Socioeconomic Disparities in Postoperative Outcomes of Osteocutaneous Fibula Free Flaps for Head and Neck Reconstruction.

BACKGROUND: Osteocutaneous fibula free flaps (FFFs) are a fundamental component of reconstructive surgery in the head and neck region, particularly after traumatic injuries or oncologic resections. Despite their utility, FFFs are associated with various postoperative complications, such as infection, flap failure, and donor site morbidity, impacting up to 54% of cases. This study aimed to investigate the influence of socioeconomic variables, with a particular focus on median household income (MHI), on the incidence of postoperative complications in FFF reconstruction for head and neck cancer. METHODS: A retrospective analysis of 80 patients who underwent FFF reconstruction for head and neck cancer at a single center from 2016 to 2022 was conducted. Demographic and patient characteristics, including race, MHI, insurance type, history of radiation therapy, and TNM (tumor, node, metastasis) cancer stage, were evaluated. Logistic regression, controlling for comorbidities, was used to assess the impact of MHI on 30-, 90-, and 180-day postoperative complications. RESULTS: The patient population was predominantly male (n = 51, 63.8%) and White (n = 63, 78.8%), with the majority falling within the $55,000 to $100,000 range of MHI (n = 51, 63.8%). Nearly half of the patients had received neoadjuvant radiation treatment (n = 39, 48.75%), and 36.25% (n = 29) presented with osteoradionecrosis. Logistic regression analysis revealed that the $55,000-$100,000 MHI group had significantly lower odds of developing complications in the 0- to 30-day postoperative period when compared with those in the <$55,000 group (odds ratio [OR], 0.440; 95% confidence interval [CI], 0.205-0.943; P = 0.035). This trend persisted in the 31- to 90-day period (OR, 0.136; 95% CI, 0.050-0.368; P < 0.001) and was also observed in the likelihood of flap takeback. In addition, the $100,000-$150,000 group had significantly lower odds of developing complications in the 31- to 90-day period (OR, 0.182; 95% CI, 0.035-0.940; P = 0.042). No significant difference was found in the >$150,000 group. CONCLUSIONS: Median household income is a significant determinant and potentially a more influential factor than neoadjuvant radiation in predicting postoperative complications after FFF reconstruction. Disparities in postoperative outcomes based on income highlight the need for substantial health care policy shifts and the development of targeted support strategies for patients with lower MHI.

Correcting for Rater Effects in Operating Room Surgical Skills Assessment.

OBJECTIVE: To estimate and adjust for rater effects in operating room surgical skills assessment performed using a structured rating scale for nasal septoplasty. METHODS: We analyzed survey responses from attending surgeons (raters) who supervised residents and fellows (trainees) performing nasal septoplasty in a prospective cohort study. We fit a structural equation model with the rubric item scores regressed on a latent component of skill and then fit a second model including the rating surgeon as a random effect to model a rater-effects-adjusted latent surgical skill. We validated this model against conventional measures including the level of expertise and post-graduation year (PGY) commensurate with the trainee's performance, the actual PGY of the trainee, and whether the surgical goals were achieved. RESULTS: Our dataset included 188 assessments by 7 raters and 41 trainees. The model with one latent construct for surgical skill and the rater as a random effect was the best. Rubric scores depended on how severe or lenient the rater was, sometimes almost as much as they depended on trainee skill. Rater-adjusted latent skill scores increased with attending-estimated skill levels and PGY of trainees, increased with the actual PGY, and appeared constant over different levels of achievement of surgical goals. CONCLUSION: Our work provides a method to obtain rater effect adjusted surgical skill assessments in the operating room using structured rating scales. Our method allows for the creation of standardized (i.e., rater-effects-adjusted) quantitative surgical skill benchmarks using national-level databases on trainee assessments. LEVEL OF EVIDENCE: N/A Laryngoscope, 2024.

Rationale for the Development of a Novel Clinical Grading Scale for Postoperative Facial Nerve Function: Results of a Multidisciplinary International Working Group.

OBJECTIVE: The objective of the current study was to present the results of an international working group survey identifying perceived limitations of existing facial nerve grading scales to inform the development of a novel grading scale for assessing early postoperative facial paralysis that incorporates regional scoring and is anchored in recovery prognosis and risk of associated complications. STUDY DESIGN: Survey. SETTING: A working group of 48 multidisciplinary clinicians with expertise in skull base, cerebellopontine angle, temporal bone, or parotid gland surgery. RESULTS: House-Brackmann grade is the most widely used system to assess facial nerve function among working group members (81%), although more than half (54%) agreed that the system they currently use does not adequately estimate the risk of associated complications, such as corneal injury, and confidence in interrater and intrarater reliability is generally low. Simplicity was ranked as the most important attribute of a novel postoperative facial nerve grading system to increase the likelihood of adoption, followed by reliability and accuracy. There was widespread consensus (91%) that the eye is the most critical facial region to focus on in the early postoperative setting. CONCLUSIONS: Members were invited to submit proposed grading systems in alignment with the objectives of the working group for subsequent validation. From these data, we plan to develop a simple, clinically anchored, and reproducible staging system with regional scoring for assessing early postoperative facial nerve function after surgery of the skull base, cerebellopontine angle, temporal bone, or parotid gland.

Reconstruction in open anterior skull base surgery: A review and algorithmic approach.

PURPOSE: Defects resulting from open resection of anterior skull base neoplasms are difficult to reconstruct. Our objective was to review the literature and describe an evidence-based algorithm that can guide surgeons reconstructing anterior skull base defects. METHODS: A research librarian designed database search strategies. Two investigators independently reviewed the resulting abstracts and full text articles. Studies on reconstruction after open anterior skull base resection were included. Studies of lateral and posterior skull base reconstruction, endoscopic endonasal surgery, traumatic and congenital reconstruction were excluded. Based on the review, a reconstructive algorithm was proposed. RESULTS: The search strategy identified 603 unique abstracts. 53 articles were included. Adjacent subsites resected, defect size, radiotherapy history, and contraindications to free tissue transfer were identified as key factors influencing decision making and were used to develop the algorithm. Discussion of the reconstructive ladder as it applies to skull base reconstruction and consideration of patient specific factors are reviewed. Patients with a prior history of radiotherapy or with simultaneous resection of multiple anatomic subsites adjacent to the anterior skull base will likely benefit from free tissue transfer. CONCLUSIONS: Reconstruction of anterior skull base defects requires knowledge of the available reconstructive techniques and consideration of defect-specific and patient-specific factors.

Visual Attention to Facial Defects Predicts Willingness to Pay for Reconstructive Surgery.

Background: The relationship between the value of reconstructive surgery and the visual attention drawn by facial deformity has not been studied. Objectives: We hypothesized that willingness to pay (WTP) for reconstructive surgery would increase as visual attention to deformity increased in a Mohs defect eye-tracking model. Methods: We conducted a randomized observational study. Eighty casual observers participated in timed eye-tracking trials utilizing preoperative and postoperative photographs from 32 patients with facial Mohs defects. Fixation on each defect was quantified in milliseconds. For each photograph, casual observers reported how much they would be willing to pay for a perfect reconstruction and rated defect severity and patient attractiveness. The associations between defect fixation time and WTP, attractiveness, and severity were modeled using a multivariate mixed-effects model. Results: Increased defect fixation time was associated with increased WTP (regression coefficient = 0.332651, p < 0.001), decreased attractiveness (regression coefficient = -0.221779, p < 0.001), and increased severity (regression coefficient = 0.363111, p < 0.001). As defect fixation time increased, WTP increased exponentially. Conclusions: Observer WTP for facial reconstruction increases exponentially as defects become more distracting. These findings justify the dedication of health care resources to reconstructive procedures that decrease attentional distraction to the greatest extent possible.

Do Attending and Trainee Surgeons Agree on What Happens in the Operating Room During Septoplasty?

Background: Surgeons must select cases whose complexity aligns with their skill set. Objectives: To determine how accurately trainees report involvement in procedures, judge case complexity, and assess their own skills. Methods: We recruited attendings and trainees from two otolaryngology departments. After performing septoplasty, they completed identical surveys regarding case complexity, achievement of goals, who performed which steps, and trainee skill using the septoplasty global assessment tool (SGAT) and visual analog scale (VAS). Agreement regarding which steps were performed by the trainee was assessed with Cohen's kappa coefficients (κ). Correlations between trainee and attending responses were measured with Spearman's correlation coefficients (rho). Results: Seven attendings and 42 trainees completed 181 paired surveys. Trainees and attendings sometimes disagreed about which steps were performed by trainees (range of κ = 0.743-0.846). Correlation between attending and trainee responses was low for VAS skill ratings (range of rho = 0.12-0.34), SGAT questions (range of rho = 0.03-0.53), and evaluation of case complexity (range of rho = 0.24-0.48). Conclusion: Trainees sometimes disagree with attendings about which septoplasty steps they perform and are limited in their ability to judge complexity, goals, and their skill.

Predictors of Free Flap Volume Loss in Nonosseous Reconstruction of Head and Neck Oncologic Defects.

OBJECTIVES: Free tissue reconstruction of the head and neck must be initially overcorrected due to expected postoperative free flap volume loss, which can be accelerated by adjuvant radiation therapy. In this study, we aim to identify patient and treatment-specific factors that may significantly contribute to this phenomenon and translate these characteristics into a predictive model for expected percent free flap volume loss in a given patient. METHODS: Patients with a history of oral cavity and/or oropharyngeal cancer who underwent nonosseous free flap reconstruction were reviewed between January 2009 and November 2018 at a tertiary care center. Demographics/characteristics, total radiation dose, radiation fractionation (RF), and pre/postradiation free flap volume as evaluated by computed tomography imaging were collected. Free flap volume was measured by a fellowship-trained neuroradiologist in all cases. Only patients receiving adjuvant radiotherapy with available pre/postradiation imaging were included. Multivariable linear regression modeling for prediction of free flap volume loss was performed with optimization via stepwise elimination. RESULTS: Thirty patients were included for analysis. Mean flap volume loss was 42.7% ± 17.4%. The model predicted flap volume loss in a significant fashion (P = .004, R2 = 0.49) with a mean magnitude of error of 9.8% ± 7.5%. Age (ß = 0.01, P = .003) and RF (ß = -0.01, P = .009) were individual predictors of flap volume loss. CONCLUSIONS: Our model predicts percent free flap volume loss in a significant fashion. Age and RF are individual predictors of free flap volume loss, the latter being a novel finding that is also modifiable through hyperfractionation radiotherapy schedules.

Vascularized Prelaminated Thermoplastic Bioabsorbable Scaffold in Tracheal Reconstruction.

Successful tracheal reconstruction remains a challenging task for the reconstructive surgeon. A variety of techniques have been previously employed, using both autografts and allografts. The authors present a novel method for tracheal reconstruction utilizing a prelaminated fascial flap in conjunction with a bioabsorbable scaffold. Laryngoscope, 132:550-553, 2022.

Primary diffuse large B-cell lymphoma of the nasal bone and palate: An unusual clinical presentation.

Primary bone lymphomas account for 3-5% of extranodal non-Hodgkin lymphomas in adults and are typically present in the axial skeleton and weight-bearing bones. We present a unique case of primary bone diffuse large B-cell lymphoma (DLBCL) of the nasal bone and palate. We discuss the pathologic and radiologic findings and review the current literature and clinical management to highlight how this unusual clinical entity should be considered in differential diagnoses of head and neck bone masses.

Intraoperative Radiographic Assessment of Bone Resection Margins During Mandibulectomy: A Case Series.

BACKGROUND AND PURPOSE: Mandibulectomy remains the treatment of choice for oral cavity squamous cell carcinoma with infiltration of bone and for benign tumors with full mandibular thickness involvement. Although bone resection margins are critical for patient outcomes, intraoperative immediate bone margins assessment is inadequate, and few alternative options have been described. The purpose of this study was to describe the use of an existing intraoperative radiographic system for objective determination of bone resection margins during mandibulectomy. METHODS: We conducted a retrospective case series of all patients at the Greater Baltimore Medical Center who underwent mandibulectomy and received intraoperative Faxitron radiography from January 1, 2016, to March 1, 2019. Patient characteristics including age, sex, diagnosis, tumor location, clinical and pathologic stage, procedure performed, and bone resection margins were reviewed. RESULTS: A total of 10 patients underwent mandibulectomy with intraoperative radiography. Nine (90%) received surgery for squamous cell carcinoma, with 1 (10%) for ameloblastoma. Out of those with squamous cell carcinoma, tumor location varied, and all were clinically stage T4. Final pathologic margins were negative in all cases (10/10), though in 2 cases, close margins were assessed intraoperatively, leading to further resection or change in operative plan. CONCLUSION: Intraoperative radiographic assessment of bone resection margins is a promising technique, though further validation is required.

Predicting Resting Oral Commissure Tone Outcomes Following Masseter Nerve Transfer in Facial Reanimation.

Objective: To quantify the degree of oral commissure resting tone improvement in patients undergoing masseter to facial nerve transfer. Methods: A retrospective cohort study was completed in a tertiary academic medical practice. Consecutive cases of masseter nerve transfer patients within a patient database were evaluated from 6/2012 to 9/2017. Inclusion criteria were patients >18 years of age, with complete unilateral paralysis, receiving a masseter to facial nerve transfer, with at least 12 months of recovery, and possessing complete pre- and postoperative data. Patients were excluded if a simultaneous adjunctive procedure was performed so that tone could not be attributed to masseter transfer alone. The main outcome measure was the facial asymmetry index (FAI): the measured difference in distance between the medial canthus and oral commissure of the healthy and paralyzed sides. Results: Twenty-nine patients met inclusion and exclusion criteria and were further analyzed for this study. The oral commissure symmetry improved from 4.7 ± 2.8 mm preoperatively to 2.2 ± 2.3 mm postoperatively. In multivariate analysis, the preoperative FAI was the only significant predictive factor for improvement in commissure symmetry at rest (r = 0.589). This suggests that for each 1.0 mm of worse preoperatively oral commissure asymmetry, the improvement postoperatively was 0.6 mm. Age, gender, body mass index, side of paralysis, duration of paralysis, and recipient branch of facial nerve were not significant predictors in a multivariate analysis. Conclusion: Masseter to facial nerve transfer yields an estimated 60% correction in the oral commissure asymmetry. This estimation may be helpful in determining if adjunctive procedures should be utilized.

Free Functional Gracilis Flaps for Facial Reanimation in Elderly Patients.

Importance: The free functional gracilis flap (FFGF) is a versatile procedure in reanimating the paralyzed face, yet its application in seniors is limited by perceptions of morbidity and inefficacy. Objective: The study objective was to compare the morbidity and effectiveness of FFGF reanimation among senior and younger patients. Design, Setting, and Participants: A retrospective chart review was performed on 20 consecutive patients aged 60 years and above (seniors) and 35 patients aged 40 years and below (juniors) who underwent FFGF for facial reanimation. Among this group, 16 senior and 22 junior patients with available long-term follow-up data were analyzed for functional outcomes. Main Outcomes and Measures: The length of postoperative stay and postoperative complications were compared with assess immediate results. A second analysis for functional outcomes was assessed by resting and smile facial asymmetry index (FAI), as well as maxillary dental display to compare facial tone and lip excursion. Results: The average age of seniors was 67 ± 5 years and that of juniors was 27 ± 10 years. Mean lengths of postoperative stay were 4 ± 2 versus 3 ± 1 days in seniors versus Juniors, respectively (p = 0.16). There were no intraoperative complications and postoperative complications in one (5%) senior and four (11%) juniors (p = 0.64). There was functional muscle recovery in all cases, with more pronounced correction of both resting (Δ3.0 mm vs. Δ2.4 mm, p = 0.66) and dynamic (Δ5.2 mm vs. Δ4.2 mm, p = 0.37) FAI in seniors than in juniors. Among patients who underwent a multivector FGFF, there was an additional three versus one visualized maxillary teeth (p = 0.03) in seniors versus juniors, respectively. Conclusions and Relevance: The FFGF is effective for facial reanimation among seniors and can be performed with minimal morbidity. Age alone should not preclude the application of the FFGF in seniors with a preference for more dynamic options.

Management of Complicated Nasal Defects.

The nose is the most common site for nonmelanoma skin cancer. Fortunately, most skin cancer lesions on the nose are discovered early and their timely diagnosis and excision result in superficial defects that can be reconstructed with minimal impact on the aesthetics and function. Reconstruction of full-thickness defects of the nose remains a challenging endeavor for reconstructive surgeons. An organized and systematic approach is necessary to streamline the analysis, planning, and reconstruction complex nasal defects to consistently achieve optimal results. This article reviews options for reconstructing full-thickness nasal defects and highlights current advances in established techniques.

The African Rhinoplasty.

Across ethnicities, patients seeking rhinoplasty have similar goals-a natural looking nose that fits and complements the rest of their facial features. Beyond a harmonious nose, patients of African descent have a particularly strong desire for ethnically congruent results in spite of individual aesthetic rhinoplasty preferences. This strong appeal for ethnically sensitive alterations is fueled by the desire to maintain physical identification with one's African ethnicity. There are psychosocial penalties when rhinoplasty outcomes stray toward complete racial transformation. Consequently, rhinoplasty in patients of African descent requires a fundamental understanding of acceptable beauty norms, associated psychological underpinnings, as well as unique facial and nasal features among Africans. Beyond these ethnically sensitive nuances, classic rhinoplasty techniques of framework modification with cartilage contouring, grafting, and bone remodeling are applicable in reshaping the African nose.

Normal Gaze Patterns of the Face in Lateral View.

Importance: Current efforts to quantify the attentional distraction of facial deformities have been limited to deformities that are best perceived when the face is in frontal view, and there remains a paucity of knowledge of societal perception of the face in lateral view. To date, no attempts have been made to characterize the fixation patterns of the face in lateral view. Objective: To characterize the fixation patterns and gaze patterns of the face in lateral view. Design, Setting, and Participants: This was a prospective randomized controlled trial at an academic tertiary medical center. Eighty participants (mean age 23.6 ± 1.7 years, 52.5% female) gazed freely at 11 images of faces in lateral view for 10 s each as an infrared eye-tracker recorded eye movements in real time. Main Outcomes and Measures: Recorded eye movements are superimposed on the images to visualize areas of interest (AOIs) that attract the most attention. Fixation duration targeted at each AOI is transformed into relative fixation of the entire face and neck. Hotelling's test of variance followed by post hoc t-testing assessed for the significance of fixation differences between the mouth and cheeks. Results: Participants spent an average of 6.0 (95% CI 5.8-6.2) s gazing at the face and neck areas of each image. Of this attention, 2.8 s or 49.8% (45.4-54.2%) was directed toward the eye, followed distantly by the nose (mean, 95% CI) (16.4%, 14.5-18.3%), cheek (12.0%, 11.4-14.5%), neck (4.6%, 3.8-5.4%), and mouth (4.0%, 3.4-4.6%). These differences were found to be significant by Hotelling's analysis and post hoc testing. A student's t-test also indicated observers directed significantly more attention within the eye-nose-cheek triangle [4.6 s or 79.5% (75.6-83.5)] compared with the eye-nose-mouth triangle [4.1 s or 71.2% (66.9-75.5)] (p < 0.001). Conclusions and Relevance: When perceiving novel faces in lateral view, casual observers preferentially directed attention toward the eye, nose, and cheek. These findings suggest that we draw from a slightly different collection of features to build a schema of the sagittal face, which may serve to complement the central triangle and build upon a three-dimensional model of the "normal" human face. Level of Evidence: NA.