The Online Physician Image: A Brave New World.

The online physician image is a point of emerging importance in the field of medicine. Online information has become critically important to patients who are seeking out care. Leaving online reviews has become a common practice among patients and as such, physician practices have embraced the use of social media to help grow their online presence. In addition, attention to online review sites has come to be an important part of protecting a physician's image. This article will discuss the importance of engaging the physician online review sites and help identify strategies for reviewing and improving a physician's online image.

Radial Forearm Free Flap Reconstruction of Glossectomy Defects Without Tracheostomy.

OBJECTIVES: To assess the feasibility of radial forearm free flap (RFFF) reconstruction of glossectomy defects without tracheostomy tube (TT). METHODS: Retrospective review of patients with at least oral tongue defects who underwent RFFF reconstruction. Pre- and intra-operative factors were documented. Post-operative respiratory complications included inability to extubate, pneumonia, or need for re-intubation or TT within 30 days. RESULTS: Twenty-one patients underwent RFFF reconstruction without TT, and 36 patients with TT. The average hospital length of stay was 1.5 days shorter in those without TT (P < .01). Two patients who underwent TT placement experienced a respiratory complication (P = .27). There were no respiratory complications among those without TT. After multivariate analyses, large tongue base defect (>25% resection, P < .001) and bilateral neck dissection (P < .001) were independently associated with TT placement. CONCLUSIONS: In our experience, RFFF reconstruction of glossectomy defects is feasible without TT among selected patients with small tongue base defects (≤25% resection) and unilateral neck dissection.

Adverse events in facial plastic surgery: Data-driven insights into systems, standards, and self-assessment.

PURPOSE: Complications in facial plastic surgery can lead to pain, suffering, and permanent harm. Yet, the etiology and outcomes of adverse events are understudied. This study aims to determine the etiology and outcomes of adverse events reported in aesthetic facial plastic surgery and identify quality improvement opportunities. MATERIAL AND METHODS: A cross-sectional survey analysis was conducted using an anonymous 22-item questionnaire distributed to members of the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) and American Academy of Facial Plastic and Reconstructive Surgery (AAFPRS). Participants were queried on demographics, practice type, and adverse events related to aesthetic facial surgeries. RESULTS: Two hundred fifty-three individuals participated; nearly half of respondents (49.0%) held membership in both AAO-HNS and AAFPRS. Of these, 40.8% of respondents reported at least one adverse event within the past 12 months of practice. A total of 194 adverse events were reported, most commonly related to facelift (n = 59/194, 30.4%), rhinoplasty (n = 55/194, 28.4%), and injection procedures (n = 38/194, 19.6%), with hematoma or seroma being the most commonly described. Most adverse events were self-limited, but approximately 68% resulted in further procedures. Surgeon error or poor judgement (n = 42) and patient non-adherence (n = 18) were the most commonly ascribed reasons for adverse events; 37.1% of participants reported a change in clinical practice after the incident. CONCLUSIONS: Adverse events were not infrequent in facial plastic surgery. Understanding these adverse events can provide impetus for tracking outcomes, standardization, and engagement with lifelong learning, self-assessment, and evaluation of practice performance.

Follicular Unit Transplantation.

Hair transplant is a powerful and reliable procedure that provides a natural and high-impact result. This procedure can be used to restore scalp hair, eyebrow hair, beard hair, body hair, or areas of hair loss due to scarring. The hair transplant techniques of the past (hair plugs, scalp reductions) have etched a negative impression of hair restoration surgery in the public memory. With the improved techniques of follicular unit transplantation, more natural and discreet results can be obtained with minimal downtime and preservation of patient privacy. This article focuses on follicular unit transplantation and performance of the strip technique.

Deep Plane Facelift: An Evaluation of the High-SMAS versus Standard Incision Points.

In surgery of the aging face, operative adjustments of the superficial musculoaponeurotic system (SMAS) enhance facial contours. The senior author has observed that the standard deep plane face lift entry points on the SMAS do not provide as much tissue movement in a vertical direction as high-SMAS deep plane face lift entry points. In this study, tissue movement was measured comparing the conventional SMAS entry point with a high-SMAS entry point for deep plane face lifts. Institutional review board approval was obtained. Fourteen facelift patients were enrolled, 10 female and 4 male. Average age was 63.4 (50-81) years. Tissue movement at three points along the jaw line was measured intraoperatively. Standard SMAS entry point suspension resulted in average vertical movements of 6.4, 10.3, and 13.8 mm and average horizontal movements of 3.5, 5.7, and 6.5 mm. High-SMAS entry point resulted in average vertical movements of 11.8, 17.9, and 24.1 mm and average horizontal movements of 5.8, 9.8, and 9.9 mm. This resulted in a 77.3% increase (p = 0.03) in vertical movement and a 61.4% increase (p = 0.02) in horizontal movement with a high-SMAS entry compared with standard SMAS entry. The high-SMAS entry point for a deep plane facelift resulted in a significant increase in lift for both the horizontal and vertical vector on the facial skin flap when compared with the conventional entry.

Platelet-Rich Plasma for Hair Loss: Review of Methods and Results.

Given substantial advances in hair regrowth research and platelet-rich plasma (PRP) science, a review of currently used systems and results is informative for physicians using a biologics approach to hair restoration. Overall positive clinical response to the use of PRP in androgenetic and alopecia areata patients is observed. The effects on hair density, count, and thickness were demonstrated through multiple clinical trials. Use as an adjunct to hair transplantation and with other technologies is also described. When compared with traditional oral/topical treatments, the lack of identifiable complications and convenience of treatment provide a positive outlook for future use and investigation.

The Prevalence of Cosmetic Facial Plastic Procedures among Facial Plastic Surgeons.

This is the first study to report on the prevalence of cosmetic facial plastic surgery use among facial plastic surgeons. The aim of this study is to determine the frequency with which facial plastic surgeons have cosmetic procedures themselves. A secondary aim is to determine whether trends in usage of cosmetic facial procedures among facial plastic surgeons are similar to that of nonsurgeons. The study design was an anonymous, five-question, Internet survey distributed via email set in a single academic institution. Board-certified members of the American Academy of Facial Plastic and Reconstructive Surgery (AAFPRS) were included in this study. Self-reported history of cosmetic facial plastic surgery or minimally invasive procedures were recorded. The survey also queried participants for demographic data. A total of 216 members of the AAFPRS responded to the questionnaire. Ninety percent of respondents were male (n = 192) and 10.3% were female (n = 22). Thirty-three percent of respondents were aged 31 to 40 years (n = 70), 25% were aged 41 to 50 years (n = 53), 21.4% were aged 51 to 60 years (n = 46), and 20.5% were older than 60 years (n = 44). Thirty-six percent of respondents had a surgical cosmetic facial procedure and 75% has at least one minimally invasive cosmetic facial procedure. Facial plastic surgeons are frequent users of cosmetic facial plastic surgery. This finding may be due to access, knowledge base, values, or attitudes. By better understanding surgeon attitudes toward facial plastic surgery, we can improve communication with patients and delivery of care. This study is a first step in understanding use of facial plastic procedures among facial plastic surgeons.

Comparison of Conventional, Revascularized, and Bioengineered Methods of Recurrent Laryngeal Nerve Reconstruction.

IMPORTANCE: Damage to the recurrent laryngeal nerve (RLN) is highly detrimental to voice, swallow, and cough. The optimal method for reconstitution of a nerve gap after injury is unknown. OBJECTIVE: To evaluate multiple methods of RLN reconstruction. DESIGN, SETTING, AND PARTICIPANTS: This study used an established canine model of RLN injury to examine purpose-bred, conditioned, female, 20-kg mongrel hounds at Washington University. A total of 32 dogs were examined, with 63 experiments performed. INTERVENTIONS: Surgical transection or excision of the RLN with reconstruction by multiple methods. MAIN OUTCOMES AND MEASURES: Six months after injury repair, laryngeal adductor pressures (LAPs), spontaneous and stimulable movement, and graft axon counts by histologic analysis were assessed. RESULTS: Simple RLN transection with direct neurorrhaphy provided a mean (SD) recovery of 55.5% (12.5%) of baseline LAPs (P = .18 for comparison of LAP recovery among cases from the conventional nerve graft [39.4% (22.2%)]; P = .63 for comparison of LAP recovery among cases from the reverse autograft [60.8% (27.5%)]). Revascularized grafts provided a recovery of 54.5% (46.4%) while short and long acellular grafts provided recoveries of 60.4% (NA) and 39.5% (17.0%). Two of 11 polyglycolic acid reconstructions provided a measurable LAP with a mean (SD) recovery of 37.1% (8.9%) of baseline. Reconstruction with a neural conduit in any condition provided no measurable LAP recovery. CONCLUSIONS AND RELEVANCE: Conventional nerve grafting resulted in no significant difference in recovery of LAP function compared with simple neurorrhaphy or reverse autograft. Conventional and revascularized nerve grafts provided similar recovery. The use of bioengineered acellular nerve grafts or nerve conduits for reconstruction resulted in poor recovery of function.

Surgical Anatomy of the Eyelids.

Slight alterations in the intricate anatomy of the upper and lower eyelid or their underlying structures can have pronounced consequences for ocular esthetics and function. The understanding of periorbital structures and their interrelationships continues to evolve and requires consideration when performing complex eyelid interventions. Maintaining a detailed appreciation of this region is critical to successful cosmetic or reconstructive surgery. This article presents a current review of the anatomy of the upper and lower eyelid with a focus on surgical implications.

Septal Perforation Repair Using Polydioxanone Plates: A 10-Year Comparative Study.

UNLABELLED: Medium to large septal perforations are a challenging problem to the rhinoplasty surgeon. In this study, records and outcomes are reviewed for 25 patients who underwent septal perforation repair over a 10-year period. All patients underwent an open septorhinoplasty approach with use of bilateral opposing mucoperichondrial flaps and a unique intervening graft that included acellular dermis, temporalis fascia alone, or a novel closure technique using temporalis fascia and a polydioxanone plate. The authors identify that for medium to large septal perforations, the use of the polydioxanone plate with temporalis fascia provided the highest rate of closure as a method of scaffolding a fascial graft, and also provided ease of placement between opposing mucoperichondrial flaps. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Reconstruction of the Lateral Mandibular Defect: A Review and Treatment Algorithm.

Reconstruction of the lateral mandibular defect presents a complex challenge to the reconstructive surgeon, often involving interconnected soft-tissue and bone requirements. This review examines the current literature on functional outcomes of lateral mandibular reconstruction and presents an algorithm on selecting an optimal reconstructive choice for patients with lateral mandibular defects resulting from oncologic ablative surgery or trauma. PubMed and Medline searches on reconstructing lateral mandibular defect were performed of the English literature. Search terms included lateral mandibular defect, outcomes of mandibular reconstruction, and free flap reconstruction of mandible. Although most of the articles presented are retrospective reviews, priority was given to the articles with high-quality level of evidence. Restoration of function, including speech and swallow, and acceptable cosmetic result are the primary objectives of lateral mandibular reconstruction. When reconstructing the mandible in a patient following tumor extirpation, the patient's overall prognosis, medical comorbidities, and need for adjuvant therapy should be considered. In the patient with aggressive malignant disease and a poor prognosis, a less complex reconstruction, such as soft-tissue flap with or without a reconstruction plate, may be adequate. In a dentate patient with favorable prognosis, a durable reconstruction, such as osseocutaneous microvascular free flap, is often preferred. Various reconstructive options are available for patients with lateral mandibular defects. Depending on the predominance of the soft-tissue or bony components of the defect, with consideration of the patient's characteristics and functional and aesthetic goals, the surgeon can wisely select from these reconstructive possibilities.

Scalp reconstruction: an algorithmic approach and systematic review.

IMPORTANCE: Reconstruction of the scalp after acquired defects remains a common challenge for the reconstructive surgeon, especially in a patient with a history of radiation to the area. OBJECTIVE: To review the current literature and describe a novel algorithm to help guide the reconstructive surgeon in determining the optimal reconstruction from a cosmetic and functional standpoint. Pertinent surgical anatomy, considerations for patient and technique selection, reconstructive goals, as well as the reconstructive ladder, are also discussed. EVIDENCE REVIEW: A PubMed and Medline search was performed of the entire English literature with respect to scalp reconstruction. Priority of review was given to those studies with higher-quality levels of evidence. FINDINGS: Size, location, radiation history, and potential for hairline distortion are important factors in determining the ideal reconstruction. The tighter and looser areas of the scalp play a major role in the potential for primary or local flap closure. Patients with medium to large defects and a history of radiation will likely benefit from free tissue transfer. CONCLUSIONS AND RELEVANCE: Ideal reconstruction of scalp defects relies on a comprehensive understanding of scalp anatomy, a full consideration of the armamentarium of surgical techniques, and a detailed appraisal of patient factors and expectations. The simplest reconstruction should be used whenever possible to provide the most functional and aesthetic scalp reconstruction, with the least amount of complexity. LEVEL OF EVIDENCE: NA.

Asymptomatic p16-positive oropharyngeal squamous cell carcinoma: an emerging trend.

IMPORTANCE: The rapid increase of human papillomavirus-associated oropharyngeal cancer has demonstrated a need for new strategies in prevention, diagnosis, evaluation, and treatment. Because there are currently no available screening technologies to detect early disease, a trend of purely incidentally identified asymptomatic p16-positive squamous cell carcinoma has been observed. We identify and describe a case series of these patients. OBSERVATIONS: A total of 134 patients with p16-positive oropharyngeal cancer were identified. Of these patients, 5 (3.7%) were identified as having completely asymptomatic primary site p16-positive tumors found during workup for other nonrelated medical problems. Four patients were found with early T-stage disease without nodal metastasis, and underwent surgical treatment as a single modality. One patient had advanced-stage disease and underwent chemoradiation. At a mean follow-up of 12.6 months, all patients remained disease free. CONCLUSIONS AND RELEVANCE: With the rise of p16-positive oropharyngeal squamous cell carcinoma and lack of screening technologies for early-stage disease, purely incidentally diagnosed disease might increase in incidence. These findings underscore the importance of a comprehensive physical examination on all patients. Although follow-up is too limited for definitive conclusions, early experience suggests that these patients can be treated with unimodality therapy when presenting with stage I or II disease.

BMP-2 expression correlates with local failure in head and neck squamous cell carcinoma.

OBJECTIVE: Preclinical data show that exogenous administration of recombinant human bone morphogenetic protein-2 (rhBMP-2) to human oral carcinoma cell lines increases pathogenicity using a nude mouse model. The objectives of this study are to (1) describe the characteristics of baseline protein expression of BMP-2 in head and neck squamous cell carcinomas (HNSCC) and (2) determine if BMP-2 expression level correlates with worse oncologic outcomes. STUDY DESIGN: Retrospective analysis of previously harvested patient samples. SETTING: Academic medical center. SUBJECTS: In total, 149 patients with oral cavity, oropharynx, larynx, and hypopharynx HNSCC treated between January 1, 1997, and December 31, 2004. METHODS: A tissue microarray of HNSCC was assembled and immunohistochemistry for BMP-2 performed. Staining was quantified using a standardized scoring system. Specimens were dichotomized into high or low expression level. Statistical analyses using log-rank, Wilcoxon, and Fisher exact test were performed for associations between BMP-2 protein level and clinicopathologic features and patient survival. RESULTS: BMP-2 expression at any level was noted in 146 of 149 (98%) of samples. Tumors with high BMP-2 expression had higher rates of local failure compared with low-expressing tumors (17.3% vs 6.3%; P = .04). There was no significant association for BMP-2 expression level with tumor location, T stage, N stage, overall survival, regional failure, or distant failure. CONCLUSION: Head and neck squamous cell carcinomas with high baseline BMP-2 protein level are associated with higher rates of local recurrence. These data have important implications for using rhBMP-2 in tissue engineering reconstructive approaches in the setting of cancer-related defects.

Studies of the kinetics and thermochemistry of the forward and reverse reaction Cl + C6H6 = HCl + C6H5.

The laser flash photolysis resonance fluorescence technique was used to monitor atomic Cl kinetics. Loss of Cl following photolysis of CCl4 and NaCl was used to determine k(Cl + C6H6) = 6.4 x 10(-12) exp(-18.1 kJ mol(-1)/RT) cm(3) molecule(-1) s(-1) over 578-922 K and k(Cl + C6D6) = 6.2 x 10(-12) exp(-22.8 kJ mol(-1)/RT) cm(3) molecule(-1) s(-1) over 635-922 K. Inclusion of literature data at room temperature leads to a recommendation of k(Cl + C6H6) = 6.1 x 10(-11) exp(-31.6 kJ mol(-1)/RT) cm(3) molecule(-1) s(-1) for 296-922 K. Monitoring growth of Cl during the reaction of phenyl with HCl led to k(C6H5 + HCl) = 1.14 x 10(-12) exp(+5.2 kJ mol(-1)/RT) cm(3) molecule(-1) s(-1) over 294-748 K, k(C6H5 + DCl) = 7.7 x 10(-13) exp(+4.9 kJ mol(-1)/RT) cm(3) molecule(-1) s(-1) over 292-546 K, an approximate k(C6H5 + C6H5I) = 2 x 10(-11) cm(3) molecule(-1) s(-1) over 300-750 K, and an upper limit k(Cl + C6H5I) < or = 5.3 x 10(-12) exp(+2.8 kJ mol(-1)/RT) cm(3) molecule(-1) s(-1) over 300-750 K. Confidence limits are discussed in the text. Third-law analysis of the equilibrium constant yields the bond dissociation enthalpy D(298)(C6H5-H) = 472.1 +/- 2.5 kJ mol(-1) and thus the enthalpy of formation Delta(f)H(298)(C6H5) = 337.0 +/- 2.5 kJ mol(-1).