The I-STOP Program and Narcotic Prescriptions Following Facial Reconstructive Plastic Surgeries.

OBJECTIVES: To explore the effect of e-prescribing requirements on narcotic dispersion in New York State. Slicer Dicer was used to identify patient records based on CPT codes. METHODS: We investigated the influence of New York State e-prescribing requirements on narcotic dispersion following five common facial plastics procedures. Slicer Dicer was used to identify patient records based on CPT codes.We then looked at narcotic prescription rates following those surgeries between March 2014 and March 2018 at an academic institution. RESULTS: Overall, between March 2014 and March 2018, 76.1% of the sample received a narcotic prescription following a facial reconstructive plastic surgery. Patients who underwent rhinoplasty were most likely to receive a prescription for postoperative narcotics. The implementation of ISTOP, CPT code, use of non-narcotic adjuvant, and insurance type were each significantly associated with prescription of postoperative narcotics. Surgery time and age in years were significantly associated with prescription of postoperative narcotics. Ultimately, when controlling for the aforementioned clinical and sociodemographic variables included in the study, those who underwent surgery after the implementation of ISTOP were 42.8% less likely to receive a prescription for postoperative narcotics, aOR = 0.572, 95% CI 0.356, 0.919, p = 0.021. CONCLUSIONS: New York State's ISTOP program has succeeded in reducing the number of postoperative narcotic prescriptions following facial plastic reconstructive surgeries at this academic institution. However, opioid medications can still be utilized for postoperative analgesia when clinically appropriate. LEVEL OF EVIDENCE: 3 Laryngoscope, 134:1208-1213, 2024.

Office-based facial plastics procedures: Neuromodulators.

Botulinum toxin is a potent neuromodulator commonly used for cosmetic applications in the clinic. In this article, we reviewed the various formulations of botulinum toxin type A commercially available in the United States, as well as clinical pearls for preprocedural planning, common in-office injections, and management of complications.

Second Harmonic Imaging of Nasal, Auricular, and Costal Cartilage.

OBJECTIVE: There is little knowledge about the histological organization of facial and costal cartilages in terms of matrix structure and cell morphology. Second harmonic generation (SHG) imaging is a nonlinear imaging technique that capitalizes on signal generation from highly ordered macromolecules such as collagen fibers. The purpose of this study was to use SHG microscopy to image collagen extracellular matrix (ECM) structure, chondrocyte size, and density of these cartilages. STUDY DESIGN: Experimental. METHODS: Surgical remnants of septal, lower lateral, rib, and auricular cartilages were collected following surgery, sectioned into 0.5-1 mm thick samples and fixed to facilitate batch process imaging. A Leica TCS SP8 MP Microscope and multiphoton laser were used to image the specimens. Images were analyzed for cell size, cell density, and collagen fiber directionality patterns using ImageJ. RESULTS: SHG images of septal specimens show mesh-like structure of the ECM. There appears to be a superficial layer, characterized by flattened lacunae and middle zone, marked by circular lacunae clusters, similar to what is observed in articular cartilage. The structure of the ECM depicts a visible orientation perpendicular to the surface of the perichondrium. Cell size and density analysis through ImageJ suggests variety across cartilage types. Directionality analysis indicates that the collagen in the ECM displays preferred direction. CONCLUSION: This study establishes clear extracellular models of facial and costal cartilages. Limitations include heterogeneous cartilage thickness due to processing difficulties. Further studies include automating the cutting process to increase uniformity of tissue thickness and increasing sample size to further validate results. LEVEL OF EVIDENCE: 2 Laryngoscope, 133:3370-3377, 2023.

Actinomyces: An Under Appreciated Cause of Postoperative Infection in Rhinoplasty.

OBJECTIVE: To discuss a case series of Actinomyces infection post-rhinoplasty and review the literature for correct diagnosis and management. STUDY DESIGN: Case series with chart review. METHODS: Three cases are presented of patients with a history of recurrent infectious symptoms post revision rhinoplasty later being diagnosed as Actinomyces. RESULTS: Three patients were identified having undergone revision rhinoplasty and later being diagnosed with Actinomyces infection. They initially presented with underwhelming physical exams, mild erythema, slight swelling, yet extreme pain. They also had periods of recurrent infection once antibiotics were stopped. Aerobic, anaerobic, fungal, and Actinomyces cultures were sent to pathology and returned positive for Actinomyces. Treatment typically involved a combination of prolonged antibiotics, incision and drainage, and/or surgical debridement. CONCLUSIONS: Awareness of Actinomyces as a possible cause of infection post-rhinoplasty is significant as this pathogen can lead to extensive tissue destruction and fistula formation which could be detrimental for a rhinoplasty. Duration of treatment is beyond typical lengths for other infections and a specific culture for Actinomyces is required to be sent as it isn't captured in standard aerobic/anaerobic cultures. Therefore, a high index of suspicion is required by physicians to ensure that patients are evaluated thoroughly. Laryngoscope, 133:2948-2950, 2023.

Recovery Benefit With Total Intravenous Anesthesia in Patients Receiving Rhinoplasty.

OBJECTIVE: The aim was to evaluate the difference in recovery when comparing total intravenous anesthesia (TIVA) to inhalational gas anesthesia in patients receiving rhinoplasty. STUDY DESIGN: Retrospective review. SETTING: Postoperative anesthesia care unit (PACU). METHODS: Patients who received a functional or cosmetic rhinoplasty at a single academic institution between April 2017 and November 2020 were included. Inhalational gas anesthesia was in the form of sevoflurane. Phase I recovery time, which was defined as the time it took a patient to reach ≥9/10 on the Aldrete scoring system was recorded, as well as the usage of pain medication in the PACU. The postoperative course and incidence of postoperative nausea and vomiting (PONV) were also collected. RESULTS: Two hundred and two patients were identified with 149 (73.76%) who received TIVA and 53 (26.24%) who received sevoflurane. For the patients who received TIVA, the average recovery time was 101.44 minutes (standard deviation [SD]: 34.64) compared to an average recovery time of 121.09 minutes (SD: 50.19) for patients who received sevoflurane leading to a difference of 19.65 minutes (p = 0.002). Patients who received TIVA experienced less PONV (p = 0.001). There were no differences in the postoperative course including surgical or anesthesia complications, postoperative complications, hospital or Emergency Department admissions, or administration of pain medication (p > 0.05 for all). CONCLUSION: When utilizing TIVA over inhalational anesthesia, patients undergoing rhinoplasty had significantly increased benefits in terms of reduced phase I recovery times and decreased incidence of PONV. TIVA was demonstrated to be a safe and efficacious method of anesthesia for this patient population.

Cosmetic Filler and PET Positivity: The Risk of a False Positive.

OBJECTIVE: To discuss a case of hyaluronic acid filler displaying as PET avid resulting in a false positive for local recurrence and review of the literature of how filler presents on PET. STUDY DESIGN: Case report and literature review. METHODS: Retrospective case review of a patient with angiosarcoma with PET-MRI positivity after hyaluronic acid filler injection. Review of the literature was performed. RESULTS: A 49-year-old female with low grade angiosarcoma of the right cheek pT1N0M0 was treated with wide local excision and staged reconstruction with cervicofacial advancement flap with subsequent adjuvant radiation therapy. Surveillance PET/MRI scans were conducted every 3 months. After one year without recurrence, HA injectable filler was offered to correct resultant right facial soft tissue defect. The patient proceeded with HA filler and was counseled on the risk of local increased SUV on imaging. Her PET/MRI 3 months later revealed postsurgical changes in the right premaxillary soft tissues with associated low-grade hypermetabolism with max SUV 1.8, which elevated from prior max SUV 0.9. Contralateral left maxillary soft tissues revealed max SUV 0.8. Biopsy was initially favored for concern of local recurrence until the potential for filler to be associated with elevated SUV was discussed. Further evaluation with MRI showed diffusely increased T2 signal with some trace enhancement in the region of PET activity, confirming that findings were consistent with HA filler augmentation per the neuroradiologist team. CONCLUSIONS: Fillers, including hyaluronic acid, are associated with elevated SUV on PET-CT. Otolaryngologists should be aware of these features to improve patient counseling, avoid unnecessary procedures, and reduce patient anxiety. Laryngoscope, 133:2951-2953, 2023.

Reducing Risks of Facial Scarring.

Risk factors for the formation of facial scars include skin type, ethnicity, scar location, and certain medical conditions that contribute to poor or delayed healing. Risk of scar can be reduced with appropriate surgical planning, including proper placement and design of incisions, meticulous skin closure, aseptic technique, and wound care to improve healing. Common pathologic scars include hypertrophic scars and keloid scars, each of which has unique approaches to surgical revision and medical treatment due to their respective risks of recurrence. Topical scar therapies, medical therapies, and surgical revision techniques for improvement in final scar appearance are discussed.

Management of Recurrent Fibromatosis Colli with Innervated Vastus Lateralis Free Flap.

Fibromatosis colli (FC) is a fibroblastic contracture of the sternocleidomastoid muscle, often presenting as a neck mass and torticollis. The vast majority of cases resolve with conservative measures; for persistent disease, surgical tenotomy is offered. This is a case of a 4-year-old patient with large FC who failed conservative treatment as well as surgical release and ultimately underwent complete excision and reconstruction with innervated vastus lateralis free flap. We describe a novel application of this free flap for a difficult clinical scenario. Laryngoscope, 133:2025-2028, 2023.

Nasal Septal Perforation Due to Desmopressin Nasal Spray Use.

Perforations of the nasal septum have many etiologies and occasionally result from intranasal medicated spray use. This case report describes a perforation related to the use of desmopressin nasal spray, which has not been previously reported in the literature. Clinical considerations presented in this article include appropriate technique of nasal spray application, appropriate monitoring of patients on intranasal sprays, and indications for evaluation by an otolaryngologist. Septal perforation treatment success is improved with an early diagnosis.

The profunda artery perforator flap for head and neck reconstruction.

INTRODUCTION: The profunda artery perforator (PAP) fasciocutaneous flap is underutilized in head and neck reconstruction, with advantages including ease of harvest and minimal donor site morbidity. METHODS: Cadaveric dissection of cutaneous perforators to origin at profunda femoris system to characterize vascular anatomy. RESULTS: 22 PAP flaps were studied. Each contained 1-6 cutaneous perforators originating from the profunda system, designated into A, B, or C vascular pedicle systems. Muscular perforators did not consistently extend to skin in systems A and C, but all dissections demonstrated myocutaneous perforator in system B. Average distance from groin crease to cutaneous perforators of A, B, and C respectively was 8 cm (range 3-15 cm), 11.4 cm (range 5-17 cm), and 17.5 cm (range 12.5-22 cm). Average pedicle length was 11.07 cm (range 7-16 cm), 11.78 cm (range 9-16 cm), and 11.23 cm (range 9-15 cm). Average vena comitans diameter at origin was 3.14 mm (range 1.27-4.46 mm). Average arterial diameter at origin was 2.07 mm (range 1.27-3.82 mm). Range of maximal primary closure was 6-11 cm. CONCLUSION: PAP free flap demonstrates reliable vascular anatomy in cadavers, with adequate pedicle length and vessel diameter. All specimens contained adequate myocutaneous perforator to support free tissue transfer.

Use of the O-Z flap as an alternative to free tissue transfer for reconstruction of large scalp defects.

Objective: The reconstruction of large scalp defects poses both functional and cosmetic challenges. While free tissue transfer remains the standard for defects larger than 30 cm2, prolonged anesthesia and postoperative complications remain significant limitations. The purpose of this study is to evaluate the use of O-Z flaps for the reconstruction of large scalp defects and to describe the techniques employed. Methods: This is a retrospective analysis of ten patients who underwent reconstructive surgery using an O-Z flap approach for large scalp defects between July 2017 and June 2019. The parameters included in this study were patient demographics, tumor characteristics, and postoperative management, collected for at least a year after surgery. Results: In this cohort, the mean age was 76.1 years and 90% were male. All patients were treated for neoplastic skin lesions, with 70% located on the vertex and 30% located on the temporoparietal region. The mean size of defect was 52.0 cm2 (range: 38.6 to 63.8 cm2). The maximum hospital stay was two days, and no patients were readmitted within 30 days of surgery. There were no cases of wound infection or flap necrosis. All patients reported pain control with acetaminophen and ibuprofen. Four patients received adjuvant radiation, and there was no delay to receiving treatment following surgery. Conclusions: The O-Z flap is a reliable alternative for the reconstruction of non-irradiated scalp defects in the vertex and temporoparietal regions up to 63 cm2. This technique provides advantages for patients, including hairline preservation, shorter hospital stays, and decreased postoperative complications.

Designing an evidence-based free-flap pathway in head and neck reconstruction.

Background: The use of autologous free-tissue transfer is an increasingly utilized tool in the ladder of reconstructive options to preserve and restore function in patients with head and neck cancer. This article focuses on the evidence surrounding perioperative care that optimizes surgical outcomes and describes one tertiary center's approach to standardized free-flap care. Data Sources: This article examines English literature from PubMed and offers expert opinion on perioperative free-flap care for head and neck oncology. Conclusion: Free-flap reconstruction for head and neck cancer is a process that, while individualized for each patient, is best supported by a comprehensive and standardized care pathway. Surgical optimization begins in the preoperative phase and a thoughtful approach to intraprofessional communication and evidence-based practice is rewarded with improved outcomes.

Columellar strut grafts versus septal extension grafts during rhinoplasty for airway function, patient satisfaction and tip support.

IMPORTANCE: Different techniques exist to provide tip support in rhinoplasty. There is little evidence to provide a consensus on the most effective choice. OBJECTIVE: Evaluating columellar strut graft (CSG) and septal extension grafts (SEG) for their influence on airway function, patient satisfaction and tip support. DESIGN, SETTINGS AND PARTICIPANTS: A retrospective cohort study was undertaken on 165 adult patients who underwent open rhinoplasty with either a CSG or SEG, from February 2012 to August 2019 in a single tertiary facial-plastic practice in Sydney, Australia. Operations were for both cosmetic and functional indications, and both primary and revision cases were assessed. Airway testing and patient-reported outcomes (PROMs) were performed preoperatively and at least 6 months following the procedure. Photographic tip analysis was taken from approximately 4 and 12-month postoperative photographs. MAIN OUTCOMES AND MEASURES: Nasal peak inspiratory flow (NPIF) and total nasal airway resistance (NAR) were the primary airway functional outcomes. The primary PROMs analysed were a visual analogue scale (VAS) for nasal obstruction and 13-point Likert scale for global cosmesis, the Nose Outcome Symptom Evaluation (NOSE), and the nasal obstruction score. Tip support was determined by the nasolabial angle (NLA) and Simon's ratio as assessed by Rhinobase developed by Apaydin et al. on lateral Frankfort plane photographs. Data normalised as an improvement over preoperative baseline, accounting for individual variability. RESULTS: A total of 165 patients was assessed (35.2 ± 12.9 yrs, 72% female), 100 (61%) of which received SEG. There were similar nasal airway assessments between CSG and SEG groups, with ΔNPIF (20.0 ± 42.1 L/min v 19.9 ± 44.9 L/min, p = 0.983) and Δ "obstructed" NAR (-1.13 ± 1.90 v -1.02 ± 4.33 Pa/cm3/s, p = 0.849). Amongst PROMs, a greater cosmetic outcome was seen in the SEG group (7.20 ± 2.97 v 5.69 ± 3.45, p < 0.01) with all other assessments similar between CSG and SEG techniques. Photographic analysis of tip projection showed reduced NLA distortion in the SEG. CONCLUSION AND RELEVANCE: While greater patient-perceived cosmesis was seen in patients with a SEG, there were similar airflow and patient-reported nasal function between groups. Photographic analysis of tip projection showed SEG patients additionally benefited from less NLA distortion and greater tip maintenance.

Female Representation and Academic Leadership in Facial Plastic and Reconstructive Surgery.

OBJECTIVES/HYPOTHESIS: Despite increasing the numbers of women entering the field, underrepresentation of women in otolaryngology has been reported. In the subspecialty of facial plastic and reconstructive surgery (FPRS), female representation and academic leadership have not been formally characterized. Our study aims to identify female representation and academic leadership roles in FPRS. STUDY DESIGN: Cross sectional analysis. METHODS: Analysis was performed using the 2020 American Academy of Facial Plastic and Reconstructive Surgery (AAFPRS) membership directory. Board-eligible and board-certified FPRS surgeons were included. Data regarding academic rank, leadership position, academic productivity, and years in practice were collected from publicly available departmental websites. Academic productivity was measured using h-index. RESULTS: Of 1,421 members queried in the 2020 AAFPRS membership directory, 13.0% were female and 86.9% were male. Most practitioners (87.0%) work in a private practice setting, but of the 13.0% of academic FPRS surgeons, 25.9% were female. Most female facial plastic surgeons in academic practice were Assistant Professors (72.9%), whereas ranks were evenly distributed among male FPRS surgeons. Three (4.3%) of 69 AAFPRS fellowship directors were women, and 1 (1.8%) of 56 present or past AAFPRS presidents was female. Female FPRS surgeons had fewer years in practice and lower h-indices compared with male surgeons. CONCLUSIONS: Female FPRS surgeons hold fewer academic leadership positions and have lower academic productivity in comparison to male FPRS surgeons. Future studies are needed to elucidate the etiology of these gender differences. LEVEL OF EVIDENCE: NA Laryngoscope, 132:781-785, 2022.

A one-stage method for external auditory canal reconstruction; the Wessex pre-auricular flap.

This technique has been developed with the aim of expanding the well documented pre-auricular flap to help reconstruct pinna lesions that extend into the external auditory canal. This area can be a challenge to reconstruct effectively to minimise morbidity and there are limited published techniques. This flap is a reproducible, one-stage technique that is readily available to most ENT surgeons, avoiding stenosis and allowing for adequate reconstruction of the external auditory canal.

ASA Physical Status Classification and Complications Following Facial Fracture Repair.

BACKGROUND: To investigate the association between American Society of Anesthesiologists (ASA) physical status classification and rates of postoperative complications in patients undergoing facial fracture repair. METHODS: Patients were divided into 2 cohorts based on the ASA classification system: Class I/II and Class III/IV. Chi-square and Fisher's exact tests were used for univariate analyses. Multivariate logistic regressions were used to assess the independent associations of covariates on postoperative complication rates. RESULTS: A total of 3575 patients who underwent facial fracture repair with known ASA classification were identified. Class III/IV patients had higher rates of deep surgical site infection (P = .012) as well as bleeding, readmission, reoperation, surgical, medical, and overall postoperative complications (P < .001). Multivariate regression analysis found that Class III/IV was significantly associated with increased length of stay (P < .001) and risk of overall complications (P = .032). Specifically, ASA Class III/IV was associated with increased rates of deep surgical site infection (P = .049), postoperative bleeding (P = .036), and failure to wean off ventilator (P = .027). CONCLUSIONS: Higher ASA class is associated with increased length of hospital stay and odds of deep surgical site infection, bleeding, and failure to wean off of ventilator following facial fracture repair. Surgeons should be aware of the increased risk for postoperative complications when performing facial fracture repair in patients with high ASA classification.

Lessons from rhinology and facial plastic surgery clinical negligence claims in England 2013-2018.

OBJECTIVE: This study reviewed all rhinology clinical negligence claims in the National Health Service in England between 2013 and 2018. METHOD: All clinical negligence claims held by National Health Service Resolution relating to rhinology in England between 1 April 2013 and 1 April 2018 were reviewed. RESULTS: There were 171 rhinology related claims with a total estimated potential cost of £13.6 million. There were 119 closed claims (70 per cent) with a total cost of £2.3 million, of which 55 claims resulted in payment of damages. Over three quarters of all rhinology claims were associated with surgery (n = 132). Claims associated with endoscopic sinus surgery had the highest mean cost per claim (£172 978). Unnecessary pain (33.9 per cent) and unnecessary operation (28.1 per cent) were the most commonly cited patient injuries. CONCLUSION: Patient education and consent have been highlighted as key areas for improvement from this review of rhinology related clinical negligence claims. A shift in clinical practice towards shared decision making could reduce litigation in rhinology.

Facial Trauma Patterns Among Young Athletes.

STUDY DESIGN: Retrospective case series review. OBJECTIVE: Participation in athletics is common in high school and college students and presents an increased risk of injury in this age-group. Previous studies have included National Collegiate Athletic Association athletes but not high school athletes. Here we report the trends of maxillofacial injuries in high school students. METHODS: Patients presenting to a level 1 trauma center with maxillofacial injuries were identified by chart query with associated International Classification of Diseases, 10th Revision codes for facial fractures between October 2015 and October 2017. Data collected included age, sport, fracture type, need for surgery, associated concussion, and time to return to play were measured. New York State Public High School Athletic Association regional high school sports participation data from 2016 to 2018 were used to calculate incidence. RESULTS: A total of 33 patients aged 13 to 19 years were identified. Baseball, basketball, and lacrosse were most frequently associated with maxillofacial trauma. Annual incidence rates for mandible fractures in high school athletes were 0.037%, 0.012%, and 0.01% for lacrosse, baseball, and basketball, respectively. Annual fracture incidence rates for midface fractures in high school athletes were 0.17%, 0.018%, and 0.01% for baseball, lacrosse, and basketball, respectively. CONCLUSION: Maxillofacial fractures are uncommon injuries among athletes but present with serious implications including surgical correction. Baseball was strongly associated with midface fractures despite being considered a noncontact sport. Improved facial protection across all sports will be imperative at reducing the incidences of these injuries. LEVEL OF EVIDENCE: Level 4.

Effects of COVID-19 on Facial Plastic and Reconstructive Surgery Fellowship Training and Director Practices.

OBJECTIVES: The objectives of this study include characterizing the practice patterns and testing strategies of facial plastic and reconstructive surgery (FPRS) fellowship directors (FDs) secondary to COVID-19 and to quantify the impact of COVID-19 on FPRS fellowship training. STUDY DESIGN: Cross-sectional survey. SETTING: Online. METHODS: A survey was sent to all American Academy of Facial Plastic and Reconstructive Surgery FDs and co-FDs in September 2020. Descriptive analyses were performed. RESULTS: Of 77 eligible FDs, 45 responded (58.4%) representing a diverse group across the United States. All but 1 FD routinely screened patients for COVID-19 in the preoperative setting. FDs largely believed that universal preoperative testing was cost-effective (66.7%), improved patient safety (80.0%) and health care worker safety (95.6%), and was not burdensome for patients (53.3%). With regard to volume of cosmetic/aesthetic, reconstructive, facial nerve, and trauma surgery, FDs indicated largely no change in volume (34.9%, 71.0%, 68.4%, and 80.0%, respectively) or fellow experience (67.4%, 80.6%, 84.2%, and 80.0%). Half (50.0%) of the FDs reported decreased volume of congenital/craniofacial surgery, but 75.0% did not believe that there was a change in fellow experience. Overall, of the 15 responses indicating "worsened training" across all domains of FPRS, 14 were located in the Northeast (93.33%). CONCLUSIONS: The COVID-19 pandemic has had the least impact on the volume of reconstructive procedures, facial nerve operations, and trauma surgery and a negative impact on congenital/craniofacial surgery volume, and it has accelerated the demand for cosmetic/aesthetic operations. Overall, the majority of FDs did not feel as though their fellows' trainings would be adversely affected by the ongoing pandemic.