Nonsurgical Tear Trough Volumization: A Systematic Review of Patient Satisfaction.

BACKGROUND: Nonsurgical rejuvenation of the tear trough area via the use of injectable filler material has become a popular procedure in facial rejuvenation. This procedure offers immediate, albeit temporary, results with minimal recovery time. OBJECTIVES: The aim of this systematic review was to report on patient satisfaction and complication rates to further guide practitioners. METHODS: PubMed, Cochrane, and Scopus libraries were queried for articles containing relevant terms. Articles with more than 5 patients who reported on satisfaction and/or complications from the procedure were included for review. In addition to these variables, we noted other aspects of injection, including filler material, technique, and needle or cannula delivery. Studies that did not otherwise fulfill inclusion criteria for statistical analysis but reported on intravascular injection-related complications were cited. RESULTS: Initial query resulted in 1655 studies which were assessed for duplicates and inclusion/exclusion criteria. After screening, 28 articles were included for analysis. In total, 1956 patients were captured who had been injected with 1 of 4 materials: hyaluronic acid (1535), calcium hydroxyapatite (376), autologous fibroblast/keratin gel (35), and collagen-based filler (10). Short- and long-term satisfaction rates were 84.4% and 76.7%, respectively. Minor complications were common (44%). Secondarily, we found the use of cannula for filler injection of this region to be associated with a lower rate of ecchymosis (7% vs 17%, P < 0.05). CONCLUSIONS: Filler injection volumization of tear trough deformity is an effective technique for facial rejuvenation associated with high patient satisfaction. Multiple filler materials offer acceptable satisfaction and complication profiles.

Insurance Coverage of Facial Gender Affirmation Surgery: A Review of Medicaid and Commercial Insurance.

OBJECTIVE: To provide a portrait of gender affirmation surgery (GAS) insurance coverage across the United States, with attention to procedures of the head and neck. STUDY DESIGN: Systematic review. SETTING: Policy review of US medical insurance companies. METHODS: State policies on transgender care for Medicaid insurance providers were collected for all 50 states. Each state's policy on GAS and facial gender affirmation surgery (FGAS) was examined. The largest medical insurance companies in the United States were identified using the National Association of Insurance Commissioners Market Share report. Policies of the top 49 primary commercial medical insurance companies were examined. RESULTS: Medicaid policy reviews found that 18 states offer some level of gender-affirming coverage for their patients, but only 3 include FGAS (17%). Thirteen states prohibit Medicaid coverage of all transgender surgery, and 19 states have no published gender-affirming medical care coverage policy. Ninety-two percent of commercial medical insurance providers had a published policy on GAS coverage. Genital reconstruction was described as a medically necessary aspect of transgender care in 100% of the commercial policies reviewed. Ninety-three percent discussed coverage of FGAS, but 51% considered these procedures cosmetic. Thyroid chondroplasty (20%) was the most commonly covered FGAS procedure. Mandibular and frontal bone contouring, rhinoplasty, blepharoplasty, and facial rhytidectomy were each covered by 13% of the medical policies reviewed. CONCLUSION: While certain surgical aspects of gender-affirming medical care are nearly ubiquitously covered by commercial insurance providers, FGAS is considered cosmetic by most Medicaid and commercial insurance providers, potentially limiting patient access. LEVEL OF EVIDENCE: Level V.

The impact of surgeon volume on total thyroidectomy outcomes among otolaryngologists.

PURPOSE: To evaluate the impact of surgeon volume on total thyroidectomy complications and outcomes among otolaryngologists. MATERIALS AND METHODS: This state-wide, multi-hospital retrospective review identified patients who underwent total thyroidectomy (TT) (ICD9-06.4) through the Statewide Planning and Research Cooperative System (SPARCS) between 1995 and 2015. Surgeons were categorized into high (>100), medium (10-99), and low (<10) volume groups and differences in complication rates were analyzed. Statistical analysis employed Spearman's rank correlation, Kruskal-Wallis testing, and chi-squared testing. RESULTS: 32,133 TT performed by 1032 otolaryngologists were identified. Overall complication rate in our cohort was 9.83% (CI: 9.48-10.18). The most common complication identified overall was hypocalcemia occurring in 3.85% of cases. Surgeons in the high volume group had a complication rate of 9.6%, compared to 10.0% and 11.6% in the medium and low volume groups. This represents a moderate, but statistically significant difference (rho: -0.4, p < 0.0001; KW p ≤0.0001). When looking at individual complications, temporary tracheostomy rate was higher in the low volume group (5.1%, p = 0.001). Other variables such as advanced age, sex, non-white race, or thyroid malignancy were not predictors of increased complication rates for TT. CONCLUSIONS: Otolaryngologists who perform a high volume of total thyroidectomy were found to have overall less perioperative complications than those with less volume. In particular, the risk of temporary tracheostomy is higher among low volume surgeons. These findings are consistent with previous studies of the effect of thyroidectomy volume on surgical complications.

Masseteric-zygomatic nerve transfer for the management of eye closure-smile excursion synkinesis.

OBJECTIVE: The purpose of this study is to illustrate the efficacy of masseteric-to-zygomatic nerve transfer to address eye closure-smile excursion synkinesis after facial nerve paralysis. BACKGROUND: Synkinesis after facial nerve paralysis represents a wide range of facial movement disability. One manifestation is involuntary smiling with eye closure and a concomitant reduction of oral commissure movement with attempted smile ("frozen smile") - arising as a result of aberrant fibers populating the zygomatic branch-muscle complex. This is a particularly difficult area to treat with conservative management. We propose a single-stage procedure to sever the dysfunctional zygomatic nerve and perform a masseteric-zygomatic nerve coaptation to recover a voluntary smile. METHODS: We present a case series of eight patients with eye closure/smile excursion synkinesis who underwent single-stage masseteric-zygomatic nerve transfer by a single surgeon. The surgical technique and indications for surgery were reviewed. Patients underwent facial movement analysis using Emotrics. RESULTS: We analyzed the pre- and post- surgical photographic images of 8 patients with synkinesis (7 female, 1 male). Masseteric-facial nerve transfer was performed from 18 months to 22 years after the initial facial paralysis. Eyelid and brow positioning were more symmetric after surgery, with discrepancy between affected and unaffected side decreasing from 2.1 to 1.0 mm (p < .05) and 1.74 to 1.29 mm (p < .05), respectively. Symmetry of smile excursion postoperatively was also improved with commissure excursion discrepancy decreasing from 8.8 to 3.78 mm (p < .05). Discrepancy in the smile angle when comparing affected to unaffected side improved postoperatively from 10.3 to 5.2 degrees (p < .05). Improvement in oral commissure height was noted, but not statistically significant. CONCLUSIONS: The masseteric-zygomatic nerve transfer is a useful technique for the treatment of eye closure/smile excursion synkinesis after failure of chemodenervation and/or physical therapy.

Demographic Differences Among Patients Undergoing Blepharoplasty Based on Surgeon Training in New York State.

PURPOSE: To evaluate whether patient demographics and surgical metrics varied among differently trained surgeons performing blepharoplasty. METHODS: The Statewide Planning and Research Cooperative System database was used to identify patients who underwent blepharoplasty in New York State. Surgeons were grouped based on residency training as listed in the New York State Physician Profile. Multivariate regression analysis was used to determine predictors of patient characteristics based on surgeon training. RESULTS: There were 361 surgeons who performed 39,932 cases of blepharoplasty in New York State from 2008 to 2016. When aggregated by surgeon training, there were significant differences among procedure times and total charges for blepharoplasty. On average, cases performed by ophthalmologists took 66.7 minutes and patients were charged $6,860; cases performed by otolaryngologists took 158.2 minutes and patients were charged $9,084; and cases performed by plastic surgeons took 131.8 minutes and patients were charged $11,028. Unlike plastic surgeons or otolaryngologists, ophthalmologists tended to have older patients and more male patients. Ophthalmologists were more likely to operate on patients with comorbidities as well as non-white patients (p < 0.0001). They were also significantly more likely to have patients with insurance coverage than self-pay (p < 0.0001). CONCLUSIONS: Demographic and surgical metrics of blepharoplasty cases performed by surgeons trained in otolaryngology and plastic surgery are similar. Ophthalmology-trained surgeons performed blepharoplasty on patients that were more likely to be older, male, non-white, and had insurance coverage. Ophthalmologist procedure time for blepharoplasty was also less than half of the procedure time of otolaryngologists and plastic surgeons.Blepharoplasty is a surgical procedure commonly performed by ophthalmologists, otolaryngologists, and plastic surgeons to address cosmetic concerns or visual impairment related to the eyelids.

Two Cases of Bilateral Vocal Fold Mobility Impairment After LMA Use In 7 Months.

OBJECTIVES: To increase awareness of vocal fold mobility impairment secondary to laryngeal mask airway (LMA) use in the operating room. METHODS: We report 2 cases of bilateral vocal fold mobility impairment after LMA use within 7 months of each other. One patient is a 52-year-old female who developed this complication after orthopedic elbow surgery. The second case is a 75-year-old male who presented after undergoing inguinal hernia repair. RESULTS: The patient from the first case required a 7-day hospital stay in the SICU due to airway compromise with spontaneous resolution of right-sided vocal fold immobility and improvement of symptoms. The 75-year-old male required direct laryngoscopy and bilateral true vocal fold injection medialization to correct his bilateral vocal fold paresis causing dysphonia and aspiration of liquids. CONCLUSIONS: Bilateral vocal fold immobility secondary to LMA use is likely an underreported phenomenon of which otolaryngologists and anesthesiologists should be aware. Presentation may be severe, requiring hospitalization or operative intervention.

Platelet-Activating Factor Induces Epigenetic Modifications in Human Mast Cells.

UV radiation-induced systemic immune suppression is a major risk factor for skin cancer induction. The migration of dermal mast cells from the skin to the draining lymph nodes has a prominent role in activating systemic immune suppression. UV-induced keratinocyte-derived platelet-activating factor (PAF) activates mast cell migration, in part by upregulating the expression of CXCR4 on the surface of mast cells. Others have indicated that epigenetic mechanisms regulate CXCR4 expression; therefore, we asked whether PAF activates epigenetic mechanisms in mast cells. Human mast cells were treated with PAF, and the effect on DNA methylation and/or acetylation was measured. PAF suppressed the expression of DNA methyltransferase (DNMT) 1 and 3b. On the other hand, PAF increased p300 histone acetyltransferase expression, and the acetylation of histone H3, which coincided with a decreased expression of the histone deacetylase HDAC2. Chromatin immunoprecipitation assays indicated that PAF treatment activated the acetylation of the CXCR4 promoter. Finally, inhibiting histone acetylation blocked p300 upregulation and suppressed PAF-induced surface expression of CXCR4. Our findings suggest a novel molecular mechanism for PAF, activation of epigenetic modifications. We suggest that PAF may serve as an endogenous molecular mediator that links the environment (UV radiation) with the epigenome.

The human oncogene SCL/TAL1 interrupting locus is required for mammalian dopaminergic cell proliferation through the Sonic hedgehog pathway.

The human oncogene SCL/TAL1 interrupting locus (Stil) is highly conserved in all vertebrate species. In humans, the expression of Stil regulates cancer cell proliferation and survival. In this study, we examined the function of Stil in neural progenitor cell proliferation and neural differentiation using the mammalian dopaminergic (DA) PC12 cells. Stil is expressed in both proliferating and differentiated PC12 cells. The RNAi-mediated knockdown of Stil expression yielded a decreased proliferation rate of PC12 cells, whereas the overexpression of Stil transcript increased PC12 cell proliferation. The up- and down-regulation of the Sonic hedgehog (Shh) pathway by pharmacological approaches targeting Smoothened (Smo) demonstrated that Stil functions in the Shh pathway for PC12 proliferation. Smo antagonist cyclopamine decreased the proliferation rate of PC12 cells, whereas the overexpression of Stil rescued the cyclopamine-induced decrease in cell proliferation. Oppositely, the application of Smo agonist purmorphamine increased the rate of PC12 cell proliferation. However, the proliferation defect caused by Stil knockdown remained evident after activating the Shh pathway by purmorphamine. The expression of Stil is not required for PC12 cell neural differentiation. In PC12 cells transfected with Stil shRNA plasmids, the outgrowth of neurites persisted after treatment with nerve growth factor (NGF), whereas overexpression of Stil did not increase neurite growth in response to NGF induction. Together, the results from this study suggest a novel role for the oncogene Stil in neural progenitor cells through the Shh pathway, and further introduces Stil as a bio-marker for DA cells.