Effect of Underlying Mental Health Disorders on the Correlation Between Patient- and Surgeon-Graded Synkinesis Scores.

Background: Little is known about how depression and appearance anxiety affect patient reporting of synkinesis severity. Learning/Study Objective: Measure prevalence of depression and appearance anxiety in facial synkinesis and correlations between subjective and surgeon-graded synkinesis severity. Design Type: Prospective cohort. Methods: Patients with synkinesis volunteered and completed: Synkinesis Assessment Questionnaire (SAQ), facial clinimetric evaluation (FaCE) scale, Center for Epidemiological Studies Depression Scale (CES-D), and Fear of Negative Appearance Evaluation Scale (FNAES). Standardized videos were scored by facial plastic surgeons using Sunnybrook Scale and eFaCE. Multivariate linear regression was used to compare patient- and surgeon-graded metrics. Results: One hundred patients participated, 91 were female. Mean age was 56.4 (12.3). Eight percent identified as Black and 87% White. The most common nerve injury etiology was idiopathic (47%). Mean synkinesis duration was 7.6 years (6.2). Twenty percent and 15% reported history of an anxiety or depressive disorder, respectively. Patient (SAQ, FaCE) and clinician (Sunnybrook, eFaCE) scores were correlated (Pearson's r 0.223-0.294, p < 0.05). Upon adjusting for CES-D/FNAES, correlations between most patient and clinician metrics became stronger. As CES-D and FNAES worsened, patient-clinician correlations weakened. Conclusions: Depression and appearance anxiety may affect patient reporting of synkinesis severity. Worse mental health scores may decorrelate patient and clinician synkinesis assessments.

National Trends of Otolaryngology Involvement in Cleft Surgical Management over 10-Years.

OBJECTIVE: Surgical management of cleft lip/palate and cleft rhinoplasty have historically been performed by plastic surgeons. No study has addressed temporal trends in cleft-associated surgeries. This study assesses trends in cleft surgical management and complications in a national database. METHODS: Cross-sectional analysis of the National Surgical Quality Improvement Program Pediatric database from 2012 to 2021. Patients receiving cleft lip and/or palate repair were isolated using CPT codes. A subset receiving cleft rhinoplasty was also analyzed. The yearly proportion of otolaryngologists compared to general plastic surgeons performing surgeries was noted. Regression analysis was used to identify trends and predictors of management by OHNS. RESULTS: We identified 46,618 cases of cleft repair, of which 15.6% (N = 7,255) underwent repair with otolaryngology. On univariate Pearson correlation analysis, neither cleft rhinoplasties performed by OHNS over time (R = 0.371, 95% CI -0.337 to 0.811, p = 0.2907) nor all cases (R = -0.26, -0.76 to 0.44, p = 0.465) exhibited a significant change. On multivariable regression, the operative year was not associated with being treated by otolaryngology (p = 0.826) for all cleft cases but was associated with such in cleft rhinoplasties (OR 1.04, 1.01-1.08, p = 0.024). On multivariable analysis, the operative year was correlated with a higher rate of complications overall (OR 1.04, 1.01-1.07, p = 0.002). Surgeon specialty was not associated with complication rates. CONCLUSIONS: In the last 10 years, no change in the proportion of cleft lip/palate repair performed by OHNS was observed. Otolaryngologists are performing more cleft rhinoplasty but at a marginal rate. Otolaryngologists also manage more complex patients with multiple comorbidities compared to their colleagues. Complication rates have increased overall regardless of surgeon specialty, warranting further investigation. LEVEL OF EVIDENCE: 3 Laryngoscope, 134:671-677, 2024.

Early Postoperative Complications in Microtia Reconstruction: An Analysis of the NSQIP-P Database.

OBJECTIVES: Microtia and anotia repair require techniques that consider both aesthetics and function. The outcomes of different reconstructive frameworks such as costal cartilage or a porous polyethylene implant have not been evaluated on a national scale. We aim to understand differences in outcomes/complication rates and operative times between different reconstructive frameworks used in microtia/anotia reconstruction. METHODS: This was a retrospective review of the National Surgical Quality Improvement Program Pediatric database between 2012-2019. Patients with ICD-9/10 codes for microtia/anotia were isolated. Reconstruction methods were identified using CPT codes for rib graft, ear cartilage graft, and alloplastic implants (biocompatible implants, porous polyethylene, etc). Outcomes included operative-time, wound complications, and unplanned re-operations within 30 days of surgery. Multivariable logistic regression was performed to control for confounders. RESULTS: We included 593 patients for analysis. Reconstruction with rib grafts (N = 506, 85%) was the most common. In 58 patients (9.8%), an implant was used for the auricular framework, whereas in 47 (7.9%) ear cartilage grafts were used. The overall wound complication rate was 3.4%. On univariate analysis, alloplastic implants exhibited a higher rate of wound complications (8.6% vs. 2.8%, p = 0.037) and longer operative times (350 min vs. 235 min, p < 0.001). After controlling for demographics and comorbidities, implants conferred an independently increased risk of wound complications (OR 3.52, 1.10-9.54, p = 0.020). CONCLUSION: Although the use of alloplastic implants (e.g., porous polyethylene) may confer an increased risk of early complications, the long-term clinical implications of these findings are unclear relative to aesthetic benefits. Multi-institutional studies are needed to validate these findings using patient-specific and surgeon-specific data. LEVEL OF EVIDENCE: 3 Laryngoscope, 134:1214-1219, 2024.

Time-to-operation delays and in-hospital complications in operative facial trauma: A national analysis.

BACKGROUND: Management of facial fractures is variable. Understanding how time to operative management impacts outcomes can help standardize practice. METHODS: Retrospective analysis of the ACS Trauma Quality Improvement Program (TQIP) database between 2016 and 2019. Adult patients with operative facial fractures were isolated by ICD-10 procedure codes, and further stratified by fracture location, including the mandible, orbit, maxilla, zygoma, and frontal bone. Multivariable logistic regression was conducted to predict in-hospital complications (both surgical and systemic complications) adjusting for time-to-operation, comorbidities, fracture location, AIS, and demographics. RESULTS: 1678 patients with operative facial fractures were identified. The median time-to-operation was 2 days (IQR 1.0-2.0 days). Most patients only had one operative fracture (95 %) and orbital fracture was the most common (44 %). The overall complication rate was higher for those operated after 2 days compared to those operated between 1 and 2 days and within 24 h (2.8 % vs 0.6 % vs 0.7 %; p < 0.001). Patients who were operated on after 48 h exhibited an increased risk of any complication (OR 4.72, 95 % CI 1.49-16.6, p = 0.010) on multivariable models. CONCLUSION: Delays in the management of facial fractures are associated with more in-hospital complications. However, the incidence of short-term postoperative complications remains low. Injury characteristics are the primary predictor of delays in operation, however Hispanic patients independently experienced delays in care.

Forehead Flap Practices: A Cross-Sectional Survey of Facial Plastic and Reconstructive Surgeons.

Background: The paramedian forehead flap (PMFF) is a well-established technique utilized for reconstruction of complex nasal defects. Objective: To identify the different techniques and management of patients undergoing PMFF reconstruction and compare these with current literature. Methods: Members of the American Academy of Facial Plastic and Reconstructive Surgery were sent a practice survey highlighting various nuances in PMFF reconstruction. The survey included questions about flap design, operative techniques, and perioperative care. Results: In total, 172 responses were received (14% response rate). Mean years of practice after fellowship was 15.8 years with most respondents performing either 1-5 (33.1%) or 6-10 (27.3%) PMFFs per year. Common practices included the use of general anesthesia, elevation of PMFF in the subgaleal plane (59.6%), and pedicle division at 3 weeks (80%) (p < 0.001). Complication rates ranged between 1% and 5%. The nose was the most common site for revision (p < 0.001) and the average number of secondary procedures after forehead flap division was 1.1 (standard deviation 0.81). The most variability in responses was seen for methods of internal lining reconstruction. Conclusion: Reconstructive surgeons frequently divide the PMFF pedicle at 3 weeks or later and have variable approaches to reconstruction of the internal lining with low complication rates overall.

Balloon Sinuplasty and Stenting in the Management of Complex Frontal Sinus Outflow Tract Fractures.

OBJECTIVE: Classical management of complex fractures involving the frontal sinus outflow tract (FSOT) favors obliteration or cranialization to avoid delayed complications. We aim to exhibit success with a novel application of balloon sinuplasty and frontal stenting in the management of complex injuries disrupting the FSOT, which might have otherwise required more invasive interventions. STUDY DESIGN: Retrospective review. SETTING: Single institution, level 1 trauma center. METHODS: Retrospective review of patients presenting to a level 1 trauma center with fractures involving the FSOT. Outcomes include patency of the FSOT on imaging and endoscopy, rate of complications, degree of residual tabular displacement, and need for revision surgery. RESULTS: Twenty-five patients met inclusion criteria, with complete FSOT obstruction seen in all cases on computed tomography. All patients underwent balloon sinuplasty with frontal sinus stenting; 48% underwent concurrent anterior table repair, and 36% open repair of nasoorbitoethmoid complex fractures. The mean follow-up length was 13.9 months, at which time 91.3% of patients demonstrated radiographic and endoscopic FSOT patency. No residual sinus opacification or pneumocephalus was observed. CONCLUSION: Balloon sinuplasty with frontal sinus stenting is a straightforward and minimally invasive technique that can create a safe sinus in complex fractures disrupting the FSOT while avoiding the need for more invasive procedures.

State of the Evidence for Facial Skin Cancer Reconstruction.

This review provides a comprehensive presentation of the evidence available in facial reconstruction post-Mohs micrographic surgery. Given the large diversity in post-Mohs reconstruction, there are limited guidelines in the management of defects. The aim of the present work is to provide a review of the best evidence as it pertains to several considerations in facial reconstruction. Data suggests that Mohs micrographic surgery and many reconstructive procedures can be performed as outpatient procedures under local anesthesia, with narcotic pain medication only given in certain patient populations following a minority of reconstructive procedures. Perioperative and topical antibiotics are generally not indicated. Aspirin and warfarin can generally be continued for most reconstructive procedures, but clopidogrel and novel anticoagulants may predispose to increased bleeding complications. Delayed reconstruction appears to be safe, although data are discordant on this topic. No specific wound closure technique or suture choice appears to be consistently superior. Given the lack of robust comparative studies, consistent methodology, and variable defect sizes/locations, no robust evidence-based guidelines can be generated for reconstruction techniques of facial subsites.

Normative Values of the Nasal Obstruction Symptom Evaluation Scale.

Background: The Nasal Obstruction Symptom Evaluation (NOSE) scale is widely used by clinicians in evaluation of nasal airway obstruction (NAO). Objective: To determine normative values for the NOSE scale among both symptomatic and asymptomatic members of the general U.S. population. Methods: A survey of NAO symptoms in adults of age 18 years and older was performed. The distribution of NOSE scores among the general population was estimated. Influence of features including age, gender, race, location, and symptomatology on NOSE scores was evaluated. Results: Surveys were completed by 2333 participants. Mean NOSE score was 11 (standard deviation [SD] 11) in the asymptomatic, and 28 (SD 22) in the symptomatic population (p < 0.0001). Increasing age was associated with an increase in scores until 45 years, after which it was associated with decreasing scores. No significant differences were found related to other investigated demographics. Conclusions: Normative ranges for the NOSE scale are established, and are largely consistent with values in the existing literature. NOSE scores do not appear to be influenced by gender, race, or geography, although age should be considered in their interpretation.

Chemodenervation of the Posterior Belly of the Digastric Muscle in Facial Synkinesis.

Background: Patients with facial synkinesis may have jaw tightness and swallow discomfort despite chemodenervation of facial mimetic musculature, and the posterior belly of the digastric (PBD) muscle is a logical target to treat these symptoms. Learning/Study Objective: To compare patient-reported outcomes of botulinum toxin (BT) chemodenervation of the posterior belly of digastric muscle in patients with postparalytic facial synkinesis. Design Type: Retrospective review. Methods: Patients with facial synkinesis who underwent electromyography (EMG)-guided PBD BT chemodenervation in addition to their baseline therapeutic regimen were included. Pre- and post-treatment Synkinesis Assessment Questionnaires (SAQ) and a two-question survey regarding jaw tightness and swallow discomfort were administered. Results: Twenty-nine patients were included. An average of 5 U of BT-A was injected into the PBD, and 46.5 U across all facial muscles. From pre- to post-injection, patients demonstrated improvement in jaw tightness at rest (3.02 vs. 1.98/5.0, p < 0.001), with swallow (2.78 vs. 1.94/5.0, p < 0.001), and total SAQ (64.3 vs. 51.2/100, p < 0.001). Patients rated subjective benefit from PBD injection compared with prior treatments without PBD injection as 4.5/5.0. Conclusion: Synkinesis patients with jaw tightness or swallow discomfort may benefit from the addition of PBD injections to the therapeutic regimen.

Septal Perforation Repair Using a Temporoparietal Fascia and Polydioxanone Plate Construct: A Multi-Institutional Analysis.

Background: Nasal septal perforations (NSPs) are notoriously difficult to fix and closure can paradoxically lead to worsening of symptoms, prompting numerous techniques for repair including temporoparietal fascia (TPF)-polydioxanone (PDS) plate interposition grafting. Objectives: To compare rates of NSP closure with TPF-PDS interposition grafting among a variety of institutions with diverse environmental influences and patient-specific factors. Methods: Retrospective review of patients undergoing TPF-PDS interposition grafting at seven different U.S. institutions over 5 years. Outcomes include closure rate, self-reported symptom improvement, change in Nasal Obstruction Symptomatic Evaluation (NOSE) score, and postoperative complications. Results: Sixty-two patients (39 female) with a mean age of 41.5 years were included. Most common perforation location was anterior (53%), and average size was 1.70 cm2. NSP closure with symptomatic improvement was achieved in 95% of participants. Postoperative NOSE scores decreased on average by 42 points. Residual crusting occurred in 29% of patients, independent of external factors. Conclusions: TPF-PDS interposition grafting is highly effective for NSP repair in a wide variety of settings, and NOSE scores correspond well with patient-reported outcomes.

Professional Social Media in Facial Plastic and Reconstructive Surgery: Usage, Resources, and Barriers.

BACKGROUND: Social media is an important tool for networking, recruitment, and promoting clinical practice. No study has specifically assessed which FPRS practitioners have professional social media accounts, how they utilize them, and what barriers or resources exist to their use. OBJECTIVES: This study aims to examine differences in social media use based on provider demographics and practice setting, and identify resources and barriers to professional social media use. METHODS: This cross-sectional analysis was an anonymous survey sent to AAFPRS members. Data collected included demographics, practice setting, resources, and barriers encountered to use of professional social media. RESULTS: Most facial plastic surgeons (80%) use professional social media, notably Instagram and Facebook, and mostly post patient photos and stories (67.9%). Social media is more commonly utilized in private practice (56% vs 23%, P = .0016), where there are less institutional barriers (10% vs 40%, P = .02) and more resources available (82.5% vs 12.5%, P = .01). CONCLUSIONS: Social media is widely used in FPRS. Working in private practice is associated with increased availability of resources for support, and a reduction in institutional barriers to maintaining a social media presence. With this understanding, facial plastic surgeons can be better equipped for networking, marketing, and promoting the field of FPRS.

Optimizing Flap Harvest in Auricular Reconstruction.

INTRODUCTION: The temporoparietal fascial (TPF) and occipital cranial fascial (OCP) flaps are the mainstay of implant coverage in alloplastic auricular reconstruction. Their optimal design is critical for elevating a robust flap that ultimately leads to favorable outcomes. MATERIALS AND METHODS: Sixteen TPF and OCP dissections were performed on 8 cadaveric specimens. Vascular anatomy and key landmarks were documented. The minimum flap size that incorporated ideal vasculature and would appropriately cover a porous polyethylene implant was measured. RESULTS: The minimum flap dimensions (length × width × base width) to cover a standard PPE auricular implants were on average 11×8.3×6.4 cm for TPF and 13.1×8.6×6.5 cm for OCP. The average axial length of the superficial temporal artery and occipital artery were 12.51 and 13.2 cm, respectively. An "occipital elbow" was located on average 8.2 cm posterior to the external acoustic canal. The postauricular fascia contained additional contributions from the occipital artery and mastoid emissary vein, which was located on average 5.9 cm posterior to the superficial temporal artery. CONCLUSIONS: This study highlights the anatomic features behind optimal TPF and OCP flap design for auricular reconstruction. Contributions to axial length and anatomic relationships of their primary arterial supply, significance of the occipital elbow as a reliable landmark for fascial dissection, and importance of the postauricular fascia and its vascular supply for flap viability are emphasized. Ultimately, the authors provide minimal dimensions for both TPF and OCP flaps to obtain adequate alloplastic implant coverage.

Complications Associated with Use of Porous High-Density Polyethylene in Rhinoplasty.

Background: Porous high-density polyethylene (pHDPE) has successfully been used as an alternative to cartilage for grafting in rhinoplasty; however, concerns exist surrounding its potential for infection and/or extrusion. Objectives: To analyze the relationship between complication rates associated with pHDPE in rhinoplasty and graft location relative to shear force applied by external manipulation. Methods: Retrospective review of 116 patients undergoing pHDPE rhinoplasty for 10 years. Results: Minor postoperative complications occurred in 3.4% of patients, each resolving with conservative management. Major complications including infection or extrusion occurred in 5.2% of all patients, at an average of 36.9 months postoperatively. All major complications occurred in patients with grafts extending into the caudal nose, and two-thirds ultimately necessitated surgical intervention. Conclusions: Cephalically contained pHDPE grafts are less prone to failure than those extending into the caudal nose. Long-term follow-up is recommended for all patients based on the risk for delayed complications.

Repair of Septal Perforations.

Nasal septal perforations have varied etiologies, clinical presentations, and methods of management. Some patients may be asymptomatic, while others may complain of nasal obstruction, crusting, epistaxis, and whistling. Management of nasal septal perforations is guided by the patient's symptoms and characteristics of the perforation. Some lesions can be managed conservatively or with minimally invasive procedures, while others require surgery. Surgical repair of perforations can be challenging and many techniques have been described without a standardized method of management. This article aims to provide a comprehensive review of options for repair of nasal septal perforations.

Augmented Skin Grafting: A New Rung in the Reconstructive Ladder.

Importance: A gap in the reconstructive ladder exists in which complex defects may benefit from skin grafting but are not amenable due to their anatomic limitations. Similarly, some patients are intolerant of more invasive techniques in cosmetically sensitive areas. In these scenarios, augmented skin grafts may represent a unique alternative to traditional reconstructive options. Observations: This report is a clinical overview of skin grafting in complex nasal defects. We describe three types of augmented skin grafts, with examples of each. These include preliminarily augmented grafts with a dermal biomatrix, simultaneous augmentation with a perichondrocutaneous pseudo-composite graft, and delayed augmentation with staged structural grafting. Conclusions and Relevance: Augmented skin grafts represent unique methods of reconstruction for complex wounds in cosmetically sensitive areas. We propose these techniques as an evolving unique rung in the reconstructive ladder.

Nasal Fractures.

This article outlines current methods in the evaluation and management of nasal fractures including clinical workup, imaging, and treatment.

Septal Perfoplasty for Management of Symptomatic Nasal Septal Perforation: An Alternative to Surgical Closure.

Importance: Symptomatic septal perforations are often difficult to manage and can have a significant impact on patient quality of life. Available surgical techniques for repair have demonstrated a varying rate of success, presenting a need for reliable interventions targeting symptom control. Objectives: To describe the modified surgical technique here termed septal perfoplasty. To demonstrate that creation of favorable septal perforation characteristics is effective in managing symptoms and improving patient quality of life. Design, Setting, and Participants: A retrospective review of the medical record was performed of patients who underwent the procedure of interest between July 1, 2006 and October 1, 2019 at Vanderbilt University Medical Center. All patients with symptomatic septal perforation who underwent septal perfoplasty within the timeframe reviewed were included. Septal perfoplasty was standardly performed in combination with turbinate reduction in all cases. This was combined with other indicated procedures for chronic sinusitis, repair of vestibular stenosis or nasal deformity. Main Outcomes and Measures: Creation of a well-mucosalized septal perforation, combined with patient-reported acceptable symptom control, was the primary outcome. Secondary outcomes include time to resolution, duration of follow-up, postsurgical complications, and need for further intervention. Results: Twenty patients (70% female; mean [range] age, 45.8 [15-72] years) underwent septal perfoplasty over the course of 13 years. The most common etiology of perforation was trauma (40%), presenting symptom was crusting (95%), and size of perforation repaired was large (60%). Mean follow-up was 37.6 months (range, 1-153 months). Overall, favorable perforation characteristics were created in 95% of cases by the first postoperative appointment. Acceptable symptomatic control was achieved in 18 out of 20 patients (90%), with a median time to improvement of 66 days. Eight patients required additional surgery to address chronic sinusitis or vestibular stenosis. Two patients experienced postoperative infections, treated conservatively with antibiotics. Conclusion and Relevance: Septal perfoplasty is a safe, simple, and effective method for management of symptomatic nasal septal perforation, which provides an alternative to more complicated interventions with comparable rates of symptomatic resolution. This procedure should particularly be considered for patients in which difficult repair is anticipated.

Optimizing septal perforation repair techniques.

PURPOSE OF REVIEW: Multiple successful techniques and approaches for nasal septal perforation repair have been described, yet consistency in perforation and outcome metrics is required to identify the optimal approach to repair. The present article will review the recent literature. RECENT FINDINGS: Computational fluid dynamic studies continue to expand our understanding of the airflow dynamics in nasal septal perforation and after repair. Combining rhinoplasty and nasal septal perforation repair in appropriately selected patients can be safely done with excellent results. There has been a rise in utilization of a temporoparietal fascia with polydiaxonone plate construct for septal perforation repair with excellent outcomes. SUMMARY: The present review provides the reconstructive surgeon with an update on nasal septal perforation repair and describes a recently popularized technique of temporoparietal fascia-polydiaxonone plate for perforation reconstruction.