Gender-Affirming Facial Surgery: Experiences and Outcomes at an Academic Center.

Background: Gender-affirming facial surgery (GFS) is becoming more widely available for transgender individuals, but data on surgical approaches and outcomes remain limited. Methods: Retrospective analysis of surgical outcomes among consecutive GFS cases performed at a tertiary care academic center between March 2016 and August 2020. Results: Seventy-seven patients underwent 109 surgeries, including 478 individual procedures. The median age was 42 years. Ninety-five percent of patients had public health insurance. Two-stage GFS was often used in older patients (p = 0.001), with the first stage involving bone and cartilaginous alterations, and the second stage involving soft tissue procedures. Mean hospital stay after first-stage GFS was 1.2 days, with 70% discharged on postoperative day 1. Mean follow-up was 11.3 months. Among 66 patients with at least 1 month of follow-up, all complications were minor and included surgical site infection (5%), dehiscence (3.0%), seroma (3%), and medical complications (6%). Thirty-day hospital readmission rate was 1.5%. Conclusions: There are unique surgical approaches for GFS, which demonstrate low complication and readmission rates. Understanding these approaches and outcomes may help guide preoperative patient consultations and clinical decision making.

The effect of a statewide prescription drug monitoring program on opioid prescribing patterns.

PURPOSE: Determine whether opioid prescribing patterns have changed as a result of implementation of a prescription drug monitoring program (PDMP) in the state of Massachusetts. MATERIALS AND METHODS: A multicentered retrospective study was performed including patients who received tonsillectomy, parotidectomy, thyroidectomy or direct laryngoscopy and biopsy with or without rigid esophagoscopy and/or rigid bronchoscopy at Lahey Hospital and Medical Center (Burlington, MA) or Boston Medical Center (Boston, MA). Opioid prescribing patterns were compared for the 12 months prior to implementation of the Massachusetts Prescription Awareness Tool (MassPAT) to 36 months of prescribing patterns post implementation. Quantity of opioids prescribed was based on morphine milligram equivalents (MME). Continuous variables were compared using analysis of variance (ANOVA) while categorical variables were compared using chi-squared test or Fisher's exact test. Multivariate analysis was performed using linear regression. RESULTS: A total of 2281 patients were included in the study. There was a significant association in mean overall MME prescribed comparing pre-MassPAT and post-MassPAT data [tonsillectomy: 635.9 ± 175.6 vs 463.3 ± 177.7 (p < 0.0001), parotidectomy: 250.4 ± 71.33 vs 169.8 ± 79.26 (p < 0.0001), thyroidectomy: 186.2 ± 81.14 vs 118.3 ± 88.79 (p < 0.0001), direct laryngoscopy with biopsy: 308.3 ± 246.9 vs 308.3 ± 246.9 (p = 0.0201)]. There was also a significant association between length of opioid prescription (days) and implementation of MassPAT, but there was no significant difference in the percent of patients requiring refills pre- MassPAT and post-MassPAT. CONCLUSION: This study demonstrates that prescribers have been able to significantly decrease the amount of opioids prescribed for tonsillectomy, parotidectomy, thyroidectomy, and direct laryngoscopy and biopsy and patients have not required additional opioid refills.

The Impact of MassPAT on Opioid Prescribing Patterns for Otolaryngology Surgeries.

OBJECTIVE: Determine whether opioid prescriber patterns have changed for tonsillectomy, parotidectomy, and thyroidectomy after implementation of the Massachusetts Prescription Awareness Tool (MassPAT). STUDY DESIGN: Retrospective cohort study. SETTING: Single-center tertiary care hospital. METHODS: Patients were included if they received tonsillectomy, parotidectomy, or thyroid surgery at Lahey Hospital and Medical Center (Burlington, Massachusetts) between October 1, 2015, and October 1, 2019. Prescribing patterns were compared prior to implementation of MassPAT, October 1, 2015, to October 14, 2016, to postimplementation of MassPAT, October 15, 2016, to October 1, 2019. Quantity of opioids prescribed was described using total morphine milligram equivalents (MME). Data were analyzed using univariate analysis, multivariate analysis, and trend line using line of best fit. RESULTS: A total of 737 subjects were included in the study. There was a downward trend in the quantity of opioids prescribed for all 3 surgeries during the study period. There was a significant difference in the quantity of opioids prescribed pre- and postimplementation of MassPAT for tonsillectomy (647.70 ± 218.50 MME vs 474.60 ± 185.90 MME, P < .001), parotidectomy (241.20 ± 57.66 MME vs 156.70 ± 72.99 MME, P < .001), and thyroidectomy (171.20 ± 93.77 MME vs 108.50 ± 63.84 MME, P < .001). There was also a decrease in the number of patients who did not receive opioids for thyroidectomy pre- and post-MassPAT (7.56% vs 24.14%). CONCLUSION: We have demonstrated that there is an association with state drug monitoring programs and decrease in the amount of opioids prescribed for acute postoperative pain control for common otolaryngology surgeries.

Immediate Postoperative Radiation Therapy after Free Tissue Transfer for Keloid Treatment.

Keloids present a challenging clinical problem due to their propensity for recurrence and need for adjuvant therapy. We present a case where a large keloid resection required free tissue transfer and immediate radiation therapy was employed 24 hours postoperatively. There were no significant issues with flap survival, wound healing, or recurrence 2 years postoperatively. This is the first case report of successful radiation treatment 1 day after reconstruction of the head and neck with a free flap. Laryngoscope, 131:E1818-E1820, 2021.

Factors Associated With Distribution of Female Otolaryngology Residents in United States.

OBJECTIVE: The gender balance within medicine, and specifically within otolaryngology, is equalizing. It is important to determine the factors that impact the distribution of female residents among otolaryngology programs in the United States to better understand factors that may affect these changing trends. STUDY DESIGN: Retrospective Study. METHODS: Cross-sectional analysis was performed using data from 2018 of otolaryngology residents at 90 programs across the United States. Each program's website was searched for a current resident roster. Data of geography, number of female faculty, number of female physicians in leadership positions, program setting, and program size were obtained. Statistical comparison of these factors with number of female residents was performed with P < .05 as significant. RESULTS: There was a significant association between programs having a higher-than-average female faculty representation and a greater representation of female residents (P < .001). Larger residency programs were more likely to have greater female representation (P = .010). There was a slight predominance of both female residents and female faculty at urban programs (odds ratio [OR] = 1.27, P = .04; OR = 1.28, P = .03). Geographic location, presence of a female chairperson, and presence of a female residency program director were not associated with higher female-to-male resident ratio. CONCLUSION: Availability of female role models in faculty, along with program setting and size, may be more likely to promote greater female representation. Focusing on gender equality in the workplace can help promote diversity in the workforce and improve patient outcomes. LEVEL OF EVIDENCE: NA Laryngoscope, 131:E367-E372, 2021.

The case of the eyelid silicone granulomas.

Foreign body granulomas can develop even several years after autologous fat or filler injection. In some instances the foreign body granulomas have been found at sites other than the original injection site. We present a case of a 48-year-old male with reported "hyaluronic acid fillers" injected into his upper and lower eyelids several years prior. He subsequently developed periorbital swelling with negative allergic and rheumatologic workup. The patient ultimately underwent a blepharoplasty for improvement of the swelling. Histopathology suggested silicone granulomas of the upper and lower eyelid. This case illustrates the importance of keeping foreign body granulomas on the differential for all patients with a history of facial dermal filler injections. Although hyaluronic acid is the most common dermal filler, providers should suspect the use of other dermal fillers including those not FDA approved particularly when common conservative treatment methods are not sufficient.

Does suturing tonsil pillars post-tonsillectomy reduce postoperative hemorrhage?: A literature review.

OBJECTIVE: Literature review comparing post-tonsillectomy hemorrhage in pediatric and adult patients with and without suturing tonsil pillars to investigate whether suturing tonsil pillars reduces the risk of post-tonsillectomy hemorrhage. REVIEW METHODS: Online journal databases were searched using the key phrases "post tonsillectomy hemorrhage", "post tonsillectomy bleed", and "tonsil pillar suture". 10 published studies were found regarding tonsil pillar suturing, four directly related to postoperative bleeding and five focusing on postoperative pain reduction. There was one study that evaluated both pain and bleeding. The pain reduction studies were comprised of 225 patients while the postoperative bleeding studies included 3987 patients. CONCLUSIONS: Suturing tonsil pillars after tonsillectomy may be beneficial after cold tonsillectomy. IMPLICATIONS FOR PRACTICE: Post-operative bleeding is one of the most common complications that can result in increased patient distress and hospitalization. In this article, we provide a literature review of tonsil pillar suturing and post-tonsillectomy hemorrhage. Our study suggests suturing the tonsil pillars immediately post-tonsillectomy may reduce the risk of severe post-operative bleeding requiring return to the operating room for certain patients.

Rational Approach to Allergy Testing.

Allergy testing is commonly used when symptoms of allergic rhinitis are refractory to symptoms and there is potential for treatment with institution of avoidance measures or immunotherapy. Once the decision for testing has been made, the method of testing by either in vivo skin testing by prick/puncture or intradermal testing or in vitro testing of serum-specific IgE is dictated by factors in the clinical history and an informed decision by the patient. Because there is no perfect testing method, understanding the benefits and limitations of each method is important in selecting the best testing option for each patient.

Chronic methamphetamine exposure suppresses the striatal expression of members of multiple families of immediate early genes (IEGs) in the rat: normalization by an acute methamphetamine injection.

RATIONALE: Repeated injections of cocaine cause blunted responses to acute cocaine challenge-induced increases in the expression of immediate early genes (IEGs). OBJECTIVES: The aim of this study was to test if chronic methamphetamine (METH) exposure might cause similar blunting of acute METH-induced increases in IEG expression. RESULTS: Repeated saline or METH injections were given to rats over 14 days. After 1 day of withdrawal, they received a single injection of saline or METH (5 mg/kg). Acute injection of METH increased c-fos, fosB, fra2, junB, Egr1-3, Nr4a1 (Nur77), and Nr4a3 (Nor-1) mRNA levels in the striatum of saline-pretreated rats. Chronic METH treatment alone reduced the expression of AP1, Erg1-3, and Nr4a1 transcription factors below control levels. Acute METH challenge normalized these values in METH-pretreated rats. Unexpectedly, acute METH challenge to METH-pretreated animals caused further decreases in Nr4a2 (Nurr1) mRNA levels. In contrast, the METH challenge caused significant but blunted increases in Nr4a3 and Arc expression in METH-pretreated rats. There were also chronic METH-associated decreases in the expression of cAMP responsive element binding protein (CREB) which modulates IEG expression via activation of the cAMP/PKA/CREB signal transduction pathway. Chronic METH exposure also caused significant decreases in preprotachykinin, but not in prodynorphin, mRNA levels. CONCLUSIONS: These results support the accumulated evidence that chronic administration of psychostimulants is associated with blunting of their acute stimulatory effects on IEG expression. The METH-induced renormalization of the expression of several IEGs in rats chronically exposed to METH hints to a potential molecular explanation for the recurrent self-administration of the drug by human addicts.

Visual inspection versus quantitative flow cytometry to detect aberrant CD2 expression in malignant T cells.

BACKGROUND: Abnormal levels of T-cell antigen expression occur in T-cell neoplasia. We examined CD2 expression in malignant and normal T cells to determine if the level of CD2 expression differed significantly and if quantitation assisted in detecting this difference. METHOD: Flow cytometric immunophenotypic (FCI) evaluation was performed on specimens from 36 patients with mature T-cell neoplasia. Abnormal T cells were identified based upon the abnormal FCI and morphology. Levels of CD2 expression were quantitated using 1:1 PE conjugates of anti-CD2 and QuantiBRITE bead standards to calculate the antibodies bound per cell (ABC). The efficacy of ABC measurement versus simple examination of dots plots was compared. RESULTS: Abnormal levels of CD2 expression were frequently observed in mature T-cell malignancies. The CD2 ABC values were highly sensitive in detecting differences between malignant and normal T cells (P = 0.0028). In most cases (24/32 specimens, 75%), CD2 ABCs differed by >20%. CD2 ABCs had high variability in normal T cells. CONCLUSIONS: CD2 expression by malignant T cells differed significantly from that of normal T-cells by CD2 ABC quantitation. The high variability in normal T-cell CD2 ABCs limited the determination of normal reference ranges and, thus, its utility in the diagnosis of T-cell neoplasia. However, examination of CD2 can help in detection of tumor cells when residual normal T cells are present for comparison. Moreover, the increased sensitivity of CD2 quantitation is valuable in confirming FCI cases where abnormalities in CD2 expression are difficult to appreciate by visual inspection alone.