CPD), a syndrome involving the inability to belch previously described by only one institution. Additionally, because all patients initially learned of their condition and sought treatment as a result of social media posts, we queried their source and comfort with this form of medical referral. METHODS: Retrospective chart review of patients who underwent botulism toxin injection into the cricopharyngeus muscle for treatment of R-CPD from 2019 to 2022. Demographic data, most common symptoms at presentation, and response to treatment and complications were documented. Post-treatment questionnaires were reviewed. RESULTS: A total of 85 patients were identified. Mean age at surgery was 27 years. There were 54 (63.5%) females and 31 (36.5%) males. The inability to burp (98.8%), bloating (92.9%), gurgling noises (31.8%), and excessive flatulence (21.2%) were the most common symptoms. The minimum units of botox utilized were 25, whereas the maximum was 100. The majority of patients (88.2%) had a successful response at initial follow-up visit. The most common complication was mild dysphagia (30.6%), which was transient for all patients. Most patients learned of our practice through social media, with only one patient being referred by a medical provider. CONCLUSIONS: The majority of patients in our cohort were young and female. The inability to burp and bloating were the most common presenting symptoms. Social media was the primary source of referral. Our institution favors 80-100 units for an effective response. Laryngoscope, 133:1081-1085, 2023.

Patient Referral and Acceptance of Maxillomandibular Advancement for Obstructive Sleep Apnea.

OBJECTIVE: Maxillomandibular advancement (MMA) is an effective surgical treatment for obstructive sleep apnea (OSA); however, it is unclear how many patients who are referred for MMA actually undergo surgery. This study aims to determine follow-up rates for patients referred for MMA and the reasons behind their choices. METHODS: Via retrospective review, we assessed consecutive patients with OSA intolerant to continuous positive airway pressure (CPAP) who underwent drug induced sleep endoscopy (DISE) between 2018 and 2020 at our institution. Patients recommended for MMA based on DISE and other findings were included. Patients were then contacted and administered an IRB-approved survey in present time. RESULTS: One hundred and fifty nine patients were referred to oral maxillofacial surgery (OMFS) for MMA consult. Seventy seven patients (48%) followed up with OMFS and 29 (18%) underwent MMA. Sixty two (40%) patients resumed CPAP. Fifty eight patients (36.5%) were lost to follow up. Seventy three patients (46%) completed our survey. Of those patients, 37 (51%) followed up with OMFS and 17 (23%) underwent MMA. Patients who did not follow up with OMFS cited the invasiveness of the surgery (39%), recovery time (17%), or both (31%) as reasons. Those who pursued consultation cited inability to tolerate CPAP (73%), not being a candidate for inspire (14%), and desire to learn about alternative treatments (14%) as reasons. Of those who did not undergo MMA, 28.6% are not using OSA treatment. CONCLUSION: Less than half of patients referred for MMA followed up, and less than half of those patients underwent MMA. Most patients cited concerns about the invasiveness of the surgery and recovery process. LEVEL OF EVIDENCE: 4 Laryngoscope, 2023.

Impact of Head and Neck Cancer Diagnosis and Treatment on Patient-Partner Intimacy.

OBJECTIVE: To determine the effects of head and neck squamous cell carcinoma diagnosis and treatment on patient- and partner-perceived intimacy and to understand if a diagnosis of HPV-related head and neck squamous cell carcinoma influences patient-partner intimacy. STUDY DESIGN: Prospective observational. SETTING: Single tertiary care center. METHODS: An investigator-developed questionnaire was used to prospectively survey patients and partners in 2 groups based on human papillomavirus (HPV) status: HPV+ and HPV- at diagnosis (visit 1) and after treatment (visit 2). Surveys were scored on a 60-point scale, and results were categorized as follows: loss of intimacy (0-30), stable relationship (31-41), or improvement in intimacy (42-60). Responses of couples who participated together were assessed for concordance. Responses were considered discordant if patient and partner scores equated to different levels of perceived intimacy. Median patient and partner scores were compared via Mann-Whitney U test, and concordance was assessed with a chi-square test. RESULTS: Thirty-four patients and 28 partners completed surveys at visit 1 and 28 patients and 15 partners at visit 2. Median scores among patients and partners were similar at the first time point (HPV+, 45 vs 45, P = .64; HPV-, 42.6 vs 40.8, P = .29) and the second (HPV+, 44.5 vs 44, P = .87; HPV-, 40.2 vs 39.6, P = .90). Concordance rates between HPV+ and HPV- couples were 63% vs 44% (P = .43) for the first time point and 89% vs 50% (P = .24) for the second. CONCLUSION: Patients and partners reported stable or improved intimacy at both time points, and most couples tended to agree on their levels of perceived intimacy. A diagnosis of HPV did not appear to significantly affect intimacy scores.

CD8+ and FoxP3+ T-Cell Cellular Density and Spatial Distribution After Programmed Death-Ligand 1 Check Point Inhibition.

OBJECTIVES: To analyze CD8+ and FoxP3+ T-cell cellular density (CD) and intercellular distances (ID) in head and neck squamous cell carcinoma (HNSCC) samples from a neoadjuvant trial of durvalumab +/- metformin. METHODS: Paired pre- and post-treatment primary HNSCC tumor samples were stained for CD8+ and FoxP3+. Digital image analysis was used to determine estimated mean CD8+ and FoxP3+ CDs and CD8+-FoxP3+ IDs in the leading tumor edge (LTE) and tumor adjacent stroma (TAS) stratified by treatment arm, human papillomavirus (HPV) status, and pathologic treatment response. A subset of samples was characterized for T-cell related signatures using digital spatial genomic profiling. RESULTS: Post-treatment analysis revealed a significant decrease in FoxP3+ CD and an increase in CD8+ CDs in the TAS between patients receiving durvalumab and metformin versus durvlaumab alone. Both treatment arms demonstrated significant post-treatment increases in ID. Although HPV+ and HPV- had similar immune cell CDs in the tumor microenvironment, HPV+ pre-treatment samples had 1.60 times greater ID compared with HPV- samples, trending toward significance (p = 0.05). At baseline, pathologic responders demonstrated a 1.16-fold greater CD8+ CDs in the LTE (p = 0.045) and 2.28-fold greater ID (p = 0.001) than non-responders. Digital spatial profiling revealed upregulation of FoxP3+ and cytotoxic T-lymphocyte-associated antigen 4 (CTLA-4) in the TAS (p = 0.006, p = 0.026) in samples from pathologic responders. CONCLUSIONS: Analysis of CD8+ and FoxP3+ detected population differences according to HPV status, pathologic response, and treatment. Greater CD8+-FoxP3+ ID was associated with pathologic response. CD8+ and FoxP3+ T-cell distributions may be predictive of response to immune checkpoint inhibition. CLINICALTRIALS: gov (Identifier NCT03618654). LEVEL OF EVIDENCE: 3 Laryngoscope, 133:1875-1884, 2023.

Variance in 3D anatomic localization of surgical margins based on conventional margin labeling in head and neck squamous cell carcinoma.

OBJECTIVE: In head and neck cancer (HNC), positive margins are strongly predictive of treatment failure. We sought to measure the accuracy of localization of margin sampling sites based on conventional anatomic labels using a digital 3D-model. METHODS: Preoperative CT scans for 9 patients with HNC treated operatively at our institution were imported into a multiplanar radiology software, which was used to render a digital 3D model of each tumor intended to represent the resection specimen. Surgical margin labels recorded during the operative case were collected from pathology records. Margin labels (N = 64) were presented to participating physicians.Participants were asked to mark the anatomic location of each surgical margin using the 3D-model and corresponding radiographic planes for reference.For each individual margin, the 3D coordinates of each participant's marker were used to calculate a mean localization point called the geometric centroid. Mean distance from individual markers to the centroid was compared between participantsand margin types. RESULTS: Amongst 7 surgeons, markers were placed a mean distance of 12.6 mm ([SD] = 7.5) from the centroid.Deep margins were marked with a greater mean distance than mucosal/skin margins (19.6 [24.8] mm vs. 15.3 [14.9] mm, p = 0.034). When asked to relocate a margin following re-resection, surgeons marked a point an average of 20.6 [12.4] mm from their first marker with a range of 3.9- 45.1 mm. CONCLUSIONS: Retrospective localization of conventionally labeled margins is an imprecise process with variability across the care team. Future interventions targeting margin documentation and communication may improve sampling precision.