A Survey of Microvascular Technique Preferences Among American Head Neck Society Members.

OBJECTIVE: To identify practices in microvascular techniques in routine and challenging scenarios. STUDY DESIGN: Cross-sectional study. METHODS: A national survey addressing practices related to microvascular free flap reconstruction was distributed to AHNS members between October and November 2021. RESULTS: The respondents encompassed 95 microvascular surgeons. Median years of practice was 6 (interquartile range, 2-13) and median flaps per year was 35 (22-50). Common practices in arterial anastomosis included limited cleaning of artery (84.2%), use of a double approximating clamp (64.2%), and use of interrupted suture (88.4%). Common practices in venous anastomosis included limited cleaning (89.5%), downsizing the coupler (53.7%), and coupling to two independent venous systems (47.4%). In arterial anastomosis, respondents felt that kinking (50.5%) and tension (24.2%) were the riskiest challenges. Kinking was handled by loose sutures or native tissue/dissolvable biomaterial to orient pedicle. Excess tension was handled by additional dissection. With regards to associated practices, most surgeons perform anastomosis after partial inset (52.6%), give aspirin immediately postoperatively (66.3%), reserve transfusion for hemodynamic instability (69.5%), and utilize intraoperative pressors when needed (72.6%). More senior surgeons reported placing more suture to address leaks (p = 0.004) and perform end to side anastomosis on larger vein in case of venous mismatch (p = 0.012). In cases of tension, higher volume surgeons perform more extensive dissection (p = 0.035) and end to side coupling (p = 0.029). CONCLUSIONS: This survey of AHNS members indicates patterns of microvascular techniques in routine and challenging scenarios. There exists a variation in approaches amongst surgeons based on volume and practice length. LEVEL OF EVIDENCE: 5 Laryngoscope, 134:1265-1277, 2024.

Complications and Functional Outcomes After Esophageal Reconstruction with an Intact Larynx.

BACKGROUND: Esophageal defects can result from primary pathologies such as malignancy or stricture, or secondary ones such as perforation due to trauma or iatrogenic injury. Techniques, management, and outcomes of reconstruction in this setting are poorly understood. Herein, we aim to highlight surgical outcomes in patients undergoing local and free flap reconstruction of esophageal defects in the setting of an intact larynx. METHODS: Retrospective review of patients who underwent esophageal reconstruction with an intact larynx between 2009 and 2022 at our institution was performed. RESULTS: Ten patients met inclusion criteria. Esophageal reconstruction was performed for extruded spinal hardware (n = 8), and esophageal stricture (n = 2). Four patients underwent reconstruction with free tissue transfer, and six with local pedicled flaps. There were no cases of flap failure, esophageal fistula, hematoma, or wound dehiscence. One patient had post-operative bleeding requiring return to the operating room. Three patients had a postoperative wound infection, two of whom required washout. There were no unplanned 30-day readmissions. At three months after operation, all patients who were not tube feed-dependent prior to surgery returned to oral intake. Of the four patients who were tube feed-dependent preoperatively, three were tolerating oral intake at nine months postoperatively. Nine patients (90%) had stable flexible laryngoscopy exams pre- and postoperatively with no voice changes. CONCLUSIONS: Reconstruction of esophageal defects in the setting of an intact larynx can be challenging. In this series, surgical intervention with free tissue transfer and local pedicled flaps was effective in returning patients to oral intake with low long-term morbidity. LEVEL OF EVIDENCE: 4 Laryngoscope, 134:1227-1233, 2024.

Factors Predicting Discharge Disposition Following Head and Neck Free Flap Reconstruction.

OBJECTIVES: Patients undergoing head and neck free flap reconstruction (HNFFR) may have significant change to their baseline functional status requiring inpatient rehabilitation (IPR) after discharge. We sought to identify patient/procedure characteristics predictive of discharge destination. METHODS: Patients undergoing elective HNFFR between July 2017 and July 2022 were reviewed for discharge destination. Those discharged to IPR versus home were compared across patient/procedure characteristics and physical/occupational therapy metrics. Significance was assessed via bivariate and multivariable analyses. RESULTS: Of the 531 patients, 102 (19.2%) required IPR postoperatively. Patients discharged to IPR versus home were significantly older (70.1 [11.6] vs. 64.1 [13.1] years; p < 0.001) and more likely to lack family assistance (26.5% vs. 8.6%; p < 0.001), require baseline assistance for activities of daily living (ADLs) (31.4% vs. 9.8%; p < 0.001), have baseline cognitive dysfunction (15.7% vs. 6.1%; p = 0.001), were more likely to have neoplasm as the surgical indication for HNFFR (89.2% vs. 80.0%; p = 0.033) and more likely to have a tracheostomy postop (62.7% vs. 51.7%), and had a significantly longer length of stay (11.2 [8.0] vs. 6.8 [8.3] days; p < 0.001). There was no significant difference in gender, donor site, use of tube feeds, and use of assistive devices between the two groups. Following logistic regression, the strongest predictors of discharge to IPR include lack of family assistance (OR = 3.8; p < 0.001) and baseline assistance for ADLs (OR = 4.0, p < 0.001). CONCLUSION: Certain patient factors predict the need for discharge to rehab after HNFFR. Perioperative identification of these factors may facilitate patient counseling and discharge planning with potential to reduce hospital length of stay and further optimize patient care. LEVEL OF EVIDENCE: III Laryngoscope, 134:2721-2725, 2024.

The Impact of Surgical and Nonsurgical Interventions on Overall Oral, Palpebral Fissure, and Brow Height Symmetry in a Patient with Facial Synkinesis.

Background: The treatment of facial nerve synkinesis remains complex and variable. Objective: To compare oral, palpebral fissure, and brow symmetry among surgical and nonsurgical interventions in patients with facial synkinesis. Methods: Patients with facial nerve synkinesis at a single tertiary care center between 2008 and 2022 were analyzed before and after interventions using Emotrics software. Symmetry was compared among treatment combination groups (chemodenervation and rehabilitation [CR] vs. chemodenervation and surgery [CS] vs. chemodenervation, surgery, and rehabilitation [CSR]) and among surgical intervention groups (selective neurectomy [SN] vs. selective neurectomy with facelift [SnFa] vs. no surgery). Results: Of the 29 patients meeting inclusion criteria, 72.4% were female and the median age was 60.6 years (interquartile range 49.9-67.6). The median follow-up was 32.6 months; patients who received surgery had a greater follow-up time (57.4 months vs. 26.5 months, p = 0.045). The use of a trimodal approach (CSR) was associated with improved symmetry versus CR for smile angle (p = 0.021). Among surgical interventions, the greatest improvement in palpebral fissure symmetry was in patients who received SN versus no surgery (p = 0.039); the greatest improvement in smile angle was in patients who received SnFa versus no surgery (p = 0.008). Conclusion: We recommend a comprehensive approach to the management of facial synkinesis consisting of chemodenervation, rehabilitation, and surgery tailored to each patient's needs.

Design, printing optimization, and material testing of a 3D-printed nasal osteotomy task trainer.

BACKGROUND: For difficult or rare procedures, simulation offers an opportunity to provide education and training. In developing an adequate model to utilize in simulation, 3D printing has emerged as a useful technology to provide detailed, accessible, and high-fidelity models. Nasal osteotomy is an essential step in many rhinoplasty surgeries, yet it can be challenging to perform and difficult to receive adequate exposure to this nuanced portion of the procedure. As it currently stands, there are limited opportunities to practice nasal osteotomy due to the reliance on cadaveric bones, which are expensive, difficult to obtain, and require appropriate facilities and personnel. While previous designs have been developed, these models leave room for improvement in printing efficiency, cost, and material performance. This manuscript aims to describe the methodology for the design of an updated nasal osteotomy training model derived from anatomic data and optimized for printability, usability, and fidelity. Additionally, an analysis of multiple commercially available 3D printing materials and technologies was conducted to determine which offered superior equivalency to bone. METHODS: This model was updated from a first-generation model previously described to include a more usable base and form, reduce irrelevant structures, and optimize geometry for 3D printing, while maintaining the nasal bones with added stabilizers essential for function and fidelity. For the material comparison, this updated model was printed in five materials: Ultimaker Polylactic Acid, 3D Printlife ALGA, 3DXTECH SimuBone, FibreTuff, and FormLabs Durable V2. Facial plastic surgeons tested the models in a blinded, randomized fashion and completed surveys assessing tactile feedback, audio feedback, material limitation, and overall value. RESULTS: A model optimizing printability while maintaining quality in the area of interest was developed. In the material comparison, SimuBone emerged as the top choice amongst the evaluating physicians in an experience-based subjective comparison to human bone during a simulated osteotomy procedure using the updated model. CONCLUSION: The updated midface model that was user-centered, low-cost, and printable was designed. In material testing, Simubone was rated above other materials to have a more realistic feel.

Tap-Tap: Learning Endonasal and Percutaneous Nasal Osteotomy Techniques on 3D-Printed Midface Models.

Nasal osteotomy is one of the most challenging steps of rhinoplasty. Lack of hands-on training and confidence with this procedure adds to the complexity for learners and trainees. As three-dimensional (3D) printing becomes increasingly accessible, simulation on 3D printed models has the potential to address this educational need in a safe, reproducible, and clinically realistic manner. The simulation session described in this communication, which utilized our low-cost, 3D-printed nasal osteotomy ($12.37) task trainer, produced both educational and confidence benefits for trainees. Here we describe the design, organization, curriculum, and pilot data for a 3D-printed nasal osteotomy task trainer for the simulation of endonasal and percutaneous nasal osteotomy.

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.

Evaluating YouTube Videos on Facelift Surgery for Facial Rejuvenation as a Resource for Patients.

OBJECTIVES: This study evaluated the content and patient educational quality of YouTube videos on facelift surgery for facial rejuvenation. This study investigated the relationship between education quality compared to video content, video metrics, and popularity. METHODS: Two hundred videos were identified across 4 search terms: "facelift surgery," "facelift surgery what to expect," "facelift surgery patient education," and "what is facelift surgery." Unrelated videos, operating room recordings, medical professional lectures, non-English, non-audio, and testimonials were excluded from review. Video quality was assessed using the Global Quality Score (GQS) (range: 1-5), modified DISCERN score (range: 5-25), and JAMA Benchmark Criteria (range: 0-4). Secondary outcomes included upload source, video metrics (views, likes, dislikes, duration, days since upload, comments), and Video Power Indexto measure popularity. The first 10 comments on videos were characterized as positive, neutral, or negative. RESULTS: One hundred forty-three videos were excluded (43 did not meet criteria, 100 duplicates), and 57 videos were included. Fifty-five videos (96.5%) were uploaded by private medical practices. Overall video quality was poor across all 3 scoring systems: GQS (2.92 ± 1.14), modified DISCERN (13.03 ± 3.64), and JAMA Benchmark Criteria (1.78 ± 0.52). Popularity positively correlated with JAMA Benchmark Criteria (R = .49, P < .05) but did not correlate with other quality criteria. CONCLUSIONS: For patients undergoing facelift surgery, there are limited educational videos on YouTube with few videos detailing indications, alternatives, complications, and the postoperative course. YouTube is a growing resource for patient education and opportunities exist for medical institutions to produce higher-quality videos for prospective patients.

Functional and Symmetry Outcomes After Forehead Flap Reconstruction of Medial Peri-Ocular Defects.

BACKGROUND: Orbital defects have a profound impact on orbital function and symmetry of the face and are difficult to reconstruct given the complexity of this area. The paramedian forehead flap (PMFF) has not been well studied in reconstruction of orbital defects. METHODS: Retrospective review of patients who underwent reconstruction of periorbital defects with PMFF between 2016 and 2021. Variables were ocular adnexal asymmetry, functional outcomes, and orbital complications. RESULTS: Eighteen patients met inclusion criteria. Mean defect size was 11.1 ± 7.5 cm. The most common subsite involved was medial canthus in 88.9% of patients. There was no statistically significant difference between mean medial canthus to midline ratio and mean medial brow to midline ratio when compared to the assumed normal of 1. The medial canthus to pupil ratio and medial canthus to lateral canthus ratio had a statistically significant mean difference from 1.0 (p = 0.003 for both). In 22.2% of patients, the orbit was functional with impairment; the remaining had no impairment. Surgical sequelae occurred in 12/18 (66.7%) of patients, most commonly epiphora in 9/18 (50%) of patients, and ectropion in 5/18 (27.7%). CONCLUSION: The PMFF is feasible for medial periorbital reconstruction with acceptable functional and symmetrical outcomes and low morbidity. LEVEL OF EVIDENCE: 4 Laryngoscope, 133:2584-2589, 2023.

Artificial intelligence for objectively measuring years regained after facial rejuvenation surgery.

BACKGROUND: Few objective measures are available for assessing the success of facial rejuvenation after face lift surgery. Convolutional neural networks (CNNs) may be used for this type of measurement. The purpose of this investigation is to use artificial intelligence (AI) via CNNs to objectively classify patient photos by age before and after aesthetic surgery. Uniquely, men and patients undergoing deep plane face lifts were included. METHODS: A CNN (FaceX) was used for facial age recognition and age estimation. Patient photos were analyzed preoperatively, and at three (PO1) and 12 months (PO2) postoperatively. The study population included male and female patients who underwent facial rejuvenation at our institution from 2017 to 2021. Patient photos were collected with the same camera, distance, and lighting. RESULTS: 226 patients were analyzed with a mean true age of 62.2 (SD 6.7) years. The AI estimated the mean preoperative age to be 64.7 (SD 10.4) years. The AI was 96.0 % accurate. Across all subjects, a 3.5-year, 5 % reduction in age (p ≤ 0.001) was attributed at PO1, and a 1.7 year, 3 % age reduction (p = 0.034) at PO2. No single ancillary procedure or technique conferred more benefit than others. The 15 males had a 2.0 year, 4 % age reduction (p = 0.06) at PO1. CONCLUSION: AI can be used to objectively measure the success of facelift surgery and compare outcomes among rhytidectomy techniques. Additionally, multiple, different approaches were effective with no single approach being superior. As AI continues to rapidly advance, more accurate models may be developed for multiple applications in facial plastic surgery.

Assessing Postoperative Recovery With Volatile Gas Versus Total Intravenous Anesthesia in Patients With and Without Obstructive Sleep Apnea.

INTRODUCTION: To determine if there is a recovery time difference between patients with and without obstructive sleep apnea (OSA) when using total intravenous anesthesia (TIVA) compared to volatile gas inhalational anesthesia. PATIENTS AND METHODS: OSA and Non-OSA patients were identified at a tertiary institution between January 2019 and November 2020. Non-OSA patients were defined as those who have not been formerly diagnosed with OSA. A modified STOP-BANG score (MSBS) was performed to screen Non-OSA patients for OSA. Recovery was measured by Phase I recovery time, or time it took a patient to reach ≥9/10 on the Aldrete scoring system. RESULTS: A total of 334 patients were included with 142 in the OSA cohort (59 TIVA, 83 inhalational anesthesia) and 192 in the Non-OSA cohort (119 TIVA, 73 inhalational anesthesia). In OSA patients, there was a 41.29-minute recovery time reduction when using TIVA versus sevoflurane (P < .0001). Non-OSA patients recovered faster than OSA patients when undergoing inhalational anesthesia by 46.76 minutes and TIVA by 18.58 minutes (P < .0001 and P = .0907, respectively). Non-OSA patients with a MSBS < 3 and ≥3 had a shorter recovery time compared to OSA patients when both underwent sevoflurane anesthesia (57.27 minutes, P < .0001 and 56.23 minutes, P = .040, respectively). Non-OSA patients with a MSBS of <3 had a decrease in recovery time of 26.68 minutes when compared to OSA patients who underwent TIVA (P = .0004). CONCLUSIONS: When utilizing TIVA over inhalational anesthesia, patients with OSA have significantly increased benefit in terms of reduced Phase I recovery times as compared to Non-OSA patients.

Rate of Fat Graft Volume Loss After Parotidectomy.

BACKGROUND: Reconstruction after parotidectomy can include fat grafting, which allows for symmetry, but grafts have demonstrated volume loss over time. OBJECTIVES: To provide quantitative evidence for the rate of volume loss of fat grafts. METHODS: Patients who received parotidectomy with fat graft reconstruction at a single institution from August 2016 to October 2020 were identified. Relationships between clinical factors and the logarithmic rate of fat graft volume loss were analyzed. RESULTS: Twelve patients received parotidectomy, fat graft reconstruction, and underwent a postoperative magnetic resonance imaging (MRI) scan. Rate of fat graft volume loss was a mean of 1.8% per month (standard deviation [SD]: 2.1% per month). Total parotid fat graft volume loss was a mean of 57.4% (SD: 67.5%). The mean follow-up time was 35.5 months (range: 9-89.8 months). Correlations between body mass index (BMI), history of smoking, and history of alcohol consumption and logarithmic rates of fat graft volume loss were increased but not significantly. CONCLUSIONS: Fat grafts have the potential of 60% volume loss at approximately 1 year. If there is clinical suspicion that patients will require adjuvant radiation or have clinical factors such as a smoking or alcohol-use history, volume requirements may be even greater to maintain adequate parotid volume for aesthetic purposes.

Impact of great auricular nerve sacrifice on sensory disturbance after parotidectomy.

PURPOSE: To investigate the association between great auricular nerve (GAN) sacrifice during parotidectomy and postoperative sensory disturbance. MATERIALS AND METHODS: Patients who underwent parotidectomy between November 2016 and May 2020 at a single academic institution were included in this retrospective chart review. Operative notes were reviewed to determine incidence of GAN sacrifice. Prevalence of patient-reported sensory complaints in the GAN distribution and time to spontaneous resolution of symptoms were assessed. RESULTS: Of 305 parotidectomy patients, 111 (36.4%) endorsed complaints of postoperative sensory disturbances in the GAN distribution typically characterized by numbness or shooting pains. GAN sacrifice was present in 9 (8.1%) of 111 patients who experienced sensory disturbances compared to 9 (4.6%) who reported no sensory disturbances (p > 0.05). Twenty-five patients (32.5%) experienced spontaneous resolution of symptoms at their most recent follow-up at a mean of 6.2 months after onset of symptoms. Of those that experienced a sensory disturbance, GAN preservation was not significantly associated with likelihood of spontaneous recovery (p > 0.05). CONCLUSIONS: We report the largest series to date of post-operative sensory disturbance in parotidectomy patients as it relates to intraoperative GAN sacrifice. Although the relationship between GAN sacrifice and the incidence of postoperative sensory disturbance and its subsequent resolution were not significant, we continue to advocate for GAN preservation to reduce incidence of postoperative sensory disturbances.

A randomized control trial employing infraorbital nerve stimulation as a neural distractor during nasopharyngeal swab.

INTRODUCTION: With the global COVID-19 pandemic, nasopharyngeal swabbing has become commonplace and can occasionally cause discomfort, tearing, and anxiety. OBJECTIVE: To evaluate whether using a neural distraction device during nasopharyngeal swabbing can mitigate patient discomfort. METHODS: Participants were randomized into nasal swab with vibration first (treatment-control or Tc) or nasal swab without vibration first (control-treatment or Ct). Then the swab was repeated with the opposite technique. The vibration device was used to stimulate the infraorbital nerve at the midpupillary line, while a nasopharyngeal swab was performed according to CDC protocol. After each swab, participants filled out a survey to assess pain, discomfort, and tearing. This procedure was replicated on the contralateral nostril for a total of 4 swabs and 4 surveys. RESULTS: Thirty-four subjects were included in the analysis. In the Ct group, there was a median 1.0-point decrease in pain with the use of vibration (95% CI [-1.8, -0.3], P = 0.0117), 2.5-point decrease (95% CI [-3.0, -0.8], P = 00039) in discomfort, and a 1.0-point decrease (95% CI [-2.6, -0.2] P = 0.0303) in tearing when the vibratory device was used. In the Tc group, there was a median 2.0-point decrease in pain with vibration (95% CI [ -2.7, -1.1], P < 0.0001), 2.3-point decrease in discomfort (95% CI [-3.1, -1.5], P < 0.0001), and a 1.5-point decrease in tearing (95% CI [-2.5, -0.5], P = 0.0037) when vibration was used. CONCLUSION: Vibratory stimulation of the infraorbital nerve is safe and effectively reduced pain, discomfort, and tearing during nasopharyngeal swab. Vibration is a reasonable option to minimize patient discomfort during COVID-19 or other microbiological testing.

Postoperative Opioid-Prescribing Practices in Nasal Surgery: A Prospective Study.

Importance: There has been a greater awareness of the opioid epidemic. Studies are needed to better characterize opioid usage after outpatient nasal surgery. Objective: Provide data to guide prescription management for nasal procedures and investigate opioid prescription and subsequent consumption, with the aim of offering analysis to build evidence-based guidelines for postoperative pain management. Design, Setting, and Participants: In this prospective single-center study, morphine milligram equivalents (MME) consumption and pain scores were collected in 69 patients who underwent nasal surgery. Main Measures and Outcomes: Patient demographics, MME use, and pain scores were examined. MME use was compared with patient demographics, surgical procedure type, and postoperative pain scores. Results: In total, 3302 MME were prescribed: 2012 MME (61%) were used, leaving 1290 MME (39%). Patients were prescribed a total average of 47.8 ± 24.0 MME. Four (6%) patients required a second prescription. History of opioid use, benzodiazepine use, and obesity were negative predictors of opioid consumption (p ≤ 0.001). Conclusion and Relevance: Assessing opioid consumption for nasal procedures will guide prescribing practices. Our results indicate that prescription practices can likely be down titrated in patients with a history of certain medication consumption.

First Bite Syndrome After Parotidectomy: A Case Series and Review of Literature.

INTRODUCTION: First bite syndrome (FBS) is a rare but potentially debilitating complication observed after surgery involving the upper cervical region. Patients classically complain of severe facial pain in the ipsilateral parotid region with the first few bites of a meal. OBJECTIVE: The aim of this study is to shed light on the incidence and potential risk factors of FBS, including a series of cases depicting FBS observed after parotidectomy. METHODS: Retrospective review of 419 patients who underwent parotidectomy at a single tertiary care facility between December 2016 and June 2020. RESULTS: With a mean follow-up time of 16.5 months, 8 (2%) patients were documented to have symptoms of FBS after parotid gland surgery. Six of these patients underwent partial parotidectomy by dissection of the deep lobe of the parotid (DLP). CONCLUSION: Patients undergoing dissection of the DLP are particularly at risk for the development of FBS. All patients should be appropriately counseled during informed consent discussions, especially in high-risk cases.

Sonic Rhinoplasty: Review and Updated Uses.

The ultrasonic bone aspirator (UBA) allows for precision and provides ease of use in multiple steps of cosmetic and functional rhinoplasties. Its use has previously been described; however, since the publication of many studies the UBA has been improved and its applications for rhinoplasty have been modified and expanded. Both bony and cartilaginous modifications to the nose can be aided with the use of the UBA. From our experience, patient results have subjectively been found to be more acceptable, if not better, than with the use of other rhinoplasty instruments.

Postoperative Anatomic Position of Mandibular Free Flap Neocondyles Affects Patient Symptoms.

Importance: Mandibular condyle reconstruction with vascularized free flaps can re-establish form and function after resection. However, no reports have been published regarding the postoperative anatomic seating of these reconstructions. Objective: To use postoperative axial imaging to determine whether condylar reconstructions migrate and correlate their ultimate location with postoperative symptoms. Design, Setting, and Participants: A prospectively maintained database of free flap cases performed between 2006 and 2019 at a single institution was queried. Twenty-one consecutive patients who underwent reconstructions that involved the mandibular condyle who also had postoperative axial imaging were selected for review. Distances were measured from the reconstructed condyle to the lateral, superior, and posterior aspect of the temporomandibular joint (TMJ), and correlated with postoperative symptoms and jaw function. Main Outcomes and Measures: Condyle displacement, postoperative diet, jaw pain, trismus, and malocclusion. Results: In total, 57% of patients had 1 cm or greater displacement of the condylar reconstruction from the TMJ in at least one vector. Anterior displacement of condyle by >1 cm was associated with jaw misalignment (42.8%) and clicking (14.3%) [odds ratio (OR) 37.3, 95% confidence interval (CI) 1.6-866.9, p = 0.024]. However, 83.3% of these patients were able to return to a normal diet and denied dysphagia. All edentulous patients had acceptable anteroposterior alignment, but 42.8% of dentulous patients had anterior displacement >1 cm (p = 0.12). Inferior displacement >1 cm was associated with dysphagia (OR 23, 95% CI 1.07-494.6, p = 0.04), but not pain or trismus. Eleven patients had multiple postoperative computed tomography scans, on average 21 months apart. The reconstructed location was stable in all 11 patients. Conclusions and Relevance: Patients undergoing free flap reconstruction of the mandibular condyle often return to normal diet, even when their reconstructions do not sit perfectly within the TMJ. Anterior displacement of the neocondyle may be more common in dentulous patients due to stress on the joint from chewing and produces some dysfunction and misalignment. Inferior displacement of the neocondyle may result in dysphagia. The reconstructed condyles are unlikely to migrate over time.

Online Ratings of Facial Plastic Surgeons: Worthwhile Additions to Conventional Patient Experience Surveys.

Background: Physician review websites are now commonly used by patients. However, in facial plastic surgery, the trends and content in these websites are not well studied. We examined online reviews for U.S. facial plastic surgeons, and compared comment content with the most commonly used patient experience survey, the Consumer Assessment of Healthcare Providers and Systems (CAHPS) administered by Press Ganey. Methods: A retrospective mixed method study was employed to quantitatively compare online ratings and comments of 100 randomly selected U.S. facial plastic surgeons on vitals.com, healthgrades.com, google.com and zocdoc.com. Qualitative content analysis was utilized to categorize themes present in 957 patient-generated (unverified) comments, and compare these with CAHPS survey questions and themes. Results: The physician review websites had favorable ratings of facial plastic surgeons with 84.55% five-star reviews on Healthgrades and 78.40% on Vitals. These ratings were similar across surgeon age (p = 0.44), gender (p = 0.85), and geographic region (p = 0.29). Of sites examined, Healthgrades and Vitals were most frequently used. Analysis of patient comments identified themes aligning with CAHPS content (e.g., physician interactions, efficiency, and recommendation likelihood), as well as additional themes such as patient's outcome perception (55.28% of comments) and finances (86% of negatively rated reviews). Conclusions: These exploratory results suggest that facial plastic surgeons are generally rated positively online, and the comments left on these websites provide additional feedback that is not currently included in CAHPS surveys. In evaluating the patient experience with facial plastic surgery practices, these websites may prove to be useful.