What Tests are Used to Assess the Physical Qualities of Male, Adolescent Rugby League Players? A Systematic Review of Testing Protocols and Reported Data Across Adolescent Age Groups.

BACKGROUND: Understanding the physical qualities of male, adolescent rugby league players across age groups is essential for practitioners to manage long-term player development. However, there are many testing options available to assess these qualities, and differences in tests and testing protocols can profoundly influence the data obtained. OBJECTIVES: The aims of this systematic review were to: (1) identify the most frequently used tests to assess key physical qualities in male, adolescent rugby league players (12-19 years of age); (2) examine the testing protocols adopted in studies using these tests; and (3) synthesise the available data from studies using the most frequently used tests according to age group. METHODS: A systematic search of five databases was conducted. For inclusion, studies were required to: (1) be original research that contained original data published in a peer-reviewed journal; (2) report data specifically for male, adolescent rugby league players; (3) report the age for the recruited participants to be between 12 and 19 years; (4) report data for any anthropometric quality and one other physical quality and identify the test(s) used to assess these qualities; and (5) be published in English with full-text availability. Weighted means and standard deviations were calculated for each physical quality for each age group arranged in 1-year intervals (i.e., 12, 13, 14, 15, 16, 17 and 18 years) across studies. RESULTS: 37 studies were included in this systematic review. The most frequently used tests to assess anthropometric qualities were body mass, standing height, and sum of four skinfold sites. The most frequently used tests to assess other physical qualities were the 10-m sprint (linear speed), 505 Agility Test (change-of-direction speed), Multistage Fitness Test (aerobic capacity), bench press and back squat one-repetition maximum tests (muscular strength), and medicine ball throw (muscular power). Weighted means calculated across studies generally demonstrated improvements in player qualities across subsequent age groups, except for skinfold thickness and aerobic capacity. However, weighted means could not be calculated for the countermovement jump. CONCLUSION: Our review identifies the most frequently used tests, but highlights variability in the testing protocols adopted. If these tests are used in future practice, we provide recommended protocols in accordance with industry standards for most tests. Finally, we provide age-specific references for frequently used tests that were implemented with consistent protocols. Clinical Trial Registration This study was conducted in accordance with the Preferred Reporting Items of Systematic Review and Meta-analysis guidelines and was registered with PROSPERO (ID: CRD42021267795).

Greater symptom burden results in reduced exercise tolerance in adolescents following concussion.

OBJECTIVES: To explore the relationship between symptoms and exercise tolerance in adolescents following concussion. METHODS: A retrospective analysis of 417 adolescents who attended a concussion service between January 2015 and April 2021 was performed, with 149 meeting eligibility criteria for inclusion. Post-Concussion Symptom Scale (PCSS) and graded exercise tolerance time (min) were assessed at initial and follow-up visits. Spearman's correlation was used to examine the relationship between PCSS scores and exercise time. RESULTS: Adolescents (n = 149, 13.9 ± 1.7 years, 66.4% male) presented at 28.6 ± 19.7 days post-injury. Statistically significant correlations were identified between initial (r = -0.36, p < .001) and follow-up (r = -0.41, p < .001) PCSS scores and exercise time among all participants. Initial PCSS and initial exercise time were inversely correlated for males (r = -0.24, p = .018) and females (r = -0.22, p = .127). Follow-up PCSS and follow-up exercise time were inversely correlated for males (r = -0.30, p = .003) and females (r = -0.35, p = .014). CONCLUSION: There is a statistically significant relationship between higher PCSS and poorer exercise time and both factors should be considered together to provide the most accurate assessment, particularly in females.

Head and Neck Injury Patterns among American Football Players.

IMPORTANCE: American football is a popular high-impact sport, leading to 2.7 million injuries in the United States annually. Recent evidence in football-related neurological damage has spurred national interest in player-safety. Football players injure their head and neck in up to 26% of total injuries. Variation in injury patterns between age groups and correlated hospitalizations for football-related head and neck injury has yet to be characterized. OBJECTIVE: Our aim is to evaluate injury patterns among American-football related head and neck trauma. METHODS: A retrospective cohort study of patients with football-related head and neck injury in the National Electronic Injury Surveillance System (NEISS). RESULTS: Nearly 100 000 ED visits for football-related head and neck injuries occur annually. Males comprised 95% of patients, with a median age of 13. The head comprised 70% of injuries followed by the face (13%). The most common diagnoses were concussions (39%), internal organ injury (26%), and lacerations (11%). Pediatric patients were more likely to sustain concussions while adults experienced more lacerations (P < .05%). Fractures and nerve damage were rare injuries but caused a disproportionate share of hospitalizations. CONCLUSION: Pediatric males are most likely to present for emergency care from football-related injury to the head and neck. Evaluating physicians can anticipate concussions, internal organ injury, and lacerations among presenting patients. Concussions, facial fractures, and nerve damage are injuries most likely to lead to hospitalization.

Functional Reconstruction of Forehead and Midface Deficits Using the Endoscopic Technique and Bio-Absorbable Implants.

OBJECTIVES: Functional deficits of the forehead and midface can pose significant problems for patients varying from mild asymmetry to various degrees of functional impairment including total paralysis. Our objectives were to analyse the use of bio-absorbable implants to reconstruct forehead and midface deficits, all of which were for functional (noncosmetic) reasons. METHODS: This study was a retrospective case series between 2008 and 2018. Institutional review board approval was obtained from the Beaumont Health Human Investigation Committee. Surgeries were performed at a tertiary care centre. We evaluated 50 patients who underwent correction of functional deficits of forehead, eyebrow, and midface using the endoscopic technique and bio-absorbable implants. Patient demographics and indicated etiologies and characterization of minor and major complications and their occurrence rates were characterized. RESULTS: Fifty patients were included in the study from 2008 to 2018, with 68% female and 32% male. Combined blepharoplasty and brow lift was the most commonly performed procedure, followed by midface lift and browplasty. The mean follow-up time was 372 days. No major operative complications including stroke, permanent nerve paralysis, or mortality occurred. There was a 4% rate of temporary nerve paresthesia that resolved, 2% rate of infection, and 6% rate of implant migration requiring revision surgery. CONCLUSION: The endoscopic approach and use of bio-absorbable implants to reconstruct functional deficits of the forehead and midface are safe and effective. There were zero major complications and most of the minor complications were temporary. There was a significant association between non-age-related functional impairment and risk of complication.

OBJECTIFS: Les déficits fonctionnels du front et de la région médiofaciale représentent des problèmes importants pour les patients, qui varient entre une légère asymétrie à divers degrés d'atteinte fonctionnelle, y compris la paralysie totale. Les chercheurs visaient à analyser l'utilisation d'implants bioabsorbables pour la reconstruction des déficits du front et de la région médiofacale, dans tous les cas pour des raisons fonctionnelles (non esthétiques). MÉTHODOLOGIE: La présente série rétrospective portait sur les cas observés entre 2008 et 2018. Le comité de recherche sur la santé humaine de Beaumont est le comité d'analyse institutionnel qui a approuvé l'étude. Les opérations étaient exécutées dans un centre de soins tertiaires. Les chercheurs ont évalué 50 patients qui ont fait corriger des déficits fonctionnels du front, des sourcils et de la région médiofaciale par technique endoscopique et implants bioabsorbables. Ils ont colligé la démographie des patients, les étiologies indiquées, les complications mineures et majeures et leur fréquence. RÉSULTATS: Cinquante patients ont participé à l'étude entre 2008 et 2018, pour un pourcentage de 68 % de femmes et de 32 % d'hommes. La principale intervention était une association de blépharoplastie et de redrapage des sourcils, suivie d'un redrapage de la région médiofaciale et d'une plastie des sourcils. Le suivi moyen durait 372 jours. Les chercheurs n'ont constaté aucune complication opératoire majeure, y compris les accidents vasculaires cérébraux, la paralysie nerveuse permanente et la mortalité. Ils ont remarqué un taux de paresthésie nerveuse temporaire qui s'est résorbée de 4 %, un taux d'infection de 2 % et un taux de migration de l'implant exigeant une réintervention chirurgicale de 6 %. CONCLUSION: L'endoscopie et les implants bioabsorbables pour reconstruire les déficits fonctionnels du front et de la région médiofaciale sont à la fois sécuritaires et efficaces. Ils n'ont suscité aucune complication majeure, et la plupart des complications mineures étaient temporaires. Il y avait une association significative entre une atteinte fonctionnelle non liée à l'âge et le risque de complication.

Novel Changes in Resident Education during a Pandemic: Strategies and Approaches to Maximize Residency Education and Safety

Abstract Introduction The COVID-19 pandemic has led to a reduction in surgical and clinical volume, which has altered the traditional training experience of the otolaryngology resident. Objective To describe the strategies we utilized to maximize resident education as well as ensure patient and staff safety during the pandemic. Methods We developed a system that emphasized three key elements. First and foremost, patient care remained the core priority. Next, clinical duties were restructured to avoid unnecessary exposure of residents. The third component was ensuring continuation of resident education and maximizing learning experiences. Results To implement these key elements, our residency divided up our five hospitals into three functional groups based on geographical location and clinical volume. Each team works for three days at their assigned location before being replaced by the next three-person team at our two busiest sites. Resident teams are kept completely separate from each other, so that they do not interact with those working at other sites. Conclusions Despite the daily challenges encountered as we navigate through the COVID-19 pandemic, our otolaryngology residency program has been able to establish a suitable balance between maintenance of resident safety and well-being without compromise to patient care.

Novel Changes in Resident Education during a Pandemic: Strategies and Approaches to Maximize Residency Education and Safety.

Introduction The COVID-19 pandemic has led to a reduction in surgical and clinical volume, which has altered the traditional training experience of the otolaryngology resident. Objective To describe the strategies we utilized to maximize resident education as well as ensure patient and staff safety during the pandemic. Methods We developed a system that emphasized three key elements. First and foremost, patient care remained the core priority. Next, clinical duties were restructured to avoid unnecessary exposure of residents. The third component was ensuring continuation of resident education and maximizing learning experiences. Results To implement these key elements, our residency divided up our five hospitals into three functional groups based on geographical location and clinical volume. Each team works for three days at their assigned location before being replaced by the next three-person team at our two busiest sites. Resident teams are kept completely separate from each other, so that they do not interact with those working at other sites. Conclusions Despite the daily challenges encountered as we navigate through the COVID-19 pandemic, our otolaryngology residency program has been able to establish a suitable balance between maintenance of resident safety and well-being without compromise to patient care.

Orbital Roof Fractures: An Evidence-Based Approach.

Importance: There is controversy surrounding the management of orbital roof fractures. Guidelines with regard to when to operate and type of reconstruction are lacking. Categorizing these data will help clinicians make informed decisions about the management of orbital roof fractures and avoid preventable complications. Objective: To perform a systematic review evaluating underlying causes, associated complications, and management of orbital roof fractures including reconstructive options in the general population of children and adults. Evidence Review: A systematic review using the PubMed, EmBase, Cochrane, and MEDLINE databases identified relevant studies for inclusion. Studies were included from 1987 to 2017. Demographics, symptoms, management, reconstruction, and outcomes were reported following preferred reporting items for systematic reviews and meta-analyses guidelines. Inclusion criteria included articles discussing management of traumatic orbital roof fractures across all ages. Included studies were assessed for level of evidence. Findings: Forty-seven studies encompassing 526 patients met inclusion criteria. There were 28 case reports, 15 retrospective case series and 4 retrospective cohort studies. The most common etiologies were motor vehicle accidents (39.5%), falls (30.3%), and assault (11.8%). Periorbital ecchymosis, exophthalmos, and dystopia were the most common initial symptoms. In total, 60.0% of patients underwent surgical repair and 40% of patients were managed conservatively. The most common surgical approach was bicoronal (94.8%), followed by a superolateral orbital rim approach and transpalpebral (5.1%). A variety of grafting materials were utilized, including titanium miniplates (46.2%), bone graft (37.7%), porous polyethylene (2.8%), and silastic implants (2.8%). Overall patients undergoing surgery were adults with clinical symptoms including exophthalmos, diplopia, and gaze restriction as well as patients with dura exposure. Most patients undergoing surgery were those with concomitant fractures. The most common fractures among the surgical patients were frontal bone (32.2%), ethmoid (25.2%), and zygomaticomaxillary complex/zygoma (12.2%). Conclusions and Relevance: Management of orbital roof fractures varies based on individual clinical features including the presence of exophthalmos, gaze restriction, and concomitant injuries such as dural tears. Surgically, bicoronal approaches were performed most commonly along with reconstruction utilizing titanium miniplates. Conservative management was more common among the pediatric population. This systematic review demonstrates both conservative and surgical measures can lead to positive outcomes in appropriately selected patients.

Sparking the Debate: Facial Injury Patterns from Fireworks.

The objective of this article is to estimate the incidence, injury patterns, and demographics of patients presenting to emergency departments (EDs) for facial injury sustained from fireworks. This was an analysis of a nationwide database. The National Electronic Injury Surveillance System (NEISS) was evaluated for facial injuries from fireworks from 2013 to 2017. Relevant entries were examined for incidence, patient characteristics, location of injury, and type of injury. There were 509 NEISS entries, extrapolating to an estimated 19,816 ED visits for head and neck injuries due to fireworks from 2013 to 2017. The number of visits per year due to fireworks has been relatively stable over the past 5 years with an average of 3,963 cases per year. Greater than 90% of injuries occurred in July. Males comprised the majority of patients (67%), with the median age of 16 years. Most common sites of injury were the eyeballs (41%), followed by midface including eyelids, periorbita, and nose (31%), ears (12%), and only minor incidence of oral injuries (2%). After burns, contusions were the second most common injury from fireworks, followed by lacerations and foreign body injuries. The majority of firework injuries occurred in teenagers, reinforcing the importance of greater safety regulations and age limits for purchasing fireworks. Nearly half the incidents were eye injuries, necessitating greater public education in protective eyewear and mandating their use during festive holidays. Furthermore, injury patterns reported in this analysis may serve as a valuable adjunct for enhancing clinical history taking and physical examination to look for concurrent injuries.

Surgical Adjuncts to Rhinoplasty: An Algorithmic Approach.

BACKGROUND: Nasal aesthetics can be significantly affected by the interdependence of the surrounding bone and soft tissues of the face. These include the maxilla, septum, frontal bone, mandible, and the soft tissues and cartilage surrounding the nose. Therefore, it is pertinent to analyze and address these critical relationships of the nose in order to achieve a successful rhinoplasty. This work seeks to describe the battery of adjunct procedures available to supplement a rhinoplasty. Furthermore, each preoperative finding or indication for the adjunct is described in an algorithmic fashion. METHODS: A literature search using PubMed, Google Scholar, and a university library database was performed to locate papers describing adjunctive procedures to rhinoplasty. Indications and preoperative analysis were extracted from each paper. If the indication or finding was unclear, supplementary literature describing rhinoplasty and adjunctive analysis were sought in order to supplement our findings. RESULTS: Sixteen papers in total described adjunctive procedures for rhinoplasty. Each work highlighted a procedure or set of procedures on a surrounding facial feature including the forehead, brow, cheeks, lips, and chin, and neck. In total, 13 adjunct procedures for rhinoplasty are described with their respective indications. Additional literature and techniques were researched to clarify indicated procedures. CONCLUSION: The ability to correctly understand the critical relationships of the nose can help the surgeon correctly recognize the indication for a rhinoplasty adjunct procedure, leading to better aesthetic balance and surgical outcomes. LEVEL OF EVIDENCE II: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Fellow Selection Protocols in Facial Plastic Surgery: A National Survey of Facial Plastic Surgery Program Directors.

Background: Despite its popularity among otolaryngology residents, there is currently a paucity of knowledge on the match in facial plastics surgery fellowships and the selection criteria that drive the match process. To increase the understanding of this process and to improve the manner in which candidates are vetted, a survey study was designed. Methods: A 24-question online survey was designed to discern desired qualities regarding fellow selection, interview processes, fellow participation, and program director satisfaction with the current process. This survey was sent to all American Academy of Facial Plastic and Reconstructive Surgery fellowship program directors in the United States. Results: Overall, 40 of the 64 fellowship directors responded to the survey for a total response rate of 62.5%. Most fellowship directors reported that the reputation of an applicant's residency was an important component of the selection criteria with 34 of 40 of those who responded rating it at least "somewhat important." With regard to the otolaryngology trainee examination, nearly all fellowship directors (39/40) reported that there was no minimum cutoff score to be offered an interview. When fellowship directors were asked to rank the academic components of an application that they viewed as most important, they most commonly reported that the strength of an applicant's letters of recommendation were most important. Conclusions: With the increasing popularity of fellowships within the field of otolaryngology, having an understanding of which components of the application process are viewed as most important by fellowship directors is crucial in applicants matching into the fellowship of their choice.

Rattled: Analysis of Facial Trauma Among Toddlers.

OBJECTIVE: The aim of this study was to determine the national incidence of facial trauma among toddlers and delineate patterns of injury and their causes. METHODS: A retrospective review was designed to explore patterns of maxillofacial trauma within toddler-aged children using the National Electronic Injury Surveillance System from the Consumer Product Safety Commission. The database was searched for emergency department visits involving facial trauma sustained by children 12 months through 3 years of age from 2010 through 2014 and analyzed for patient demographics, primary diagnosis, and associated products/activities. Subset analyses were performed between age groups to determine the relationship between causes of injury and age using extrapolated national incidences. RESULTS: A sample of 45,249 patients extrapolated to an estimated 1.3 million emergency department visits for facial trauma in toddlers from 2010 to 2014, averaging 260,000 annually. Injuries involving foreign bodies and fractures had a higher incidence in toddlers 2 years or older, and fractures comprised fewer than 1% of facial injuries in any age group. Furniture was the most common source of trauma overall, with a higher frequency among toddlers aged 12 to 17 months. Trauma in the setting of sports was more common in toddlers aged 3 years. CONCLUSIONS: The low incidence of facial fractures further supports recommendations against routine imaging in toddler facial trauma and suggests that more focus should be placed on investigating for concurrent traumas and soft tissue injuries where fractures are involved. Our findings highlight prevention opportunities, particularly in furniture-related injuries for toddlers aged 12 to 17 months and sports-related traumas in toddlers aged 3 years. Our study also suggests restricting certain toys from 3-year-old toddlers to decrease the risk of aspiration.

Craniofacial injuries related to motorized scooter use: A rising epidemic.

OBJECTIVES: Over the last decade, there has been increased interest in utilizing motorized scooters for transportation. The limited regulation of this modernized vehicle raises numerous safety concerns. This analysis examines a national database to describe the yearly incidence of craniofacial injuries and patterns of injury related to motorized scooter use. METHODS: The Consumer Product Safety Commission's National Electronic Injury Surveillance system was queried for craniofacial injuries associated with motorized scooter use. Patient demographics, injury type, anatomic location, injury pattern, and helmet status were extracted for analysis. RESULTS: From 2008 to 2017, there were 990 recorded events for craniofacial injuries secondary to motorized scooters extrapolating to an estimated 32,001 emergency department (ED) visits. The annual incidence was noted to triple over that 10-year period. The majority of patients were male (62.1%) and the common age groups at presentation were young children 6-12 years old (33.3%), adolescents 13-18 years old (16.1%) and young adults 19-40 years old (18.0%). The most common injury pattern was a closed head injury (36.1%) followed by lacerations (20.5%). Facial fractures were only present in 5.2% of cases. In cases in which helmet use was recorded, 66% of the patients were not helmeted. CONCLUSION: The incidence of motorized scooter related craniofacial trauma is rising, resulting in thousands of ED visits annually. Many patients are experiencing morbid traumatic injuries and may not be wearing appropriate protective equipment. This study highlights the importance of public awareness and policy to improve safety and primarily prevent craniofacial trauma.

Public Perception of Facial Fillers.

There has been widespread coverage of cosmetic procedures, particularly facial fillers, as minimally invasive options for facial rejuvenation. The authors' objective was to characterize news media's coverage of facial fillers and its role in shaping public perception of these products over the past decade. Public view plays a significant role in policymaking, assisting patient communication, and addressing preconceived notions. Google News was searched for online news coverage related to "facial fillers" from 2008 to 2017. News articles from various sources were reviewed and analyzed with multiple objectives including complications listed, advantages, disadvantages, physician specialties, overall theme of the articles as positive, negative, or neutral and other parametrics. A chi-square test was used for statistical analysis. Of 426 articles meeting inclusion criteria, international news (20.4%), tabloids (18.8%), online health sites (18.3%), and national news (16.9%) were represented. Of articles containing adequate information, coverage was 44.7% positive, 29.9% neutral, and 26.1% negative with no significant change from 2008 to 2017. In addition, 46.0% of papers discussed complications including vascular injury and blindness associated with fillers, with significant increase by 2017 (p < 0.05). Facial fillers media coverage was overall positive, with broad coverage at both national and international levels. Complications were discussed often, and although vascular injury and vision damage are rare complications of fillers, they were frequently cited, potentially leading the public to believe they occur frequently. There were also significant concerns in the news media about greater regulation of products used as facial fillers, and practitioners administrating them. Altogether, these findings provide a comprehensive overview of patient perception and expectations of an increasingly popular and expanding cosmetic procedure.

Perioperative Desmopressin for Patients Undergoing Otolaryngologic Procedures: A Systematic Review.

OBJECTIVE: Desmopressin (DDAVP) is a hemostatic agent used to manage bleeding in patients with hemostatic disorders, and there is a lack of published data to guide its use during otolaryngology procedures. The objective of this study was to conduct an evidence-based systematic review of the reported uses, efficacy, and adverse effects of DDAVP in the otolaryngology surgical setting. DATA SOURCES: PubMed, MEDLINE, and EmBase were searched for articles on the use of DDAVP in otolaryngology. REVIEW METHODS: The Methodological Index for Non-Randomized Studies criteria and Cochrane bias tool were used to assess study quality. Patient demographics, DDAVP dosing and route, and outcomes such as bleeding and adverse events were collected. A summary of evidence table was created specifying levels of evidence, benefits, and harm. RESULTS: Nineteen studies encompassing 440 patients were included. Sixteen studies discussed DDAVP for prophylaxis, and 3 discussed postoperative use. DDAVP effectively prevented bleeding in high-risk patients and successfully facilitated a dry surgical field when necessary. DDAVP had a 100% success rate when used symptomatically. Five studies described adverse effects, including hyponatremia (12.3%), nausea (2.0%), emesis (0.9%), and seizure (0.2%). The aggregate level of evidence for its use was Level B for adenotonsillectomy, septoplasty, and turbinate procedures and Level C for rhinoplasty. CONCLUSION: Current literature supports the use of DDAVP in otolaryngology surgical procedures as both a perioperative prophylactic agent and a postoperative symptomatic intervention for bleeding. Both modalities are effective with minimal adverse events. Further well-designed randomized trials are necessary to conclusively formulate guidelines for DDAVP use in otolaryngology.

Orbital Paraganglioma: A Systematic Review.

Purpose The purpose of this study was to perform a systematic review of the literature on orbital paragangliomas, evaluating clinical presentation, diagnosis, management patterns, and prognosis. Methods The systematic review was conducted based on the principles described in the Preferred Reporting Items for Systematic Reviews and Meta-Analysis. PubMed, Cochrane databases, Embase, and Web of Science were searched for articles related to orbital paragangliomas. Inclusion criteria included English language articles with original reports on human subjects. Data on clinical presentation, diagnosis, treatment, and prognosis were collected. Results Twenty-seven articles met inclusion criteria (28 total patients). The mean patient age was 37.1 years (range, 3-75 years); 13 (46.4%) patients were male. The most common presenting symptoms were proptosis (89.2%), visual acuity changes (67.9%), and extraocular muscle restriction (64.2%). Lesions were most commonly intraconal (92.9%). Single modality therapy was employed in 19 patients (67.9%), including excision in 12 patients (42.9%) and exenteration in 5 patients (17.9%). Ten patients (35.7%) developed recurrence, and there was a 92.9% survival rate (mean follow-up, 29 months). Conclusion Orbital paragangliomas are rare tumors with an excellent prognosis. These lesions commonly present with proptosis, and are primarily managed surgically with simple excision, although exenteration and adjuvant radiation may be necessary for invasive tumors. This series is the largest and most comprehensive systematic review of orbital paragangliomas conducted to date.

Economic Analysis of Using Free Fat Graft or Acellular Dermis to Prevent Post-parotidectomy Frey Syndrome.

A decision tree was constructed to determine the incremental cost-effectiveness ratio (ICER) of grafting techniques used to prevent Frey Syndrome. The authors performed a sensitivity analysis to calculate what the probability of preventing Frey Syndrome would have to be and maximum costs associated with using grafting techniques to warrant their use as more "cost-effective" choice than using neither. Decision pathways utilized were uses of (1) free fat graft (FFG), (2) acellular dermis, and (3) no grafting. The probability of developing Frey syndrome and costs were extracted from previous studies to construct the decision tree. The primary effectiveness was the ICER of FFG or acellular dermis to prevent Frey syndrome. The initial outcomes included preventing Frey syndrome (effectiveness = 1) or developing Frey syndrome (effectiveness = 0). Compared with not using a graft, the ICER of using FFG and acellular dermis were $10,628 and $50,813, respectively. Frey syndrome was found in 2.6% of patients postoperatively in FFG group, 9.8% of patients in acellular dermis group, and 30.7% of patients who did not have a graft. The ICER shows absolute dominance of FFG with lower cost and high effectiveness over acellular dermis. This economic evaluation strongly supports the use of FFG over acellular dermis as cost-effective approach for prevention of postparotidectomy Frey syndrome.

Adverse Events in Facial Implant Surgery and Associated Malpractice Litigation.

IMPORTANCE: Facial implants represent an important strategy for providing instant and long-lasting volume enhancement to address both aging and posttraumatic defects. OBJECTIVE: To better understand risks of facial implants by examining national resources encompassing adverse events and considerations facilitating associated litigation. DESIGN, SETTING, AND PARTICIPANTS: A cross-sectional study reviewed complications following facial implants. The procedures reviewed were performed on patients at locations throughout the United States from January 2006 to December 2016. Data collection was completed in March 2017. The Manufacturer and User Facility Device Experience database, which contains medical device reports submitted to the US Food and Drug Administration (FDA), was searched for complications that occurred from January 2006 to December 2016 involving facial implants made by Implantech, MEDPOR, Stryker, KLS Martin, and Synthes. Furthermore, the Thomson Reuters Westlaw legal database was searched for relevant litigation. MAIN OUTCOMES AND MEASURES: The complications of facial implants were analyzed in relation to the location of implant and severity of complication. Litigation was analyzed to determine which factors determine outcome. RESULTS: Thirty-nine instances of adverse events reported to the FDA were identified. Sixteen (41%) involved malar implants, followed by 12 chin implants (31%). The most common complications included infection (18 [46%]), implant migration (9 [23%]), swelling (7 [18%]), and extrusion (4 [10%]). Thirty-two patients (83%) had to have their implants removed. Infection occurred at a mean (SD) of 83.3 (68.8) days following the surgery. One-third of complications involved either migration or extrusion. The mean (range) time to migration or extrusion was 381.1 (10-2400) days. In 12 malpractice cases identified in publicly available court proceedings, alleged inadequate informed consent and requiring additional surgical intervention (ie, removal) were the most commonly cited factors. CONCLUSIONS AND RELEVANCE: Infection and implant migration or extrusion are the most common complications of facial implants. Most of these complications necessitate removal. These considerations need to be discussed with patients preoperatively as part of the informed consent process, as allegedly inadequate informed consent was cited in a significant proportion of resultant litigation, and there were overlapping considerations among adverse events reported to the FDA and factors brought up in relevant litigation. Cases resolved with settlements and jury-awarded damages encompassed considerable award totals. LEVEL OF EVIDENCE: NA.

A Cross-sectional Analysis of Adverse Events and Litigation for Injectable Fillers.

IMPORTANCE: Injectable fillers are increasing in popularity as a noninvasive option to address concerns related to facial aging and volume loss. To our knowledge, there have been no large-scale analyses of adverse events and associated litigation related to filler injections. OBJECTIVES: To determine risks of injectable fillers and analyze factors raised in litigation related to injectable fillers. DESIGN, SETTING, AND PARTICIPANTS: In this cross-sectional review, the US Food and Drug Administration's (FDA) manufacturer and user facility device experience (MAUDE) database was evaluated for complications from the use of the following fillers: Juvederm, Restylane, Belotero, Sculptra, Radiesse, Artefill, Bellafill, and Juvederm Voluma from 2014 to 2016. The Westlaw Next database was used to identify jury verdicts. MAIN OUTCOMES AND MEASURES: Complications were organized by type of filler used, location of injection, and severity. Intra-arterial injections without sequelae and those resulting in blindness or necrosis were considered severe complications. Factors raised during the litigation process were also analyzed. RESULTS: Of 1748 adverse events analyzed, most cases stemmed from cheek (751 [43.0%]) or lip (524 [30.0%]) injection. Commonly reported adverse events reported included swelling (755 [43.2%]) and infection (725 [41.5%]). Among FDA-reported complications, blindness was significantly associated with dorsal nasal injections (P < .001). Vascular compromise with and without sequela of dermal necrosis and blindness were significantly associated with Radiesse injections P < .001. Of the 9 malpractice cases identified, two-thirds involved allegations of inadequate informed consent, and the median award in cases resolved with payment was $262 000. CONCLUSIONS AND RELEVANCE: Although specific complication profiles vary by material and injection site, common adverse events associated with injectable fillers include swelling and infection. More serious events include vascular compromise, resulting in necrosis and blindness; these events are also raised in cases involving litigation. This analysis illustrates the importance of outlining these risks in a comprehensive preoperative informed consent process. LEVEL OF EVIDENCE: NA.