Analysis of Patients Undergoing Cosmetic Surgery in an Academic Practice
Cameron Todd, MD (Presenter); Lauren Himes; Brian Downs, MD
Introduction: Facial cosmetic surgery is largely performed in the private practice setting, and the demographics of patients undergoing cosmetic surgery in the academic setting have not been well characterized.
Method: A retrospective chart review was performed of patients undergoing cosmetic surgery in the operating room by fellowship-trained facial plastic surgeons at a single academic institution from 2015 to 2019. Combination cases with functional components covered by insurance were included.
Results: Over the course of a 5-year period, 152 cosmetic surgical procedures were performed by all surgeons. This represented 13% of all operative procedures performed. Of the 152 cosmetic procedures, 33% were combination procedures with other functional procedures covered by insurance and 20% of patients were male. In total, 88% of patients undergoing cosmetic procedures were White, 6% other, 4% Asian, and 1% American Indian or Alaska Native.
Conclusion: One-third of facial cosmetic surgery procedures in our academic practice are performed in combination with functional components included. The patient population in this study was composed of more males and more Whites as compared with larger national demographic data.
Auricular “Hematomas” Amid COVID-19: Is This a Different Pathophysiology?
Mohammad Abraham Kazemizadeh-Gol, MD (Presenter); Ziad Rohayem
Introduction: An increase in auricular fluid collections with and without a history of trauma was noticed in our clinical practice during the COVID-19 pandemic. We sought to describe these cases and suggest that masks might be exerting pressure on the helical root or folding the ear in a way that makes the pinna more susceptible to fluid buildup.
Method: A retrospective review was conducted of patients who presented to a private practice ambulatory otolaryngology clinic during the COVID-19 pandemic from January 2020 to January 2021 with auricular fluid collections. The investigated variables included history of trauma, character of the fluid collection, and involved anatomic location.
Results: Twelve auricular fluid collections in 10 patients, aged 17 to 81 years, were identified. Five of 12 did not have a history of trauma. Anatomically, nontraumatic fluid collections and traumatic fluid collections, respectively, involved the helical root, concha cymba, and/or triangular fossa region 40% and 28% of the time and the scapha 60% and 72% of the time. Of the nontraumatic fluid collections, 40% were serous effusions and 60% were serosanguinous, whereas none of the traumatic hematomas were serous effusions.
Conclusion: The anatomic location and serous or serosanguinous nature of the nontraumatic hematomas could represent a different underlying pathophysiology of auricular fluid collections in the COVID-19 era.
Brief Workforce Analysis of Facial Plastic and Reconstructive Surgeons
Kyle Singerman (Presenter); Adam McCann, MD; Firas Houssein; Ryan Collar, MD, MBA; Tsung-yen Hsieh, MD
Introduction: Facial plastic and reconstructive surgery (FPRS) is a growing discipline that incorporates an expanding variety of reconstructive and cosmetic procedures in both academic and private practice settings. This project addresses the paucity of literature regarding practice patterns in FPRS, which is vital information for both current and future practitioners as the field continues to grow.
Method: This case-control study featured an academic cohort (AFPRS) based on employment at an academic teaching hospital, as well as a private practice cohort (PFPRS). Cohorts were case matched along geographic lines. Online data derived through public records as well as both institution and self-reported information were collected for providers with American Academy of Facial Plastic and Recontructive Surgery-credentialed training. Demographic data, industry payments, social media presence, and practice type were tabulated. Statistical analysis was performed using chi-squared, t tests, and Mann-Whitney U tests.
Results: AFPRS (n = 190) have been in practice for a median 9 years vs 15 years for PFPRS (n = 190; P < .001) and work with a mean 2.5 other FPRS vs 1.2 in PFPRS (P < .001). The AFPRS cohort is 74% male, as well as 66% White, 25% Asian, and <10% Black/Hispanic/Middle Eastern. Some 65 AFPRS have active Instagram accounts (median 896 followers) as compared with 158 PFPRS (median 1487 followers; P < .001). AFPRS received a mean $3173 in any 1 year from industry vs $9347 for PFPRS (P < .01). We found that 98% of AFPRS reported regularly performing reconstructive procedures vs 63% of PFRPS (P < .001). There was also a significantly higher proportion of reported facial reanimation, cleft lip/palate, and free tissue transfer as major parts of AFPRS practices veruss PFPRS (P < .001).
Conclusion: Broad differences appear to exist between FPR surgeons depending on their practice setting. These discrepancies may reflect both employment patterns as well as physician-industry and physician-patient interaction in the field of FPRS.
Clinical Outcome Study After External Approach Septoplasty
Ji-Yun Choi, MD (Presenter)
Introduction: This study aims to investigate the indications of external approach septoplasty and improvement in subjective symptoms and objective parameters in patients who underwent external approach septoplasty to correct septal deviation with various types of deformities.
Method: A total of 31 patients who underwent external approach septoplasty from October 2014 to January 2019 were classified by direction, location, and degree of nasal septal deviation, septal shape, and surgical techniques. Through acoustic rhinometry, the minimum cross-sectional area and nasal volume were measured before and after surgery. To evaluate the improvement in symptoms, the Nasal Obstruction Symptom Evaluation (NOSE) survey and nasal congestion visual analogue scale (VAS) were also measured.
Results: We found significant correlations between the following: the direction and degree of nasal septal deviation, the location and degree of nasal septal deviation, septal shape and location of the nasal septal deviation, septal shape and surgical techniques, and the degree of nasal septal deviation and presence of spreader grafts. The NOSE scale following external approach septoplasty improved from 14.7 ± 4.4 to 3.1 ± 3.2 (P < .001), while the VAS score improved from 7.2 ± 2.3 to 1.2 ± 1.4 (P < .001). Also, acoustic rhinometry showed that the minimum cross-sectional area and nasal volume at the convex side of nasal cavity significantly increased after surgery.
Conclusion: The external approach septoplasty is a surgical technique that is effective not only in improving subjective symptoms but also in improving objective parameters. External approach septoplasty could be used in case of caudal and/or dorsal nasal septal deviation.
Combined Surgical/Nonsurgical Approaches Improve Oral Symmetry in Facial Sykinesis
Emily Sagalow (Presenter); Kurren Gill, MD; Raphael Banoub, MD; Joel Stanek, MD; Howard Krein, MD, PhD; Ryan Heffelfinger, MD
Introduction: Facial synkinesis and paralysis can cause significant patient distress as it interferes with activities of daily living such as eating, drinking, and communicating using facial expressions. We aim to compare overall oral symmetry (OS) (oral commissure excursion, commissure height deviation, smile angle, upper lip height, and lower lip height) before and after surgical and nonsurgical interventions in facial synkinesis patients.
Method: Patients with facial nerve synkinesis were identified at a single academic institution between January 2008 and June 2020. Patient portrait images were analyzed before and after interventions (preoperative or postoperative botulinum toxin, selective neurolysis, temporalis transfer, or facial rehabilitation) using a facial analysis software, Emotrics (Massachusetts Eye and Ear). Outcome measures included oral commissure excursion and height deviation, smile angle, and upper and lower lip height.
Results: Of 126 patients with facial nerve impairment, 40 (32%) had synkinesis and 112 (89%) had paralysis/paresis. Seven patients had pre- and postintervention photos suitable for smile comparison. Nonsurgical interventions included botulinum toxin (preoperative: 3, postoperative: 3) and facial rehabilitation (1). Surgical intervention included selective neurolysis (5) and temporalis transfer (1). Mean follow-up was 30.4 days (range, 2–83). The greatest improvement in oral commissure excursion and oral commissure height deviation was with temporalis transfer (P < .0001 and P < .0001, respectively). Overall OS improved after preoperative Botox (P = .045), surgery (P = .036), and facial nerve rehabilitation (P = .069). On average, patients showed a 30% improvement between their first and most recent photos. Combined surgical-nonsurgical intervention demonstrated greater overall OS improvement compared with surgical or nonsurgical intervention alone (P = .013).
Conclusion: We advocate for combined surgical-nonsurgical management to achieve the greatest improvement in overall oral symmetry in patients with facial synkinesis.
Comprehensive Reconstruction of the External Nose
Sara Negrello (Presenter); Giacomo Colletti, MD; Sabina Figurelli; Alexandre Anesi; Luigi Chiarini
Introduction: Nasal defects caused by oncological procedures, trauma, substance abuse, and congenital defect produce very diverse needs for an optimal reconstruction. A varied, complete, and rational approach is needed to obtain satisfying results.
Method: Based on 200 patients’ experience, we tried to systematize the reconstruction. A Burget and Menick subunit concept was applied to grafts and local and interpolated flaps.
Results: Simple and composite grafts were very rarely used and mainly in old patients refusing more articulated procedures. Local flaps such as bilobed, Lemmo flap, and nasal septal flaps were used to reconstruct single-layer defects of the outer or inner lining. Interpolated refined nasojugal flaps were used to reconstruct the alae. Forehead flaps were used to reconstruct major full-thickness defects. Contextual mucosal flaps and cartilage graft were used to rebuild the nasal architecture. More complex cases such as those caused by arrhinia and cocaine abuse needed a multistep procedure.
Conclusion: While partial loss of substance of the nose is frequently easy to reconstruct, more extensive ones require a particular commitment to master all the techniques and adopt the best one. Arrhinia and nasal destruction after substance abuse are the most challenging ones. A systematic and methodical approach may grant pleasing results in most cases.
Descriptive Analysis of Physicians Answering Rhinoplasty Questions on Social Media
Jeff Gao (Presenter); Christopher C. Tseng; Guy Talmor, MD; Boris Paskhover, MD
Introduction: Rhinoplasty is one of the most common facial plastics procedures. Patients are increasingly turning to online resources to better inform their decisions. The objective of this study is to investigate the demographics of physicians who respond to patient questions regarding rhinoplasty on social media.
Method: Physician responses to the most viewed patient questions regarding rhinoplasty as of February 2020 on RealSelf.com, a social media website for cosmetic surgeries, were collected. A descriptive analysis of physicians who posted answers to patient questions was performed, including physician specialty, location of practice, and years of experience.
Results: A total of 65,901 physician responses to 2014 patient questions about rhinoplasty were collected. Most responses were from board-certified facial plastic surgeons (48.0%) followed by plastic surgeons (44.4%), physicians with unspecified specialty (4.4%), general otolaryngologists (2.7%), and oculoplastic surgeons (0.4%). Most responses were from physicians located in the major metropolitan areas of Los Angeles (23.1%), New York City (12.4%), Seattle (6.4%), Chicago (5.3%), and Miami (3.5%). These physicians had an average 22.8 years (standard deviation, 11.4 years; range, 1–56 years; median, 22 years) of experience.
Conclusion: Most physicians responding to questions about rhinoplasty on RealSelf.com are either board-certified facial plastic surgeons or plastic surgeons from major metropolitan areas and have an average 22.8 years of experience. Our study shows that physicians maximizing their social media presence are likely more experienced surgeons currently working in high-demand areas, lending increased credibility to the quality of answers given online about rhinoplasty.
Evolution of Head and Neck Trauma: Iraq and Afghanistan, 2016-2019
John W. Lally, MD (Presenter); Matthew L. Ward, MD; William Smithee, MD; Jon Robitschek, MD; Scott Bevans, MD
Introduction: This study aims to define the number and type of facial and penetrating neck injuries sustained in combat operations in Iraq and Afghanistan from 2016 to 2019 by comparing recent injury patterns to previously published data.
Method: The Department of Defense Trauma Registry (DoDTR) was queried for International Statistical Classification of Diseases, Ninth Revision (ICD-9) and International Statistical Classification of Diseases, Tenth Revision (ICD-10) diagnostic codes for facial and neck injuries from Iraq and Afghanistan from May 2003 to 1 December 2019. Data from the last 3 years were the focus of this project. Injury patterns, severity, and patient demographics were collected, assessed, and compared to previously published data from combat operations from May 2003 to May 2016.
Results: During this 3-year period, 283 active duty service members sustained a total of 656 discrete head and neck injuries. There were far fewer injuries per year than in previous combat injury studies for active service members. Of these 656 total injuries, 487 (74.2%) were soft-tissue wounds and 169 (25.8%) were fracture injuries. Head/forehead/scalp (24%), eyelid/orbit (19%), and ear/tymanic membrane (14%) were the most common sites of soft-tissue injury. Fractures of the maxilla (23%), mandible (15%), and skull base (15%) were the most commonly skeletal sites of injury. The rate of head and neck injury reported was far less than the rates seen from 2003 to 2011 and 2011 to 2016.
Conclusion: Penetrating neck and facial injuries are still present in modern warfare; however, the overall prevalence of these injuries within our active duty service member population has decreased since 2015. This decrease is consistent with our evolving operational mission. Although these head and neck injuries in an active duty population have decreased, military contractors, foreign nationals, and civilians have still been susceptible to these injury patterns and treated within Role 2/3 treatment facilities. Thus, the downrange surgeon should feel comfortable assessing and managing these injuries. Trending injury characteristics and demographic data is an important exercise for assessing our military medical readiness to support and defend.
Facial Injures From Professional Mixed Martial Arts Fighting
Alexander J. Jones, MD (Presenter); Alhasan Elghouche; Taha Shipchandler; Dominic Vernon
Introduction: Mixed martial arts (MMA) is a highly popular combative sport involving striking and grappling that imposes a high risk of incurring facial injuries, many of which require repair by facial plastic surgeons. We therefore sought to identify the facial injuries and associated risk factors of these fights.
Method: A review of the Nevada State Athletic Commission injury reports from all professional Ultimate Fighting Championship bouts from 2010 to 2020 was performed. Data collected included fighter age, sex, weight class, rounds fought, result of the fighter, how the match ended, and facial injuries. Binary logistic regressions were performed to determine predictive factors of facial injuries, presented as (P value; odds ratio [95% CI]).
Results: A total of 1462 fighters across 731 contests were included. Most participants were male (91.0%) with a mean age of 29.5 ± 4.1 years. Weight classes ranged from 115 to 265 lb, with most fights taking place between 135 and 185 lb. Most bouts lasted ≥3 rounds (59.4%) and resulted in judges’ decision (50.5%) or knockout (TKO, 31.2%). The rate of facial injury was 15.8%, which was predominantly lacerations (12.0%). Facial fractures were mostly nasal or orbital and less common (3.6%). Multivariate regression revealed being male (P = .026; 2.27 [1.11–4.66]), heavier weight (P = .028; 1.00 [1.00–1.01]), rounds fought (P = .019; 1.22 [1.03–1.45]), losing (P < .001; 2.09 [1.55–2.81]), and nonsubmission outcomes (P = .017, 1.79 [1.11–2.86]) predicted incurring any facial injury. Factors predicting facial lacerations included sex (P = .026; 2.67 [1.13–6.30]), weight (P = .059; 1.00 [1.00–1.01]), rounds fought (P < .001; 1.43 [1.18–1.72]), and losing (P = .006; 1.57 [1.14–2.17]). Facial fractures were predicted by losing (P < .001; 6.83 [3.05–15.27]) and outcome of disqualification (P = .021; 6.68 [1.32–33.34]) or TKO (P < .001; 3.10 [1.75–5.49]).
Conclusion: MMA fighting imposes a high risk of facial injuries. Patients who engage in this sport should be counseled on these risks.
Impact of COVID-19 on Head and Neck Free Flap Volume
Shannon S. Wu (Presenter); Dane Genther, MD; Peter Ciolek, MD; Brandon Prendes, MD; Brandon Hopkins, MD; Jamie Ku, MD
Introduction: This study aims to demonstrate the utility of a novel electronic medical record (EMR) dashboard by assessing the impact of COVID-19 on surgical volume and short-term postoperative outcomes of head and neck surgical patients undergoing free flap reconstruction.
Method: An EMR dashboard grouped surgical encounters by Current Procedural Terminology codes to view summaries and trends in real time at a tertiary academic institution. Outcomes of head and neck surgical patients undergoing microvascular free flap reconstruction, primarily for cancer diagnoses, were compared between 2019 and 2020 to assess COVID-19 impact. Hospital length of stay was assessed with t test, and 30-day return to emergency department (ED), readmission/observation, return to operating room, and postoperative bleeding were assessed with Fisher exact test.
Results: In 2019 190 free flap procedures were performed compared with 131 procedures in 2020, a 31.1% volume decline. Mean hospital length of stay for free flap procedures was 8.6 ± 6.0 days in 2019 and 9.1 ± 6.6 days in 2020 (P = .482). For 2019 vs 2020, return to ED rates were 21.6% vs 27.5% (P = .369); observation/readmission rates were 18.4% vs 10.7% (P = .117); postoperative hemorrhage rates were 5.8% vs 12.2% (P = .070); return to OR rates were 3.2% vs 8.4% (P = .753); and mortality rates were 0% vs 1.5% (P = .169), respectively. For all complications, there was no statistical difference detected between years.
Conclusion: The novel EMR dashboard provided summaries of changes to surgical volume and postoperative outcomes in real time. Surgical volume for head and neck free flap procedures decreased significantly during the COVID-19 pandemic. Despite selection bias for more complicated cases due to cancellation of both elective and nonelective procedures, complication rates in our cohort remained stable indicating no adverse effects on patient safety.
Impact of Malnutrition on Postoperative Outcomes Following Facial Fracture Repair
Ariel Omiunu (Presenter); Giovanna Mele; Christina H. Fang, MD; Jean Anderson Eloy, MD
Introduction: There is currently a limited understanding of the impact of malnutrition on postoperative outcomes. We aim to investigate the role of preoperative albumin levels, as a marker for malnutrition, in postoperative complications in patients undergoing surgical repair of facial fractures.
Method: The National Surgical Quality Improvement Program database was queried for patients who underwent facial fracture repair from 2005 to 2015. Patients were stratified into two cohorts based on their albumin levels: low (<3.5 g/dL) and normal (≥3.5 g/dL). Patient characteristics and postoperative outcomes were compared between the 2 patient cohorts. Multivariate analysis was performed to identify risk factors for complications.
Results: A total of 855 patients were identified. Of those, 726 patients (84.9%) had normal albumin levels and 129 (15.1%) had low albumin levels. Patients with low albumin were more likely to be older (53.0 ± 16.9 years vs 44.1 ± 17.6 years, P < .001) and have an American Society of Anesthesiologists classification of III or IV (62.0% vs 38.0%, P < .001). Hypoalbuminemia was associated with the following comorbid conditions: ventilator dependency (4.7% vs 0.1%, P < .001), bleeding disorder (10.1% vs 2.1%, P < .001), history of weight loss (3.1% vs 1.0%, P = .047), renal failure (0.8% vs 0.0%, P = .018), ascites (0.8% vs 0.0%, P = .018), history of transfusion (3.9% vs 0.3%, P < .001), and poor functional status (9.3% vs 2.5%, P < .001). Multivariate analysis did not yield any significant differences between the 2 groups.
Conclusion: Patients undergoing facial fracture repair were older with poorer functional status. However, the present study suggests that malnutrition is not an independent predictor of postoperative outcomes in patients undergoing facial fracture repair.
Independent Predictors for Body Dysmorphic Disorder in Cosmetic and Functional Rhinoplasty
Khawla Karra (Presenter); Nagi El Sabbagh; Sami Pierre Moubayed
Introduction: The Standardized Cosmesis and Health Nasal Outcomes Survey (SCHNOS) questionnaire evaluates functional and cosmetic outcomes in rhinoplasty, and we believe that SCHNOS reliably and independently predicts body dysmorphic disorder (BDD). In this study, we correlate SCHNOS and the Body Dysmorphic Disorder Questionnaire–Aesthetic Surgery (BDDQ-AS) results in rhinoplasty patients and identify the SCHNOS items that most strongly predict BDD outcome.
Method: A retrospective chart review was conducted at a single-surgeon facial plastic surgery practice. The electronic medical records of patients 18 years of age and older who consulted for primary or revision, esthetic, or functional rhinoplasty between July 2017 and November 2019 and who completed the SCHNOS and BDDQ-AS questionnaires upon initial consultation were reviewed by 2 independent reviewers. The correlation between SCHNOS individual question items and the BDDQ-AS binary result was based on the questionnaires filled out by the patient at the time of first consultation. The preoperative BDDQ-AS results were recorded as positive or negative. The preoperative SCHNOS esthetic, functional, and mood components were calculated. SCHNOS items reciever-operating characteristic curves predicting BDD were calculated via bivariate and multivariate analysis.
Results: Of the 382 patients included, 32.2% screened positive for BDDQ-AS. A positive screen was associated with younger age (P = .003), female gender (P < .001), prior cosmetic surgery (P = .002), SCHNOS-C item questions 5 through 10 (all P < .001), as well as consultation for cosmetic concerns (P < .001). History of psychiatric disease was not found to be statistically significant. SCHNOS questions 5 (odds ratio [OR] 1.427; P < .001) and 9 (OR 1.690; P = .001) were independent predictors of BDD with significantly elevated sensitivities and specificities, positive predictive values, and negative predictive values.
Conclusion: BDD treatment is nonsurgical. Accurate screening is therefore paramount in rhinoplasty practice. Questions 5 and 9 of the SCHNOS-A are independent predictors of a positive BDD screen, with question 9 having the highest sensitivity and specificity, enabling correct identification of patients with BDD and further management guidance of such patients.
Longest Multi-segment Spinal Reconstruction Using Fibula Osseous Free Flap for Chronic Osteomyelitis
Kaitlynne Y. Pak, MD (Presenter); Sameep P. Kadakia, MD; Collin Smith, DO; Danieal Quinones, MD
Introduction: We aim to recognize the indications of complicated cervical vertebral osteomyelitis that could use anterior reconstruction with vascularized fibula flap and posterior reconstruction using a trapezius myocutaneous pedicled flap. We examine the pre- and postoperative complications of hardware failure in a patient with history of anterior cervical corpectomy and fusion. We demonstrate emonstrate the longest segment of spinal reconstruction with a single-strut, vascularized, osseous fibular free flap. Reconstruction of the spine using vascularized osseous free flaps has been well documented in the medical literature, but to our knowledge, this case represents the longest segment of spinal reconstruction with a single-strut, vascularized, osseous fibular free flap.
Methods: This case represents the longest segment of spinal reconstruction with a single-strut, vascularized, osseous fibular free flap. Our patient with a longstanding history of intravenous drug abuse and C4-C7 anterior cervical corpectomy and fusion presented acutely to the emergency department with purulent anterior neck drainage, upper extremity weakness and paresthesias.
Results: Imaging obtained showed evidence of hardware failure. In the setting of the patient’s repeated hardware replacement with continued infection, autologous grafting material was considered as an alternative means for spinal stability, and a multilevel cervical reconstruction, involving C3-T1, with an anterior reconstruction using a vascularized fibula flap and posterior reconstruction using a trapezius myocutaneous pedicled flap was decided on as the best reconstructive option.
Conclusion: Reconstruction of the spine using vascularized osseous free flaps has been well documented in the medical literature, but to our knowledge, this case represents the longest segment of spinal reconstruction with a single-strut, vascularized, osseous fibular free flap. Our complex presented case emphasizes the utility of the free vascularized fibula for multilevel cervical spine reconstruction in the setting of chronic osteomyelitis.
Outpatient Free Tissue Transfer in Response to COVID-19–Related Restrictions
Kevin J. Contrera, MD, MPH (Presenter); Daniel Hewes, MD; Patrick Byrne, MD, MBA; Dane Genther, MD; Brandon Prendes, MD; Michael A. Fritz, MD
Introduction: Inpatient hospitalization is nearly universal after head and neck reconstruction using free tissue transfer; however, the use of minimal access vascularization techniques and low morbidity flaps have allowed for significantly abbreviated stays without compromising patient outcomes. This experience has led to the management of select patients on an outpatient basis during the COVID-19 pandemic.
Method: Due to COVID-related hospital policies restricting inpatient admission for nonemergent and nononcologic surgeries, 2 patients elected for outpatient free tissue transfer for management of mandibular osteoradionecrosis with anterolateral thigh fascia lata rescue flaps. Patient selection, management, and outcomes are presented along with a review of the literature.
Results: Two patients, ages 62 and 70 years, with intermediate medical comorbidities and histories of chemoradiation for oropharyngeal cancer presented with progressive osteoradionecrosis refractory to conservative management, including debridement and hyperbaric oxygen therapy. They underwent further mandibular debridement and anterolateral thigh fascia lata free tissue transfer vascularized by minimal access approaches to facial and superficial temporal vessels. Surgical procedures lasted an average of 4.4 hours (range, 3.1–5.4) with placement of a facial Penrose drain that was removed prior to discharge and a leg Jackson-Pratt drain that was removed in clinic the following week. The patients were discharged home the same day (7.3 hours after surgical closure) and the following morning (21.2 hours after surgical closure). They have been followed for an average duration of 53 days (range, 39-67) with no known complications.
Conclusion: This case series represents the shortest reported hospital duration for head and neck free tissue transfer. Outpatient status was determined through a combination of case selection, patient decision, and constraints secondary to COVID-19 hospital utilization. This report suggests that outpatient free flap surgery is safe under select circumstances.
Patient Perception Regarding Timing of Facial Fracture Repair
Prashanthi Divakar (Presenter); Nithya Puttige Ramesh; Cybele Arsan; Eric Holmgren
Introduction: Often, patients will suffer a facial fracture, and initial presentation, referral, medical stability, and operating room and/or surgeon availability may lead to treatment delay. The psychological impact of living with an untreated fracture can be overlooked and hard to assess. This study aims to depict patient perception patterns and impact on quality of life.
Method: A prospective questionnaire study was performed of patients with facial fractures who underwent operative repair at a rural tertiary care academic hospital between November 2018 and November 2020. Patients were given a survey preoperatively at the inpatient floor, outpatient clinic, or preoperative holding. Data analyzed included demographics, fracture data, and a validated quality of life enjoyment and satisfaction–short form (Q-LES-Q-SF) modified for facial trauma.
Results: In total, 21 patients were included (mean age, 46.47 years). Of these, 85.71% were male and 100% identified as White. The most common etiologies included fall (33.33%), followed by assault (28.57%). Most patients were employed (66.67%) and had a mandible fracture (76.19%). Most surveys (57.14%) were administered in the preoperative holding: 71.43% did not feel that timing of the fracture diagnosis was long, and 66.67% agreed that time between diagnosis to surgery was reasonable; 42.86% did not mind waiting a few more days, but 80.95% reported that postponing the surgery by a week would bother them; 61.90% preferred to be home prior to surgery date, and 66.67% wanted same-day discharge home postoperatively. Q-LES-Q-SF analysis noted that 61.90% reported severe impairment in quality of life as a result of the facial fracture.
Conclusion: Patient perception of the timing of facial fracture repair and quality of life are important aspects of patient care. Our patient cohort felt that the diagnosis timing and repair was reasonable and preferred outpatient surgery. Most patients did report severe impairment in quality of life. Future directions include data set expansion and correlation of perception and quality of life based on fracture type.
Practice Patterns for the Treatment of Acute Peripheral Facial Palsy
Christine M. Clark, MD (Presenter); Keon M. Parsa, MD; Alexandra Welschmeyer; Shakti Nayar, MD; Eugenia Chu, MD; Michael J. Reilly, MD
Introduction: The aims of this study are to describe the current trends in the management of acute peripheral facial palsy (APFP) among a local cohort of practicing otolaryngologists, neurologists, and emergency medicine providers and to determine if differences exist by specialty, level of training, and prior formal education regarding APFP.
Method: A cross-sectional online survey was distributed to practicing otolaryngologists, neurologists, and emergency medicine providers in the Washington, DC, metropolitan area via Survey Monkey. Residents in these fields were eligible for inclusion. General demographic information as well as prescribing practices and management strategies for APFP were elicited. Statistical analysis via Pearson chi-square testing will be performed.
Results: Preliminary data are available from 19 otolaryngologists, 52.6% of whom were attending physicians, 42.1% were residents, and 5.3% were advanced practice providers. Of these, 52.6% indicated that they see 1 to 5 new patients with APFP per year. Respondents’ approaches to the evaluation of APFP were varied, with 15.8% routinely ordering Herpes virus and Lyme titers, and 31.5% routinely recommending magnetic resonance imaging. With regard to management, 73.7% indicated that they do not refer patients with APFP for facial physical therapy. All respondents indicated that they typically prescribe prednisone for nondiabetic patients with APFP; however, there were variabilities in dosing, taper, and duration of treatment. Of respondents, 73.7% reported that they routinely prescribe antivirals; however, there was no consensus regarding medication choice, dosing, or treatment duration. Follow-up routines also differed among respondents, with the majority (52.6%) indicating that they follow patients on a monthly basis until their condition is resolved or stable.
Conclusion: There is considerable variability in the paradigms used in the evaluation and management of acute peripheral facial palsy.
Predictors of Wound Complications Following Paramedian Forehead Flap Reconstruction
Tirth R. Patel, MD (Presenter); Michael Eggerstedt; Matthew J. Urban; Ryan Smith; Peter C. Revenaugh, MD
Introduction: While complication rates for paramedian forehead flaps (PMFF) are low, it is still unclear which groups of patients are at highest risk of complication. This study aims to identify risk factors for wound failure in patients undergoing PMFF.
Method: The American College of Surgeons–National Surgical Quality Improvement Program (ACS-NSQIP) database files from 2012 to 2018 were analyzed to identify patients undergoing PMFF. Patients who suffered a postoperative surgical site infection, wound disruption, or unplanned return to the operating room were deemed as having had a wound complication. Demographic factors, comorbidities, preoperative lab results, and other details related to the surgery were extracted from the ACS-NSQIP database. These variables then were compared between the groups of patients who did and did not have wound complications to identify factors that would be predictive of wound complications.
Results: Wound complications were present in 55 of 1268 cases (4.3%). On multivariate logistic regression analysis, presence of disseminated cancer (P = .009) and albumin level less than 3.5 mg/dL preoperatively (P = .018) were significant predictors of wound complications. Nonsignificant variables for wound complications included age, body mass index, smoking history, coagulopathy, operative time, surgeon specialty, year of surgery, and annual quarter.
Conclusion: Wound complications in PMFF surgery are rare. Lower serum albumin levels and presence of disseminated cancer are associated with a greater risk of wound complications.
Prophylactic Postoperative Antibiotic Use in Primary Rhinoplasty
Brittany T. Abud, MD (Presenter); Ibrahim Salah; Tatiana Dixon, MD; Julia Kerolus, MD
Introduction: Routine antibiotic prophylaxis following rhinoplasty is common practice; however, there is limited evidence to support its efficacy in preventing postoperative infections. The purpose of this study is to evaluate infection rate after primary rhinoplasty in patients treated with and without systemic postoperative antibiotics. We also explore risk factors for infection in these 2 groups.
Method: A retrospective chart review was conducted for all patients who underwent primary rhinoplasty or septorhinoplasty at a single tertiary care center from January 2019 to June 2020. Primary outcomes included development of postoperative infection and treatment methods.
Results: Our population included 46 primary rhinoplasties, 32 of which received postoperative antibiotics. In patients who got antibiotics, the mean age was 31.1 years, 15 (46.9%) patients were male, average body mass index (BMI) was 27.7, and 13 patients had comorbidities. In this group, 21 (65.6%) were open and 16 (50%) had osteotomies. Cartilage grafting was done in 26 (81.3%) patients: 14 (38.5%) used native septum, 7 (26.9%) rib, 3 (11.5%) ear, and 2 (7.7%) temporalis fascia. In patients who did not receive antibiotics, the mean age was 33.2 years, 9 (64.3%) patients were male, the average BMI was 27, and 6 patients had comorbidities. In this group, 11 (78.6%) were open and 10 (71.4%) had osteotomies. Cartilage grafting was done in 12 (85.7%) patients: 10 (83.3%) used native septum, 1 (8.3%) rib, and 1 (8.3%) temporalis fascia. In patients who did not receive antibiotics, none developed infections. In patients who received antibiotics, 2 developed infections, for a rate of 0.063. Neither had comorbidities, and both underwent open septorhinoplasty with rib cartilage harvesting.
Conclusion: There was no increased rate of infectious complications after primary rhinoplasty in patients who did not receive postoperative antibiotics. This suggests that there may not be a role for postoperative antibiotics after primary rhinoplasty. Further studies should be done; however, this is a step forward in antibiotic stewardship as well as in standardizing postoperative rhinoplasty care.
Quantitative Analysis of Positional Changes in Nasal Tip Geometry
Ariel M. Azhdam (Presenter); Gene C. Liu, MD; Henry H. Chen; Matthew K. Lee, MD
Introduction: It is a currently accepted tenet in facial plastic surgery that the positioning of a patient (supine or upright) influences nasal tip geometry due to the effects of gravity on the soft tissues of the nose. However, empirical data to support this commonly taught principle is lacking. In the current study, we sought to assess the validity of this principle, in addition to quantifying the degree of change in tip rotation and projection.
Method: Subjects >18 years of age with no history of prior nasal surgery were recruited for this study from December 2020 to January 2021. The photographic environment was standardized with dual studio lighting and set photographic subject distance, with all photos being taken using the same digital single-lens reflex camera. Photos were obtained in all standard rhinoplasty views, in addition to a lateral supine photo. Nasal tip geometry was analyzed using a variety of methods, including measurements of the nasolabial angle, nasofrontal angle, and assessment of nasal tip projection by the Baum, Powell, Simon, and Goode methods. Statistical analysis was performed using a paired-samples t test to assess for any significant differences in nasal tip geometry between the upright and supine positions.
Results: Twenty subjects (10 male, 10 female) were included in the study, with an average age of 40.5 years. Mean nasolabial angle was 89.1° in the upright position and 92.8° in the supine position. This positional change in tip rotation (mean = 3.7°) was statistically significant at P < .05. The mean nasofrontal angle was measured at 134.8° in the upright position and 134.3° in the supine position (not significant). There were no significant positional changes in tip projection with any of the methods used for measurement.
Conclusion: Nasal tip rotation does appear to be affected by gravitational changes secondary to patient positioning. This finding has clinical implications for cosmetic and functional rhinoplasty.
Role for Bedside Neck Exploration for Interrogating Free Flap Compromise
Quinn Dunlap, MD (Presenter); James R. Gardner, MD; Deanne King, MD, PhD; Emre Vural, MD; Jumin Sunde, MD; Mauricio Moreno, MD
Introduction: Flap compromise following free tissue transfer (FFT) for head and neck reconstruction has an incidence of approximately 5% across studies. We present our experience and outcomes with the use of bedside neck exploration for instances of loss of Doppler signal in the context of equivocal clinical exam in order to limit false positive results necessitating reoperation.
Method: We conducted a retrospective chart review of 371 patients who underwent FTT at an academic tertiary center from January 2017 to October 2020. All patients with equivocal clinical exam with loss of Doppler signal prompting bedside neck exploration by an experienced microvascular surgeon were included. The primary endpoints for this study were etiology of Doppler signal loss, necessary return to the operating room (RtOR), and rate of flap salvage.
Results: Nine patients underwent bedside exploration for assessment of the microvascular pedicle. In 5 of 9 cases, RtOR was avoided. Coupler malfunction was detected and corrected in 4 of 5 cases, and a venous kink was found and remedied in 1 of 5 cases. All 5 cases were discharged as previously planned. Four patients required RtOR: early venous thrombosis requiring thrombectomy with anastomotic revision, evacuation of compressive hematoma, and release of external compression. The average time from bedside exploration to the OR was 111 minutes. No venous-related total flap failures were observed in this cohort. Avoidance of RtOR provided an estimated cost saving of $9222 per event, for a total savings of $46,110. Conclusion: Bedside neck exploration constitutes a safe and cost-effective intermediary to determine definitive need for RtOR, as well as for correction of simple etiologies of flap compromise, in instances of equivocal clinical exam with loss of implantable Doppler signal.
Surgical Outcomes of Septal Extension Graft Supported by Polycaprolactone Plate
Ji-Yun Choi, MD (Presenter)
Introduction: Tip plasty using a septal extension graft (SEG) is useful in the Asian population. However, complications such as decreased tip projection, infection, or deviation are noted postsurgery, and additional support using an SEG is often necessary. We aimed to transplant an additional 3-dimensionally (3D)-printed polycaprolactone (PCL) graft to the tip plasty using the SEG to reinforce the SEG.
Method: The study included 43 patients (20 males and 23 females; mean age, 28.7 years; range, 17–58 years) who received rhinoplasties using the SEG method combined with a 3D-printed PCL graft from November 2016 to August 2017. The mean observation period was 14.8 months (range, 12–20 months).
Results: In total, 26 patients rated their satisfaction level as excellent, 13 rated good, 3 rated fair, and 1 rated poor. In total, 28 patients did not exhibit tip drooping at the 1-year follow-up, 13 patients demonstrated mild to moderate tip drooping, and 2 patients demonstrated severe tip drooping. Some 31 patients demonstrated “stiffness” of the nasal tip, of which 11 patients reported discomfort and 20 patients reported none; 2 patients demonstrated deviation of the tip.
Conclusion: Although the 3D-printed PCL graft provided support, biocompatibility, and manipulability, care is required to prevent complications.
