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Reconstruction of nasal defects can be challenging, especially when encountering larger defects. We describe the use of a single-stage conversion of an 'A' shaped defect to a 'T' shaped scar of large nasal skin defects in the cosmetically sensitive supra-tip and supra-alar regions. This study aimed to determine whether an A-T flap is a suitable option for nasal reconstruction and if so where and what size defects it can be used for. Retrospective case series review over an 8-year period (2011–2019) in a tertiary referral center in the United Kingdom. Case analysis was undertaken in 2020 including all patients who underwent A-T reconstruction of nasal defects. A review of histology, case notes, and clinical photography was undertaken. A total of 27 patients were identified—13 (48%) female and 14 (52%) male. The median age was 73 years (range 31–90 years). Defect locations were supra-tip (48%) and supra-alar (52%). The largest defect closed was 895 mm 2 (30 × 38 mm). Range 35 to 895 mm 2 (median 264 mm 2). No patient required revision or corrective procedures. No functional impairment was identified. Patient and clinician reported aesthetic outcomes as good in all cases. No reports of this technique could be identified in the literature. The A-T flap is a viable option for supra-tip and supra-alar skin defects (up to 895 mm 2 in our series). It aligns well with the basic principles of nasal reconstruction. The flap can be performed under local anesthesia in one stage, resulting in good functional and aesthetic outcomes and so can be considered a valuable tool for the nasal reconstructive surgeon. [ABSTRACT FROM AUTHOR]

Objectives: To explore the effect of e‐prescribing requirements on narcotic dispersion in New York State. Slicer Dicer was used to identify patient records based on CPT codes. Methods: We investigated the influence of New York State e‐prescribing requirements on narcotic dispersion following five common facial plastics procedures. Slicer Dicer was used to identify patient records based on CPT codes.We then looked at narcotic prescription rates following those surgeries between March 2014 and March 2018 at an academic institution. Results: Overall, between March 2014 and March 2018, 76.1% of the sample received a narcotic prescription following a facial reconstructive plastic surgery. Patients who underwent rhinoplasty were most likely to receive a prescription for postoperative narcotics. The implementation of ISTOP, CPT code, use of non‐narcotic adjuvant, and insurance type were each significantly associated with prescription of postoperative narcotics. Surgery time and age in years were significantly associated with prescription of postoperative narcotics. Ultimately, when controlling for the aforementioned clinical and sociodemographic variables included in the study, those who underwent surgery after the implementation of ISTOP were 42.8% less likely to receive a prescription for postoperative narcotics, aOR = 0.572, 95% CI 0.356, 0.919, p = 0.021. Conclusions: New York State's ISTOP program has succeeded in reducing the number of postoperative narcotic prescriptions following facial plastic reconstructive surgeries at this academic institution. However, opioid medications can still be utilized for postoperative analgesia when clinically appropriate. Level of Evidence: 3 Laryngoscope, 134:1208–1213, 2024 [ABSTRACT FROM AUTHOR]

Perforations of the nasal septum have many etiologies and occasionally result from intranasal medicated spray use. This case report describes a perforation related to the use of desmopressin nasal spray, which has not been previously reported in the literature. Clinical considerations presented in this article include appropriate technique of nasal spray application, appropriate monitoring of patients on intranasal sprays, and indications for evaluation by an otolaryngologist. Septal perforation treatment success is improved with an early diagnosis. [ABSTRACT FROM AUTHOR]

Abstract Botulinum toxin is a potent neuromodulator commonly used for cosmetic applications in the clinic. In this article, we reviewed the various formulations of botulinum toxin type A commercially available in the United States, as well as clinical pearls for preprocedural planning, common in‐office injections, and management of complications.

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. [ABSTRACT FROM AUTHOR]

Abstract Objective The reconstruction of large scalp defects poses both functional and cosmetic challenges. While free tissue transfer remains the standard for defects larger than 30 cm2, prolonged anesthesia and postoperative complications remain significant limitations. The purpose of this study is to evaluate the use of O‐Z flaps for the reconstruction of large scalp defects and to describe the techniques employed. Methods This is a retrospective analysis of ten patients who underwent reconstructive surgery using an O‐Z flap approach for large scalp defects between July 2017 and June 2019. The parameters included in this study were patient demographics, tumor characteristics, and postoperative management, collected for at least a year after surgery. Results In this cohort, the mean age was 76.1 years and 90% were male. All patients were treated for neoplastic skin lesions, with 70% located on the vertex and 30% located on the temporoparietal region. The mean size of defect was 52.0 cm2 (range: 38.6 to 63.8 cm2). The maximum hospital stay was two days, and no patients were readmitted within 30 days of surgery. There were no cases of wound infection or flap necrosis. All patients reported pain control with acetaminophen and ibuprofen. Four patients received adjuvant radiation, and there was no delay to receiving treatment following surgery. Conclusions The O‐Z flap is a reliable alternative for the reconstruction of non‐irradiated scalp defects in the vertex and temporoparietal regions up to 63 cm2. This technique provides advantages for patients, including hairline preservation, shorter hospital stays, and decreased postoperative complications.

Objective: To discuss a case series of Actinomyces infection post‐rhinoplasty and review the literature for correct diagnosis and management. Study Design: Case series with chart review. Methods: Three cases are presented of patients with a history of recurrent infectious symptoms post revision rhinoplasty later being diagnosed as Actinomyces. Results: Three patients were identified having undergone revision rhinoplasty and later being diagnosed with Actinomyces infection. They initially presented with underwhelming physical exams, mild erythema, slight swelling, yet extreme pain. They also had periods of recurrent infection once antibiotics were stopped. Aerobic, anaerobic, fungal, and Actinomyces cultures were sent to pathology and returned positive for Actinomyces. Treatment typically involved a combination of prolonged antibiotics, incision and drainage, and/or surgical debridement. Conclusions: Awareness of Actinomyces as a possible cause of infection post‐rhinoplasty is significant as this pathogen can lead to extensive tissue destruction and fistula formation which could be detrimental for a rhinoplasty. Duration of treatment is beyond typical lengths for other infections and a specific culture for Actinomyces is required to be sent as it isn't captured in standard aerobic/anaerobic cultures. Therefore, a high index of suspicion is required by physicians to ensure that patients are evaluated thoroughly. Laryngoscope, 133:2948–2950, 2023 [ABSTRACT FROM AUTHOR]

Many facial plastic and reconstructive surgery providers are interested in incorporating clinical trials into their own practice. Clinical trials in facial plastics have made key contributions to current practices. Clinical trials range from investigating the safety and efficacy of Juvederm filler to reducing pain associated with injecting Juvederm. This article summarizes landmark clinical trials in facial plastic and reconstructive surgery and provides a framework for providers to get involved in clinical trials. [ABSTRACT FROM AUTHOR]

Objective: This study reviewed all rhinology clinical negligence claims in the National Health Service in England between 2013 and 2018. Method: All clinical negligence claims held by National Health Service Resolution relating to rhinology in England between 1 April 2013 and 1 April 2018 were reviewed. Results: There were 171 rhinology related claims with a total estimated potential cost of £13.6 million. There were 119 closed claims (70 per cent) with a total cost of £2.3 million, of which 55 claims resulted in payment of damages. Over three quarters of all rhinology claims were associated with surgery (n = 132). Claims associated with endoscopic sinus surgery had the highest mean cost per claim (£172 978). Unnecessary pain (33.9 per cent) and unnecessary operation (28.1 per cent) were the most commonly cited patient injuries. Conclusion: Patient education and consent have been highlighted as key areas for improvement from this review of rhinology related clinical negligence claims. A shift in clinical practice towards shared decision making could reduce litigation in rhinology. [ABSTRACT FROM AUTHOR]

Background: To investigate the association between American Society of Anesthesiologists (ASA) physical status classification and rates of postoperative complications in patients undergoing facial fracture repair. Methods: Patients were divided into 2 cohorts based on the ASA classification system: Class I/II and Class III/IV. Chi-square and Fisher's exact tests were used for univariate analyses. Multivariate logistic regressions were used to assess the independent associations of covariates on postoperative complication rates. Results: A total of 3575 patients who underwent facial fracture repair with known ASA classification were identified. Class III/IV patients had higher rates of deep surgical site infection (P =.012) as well as bleeding, readmission, reoperation, surgical, medical, and overall postoperative complications (P <.001). Multivariate regression analysis found that Class III/IV was significantly associated with increased length of stay (P <.001) and risk of overall complications (P =.032). Specifically, ASA Class III/IV was associated with increased rates of deep surgical site infection (P =.049), postoperative bleeding (P =.036), and failure to wean off ventilator (P =.027). Conclusions: Higher ASA class is associated with increased length of hospital stay and odds of deep surgical site infection, bleeding, and failure to wean off of ventilator following facial fracture repair. Surgeons should be aware of the increased risk for postoperative complications when performing facial fracture repair in patients with high ASA classification. [ABSTRACT FROM AUTHOR]

Objective: Cutaneous head and neck surgery can safely and effectively be performed using local anesthetic (LA). However, optimizing pain management during LA administration is paramount for patient comfort and procedural efficacy. The primary objective of this study was to investigate the comparative effectiveness of EMLA cream and ethyl chloride (EC) spray in mitigating pain associated with LA administration in cutaneous head and neck surgery., Study Design: Randomized controlled trial., Setting: University-affiliated tertiary head and neck oncology center., Methods: Sample size calculation was performed followed by computer randomization into the following groups: EMLA, EMLA placebo (aqueous cream), EC, and a control group (no topical agent). Demographics, pain, and procedural experience scores were recorded perioperatively. Statistical analysis was performed to analyse differences between groups utilizing the Mann-Whitney U test, Kruskall-Wallis test, Chi-square test, and Spearman's Rho., Results: 121 cutaneous lesions with a median patient age of 76 were analyzed. There were no statistically significant differences in pain scores (median [IQR]) between patients receiving EMLA (4 [3.75]), EMLA placebo (4.8 [3.6]), EC (5.8 [2.8]), and no treatment (5 [4.1], P = .19). Procedural experience scores were clinically similar (P = .02). Risk factors associated with elevated nociceptive sensitivity were surgical site (scalp, P = .01), malignant lesions (P < .01) and lesion surface area (rs = 0.22, P = .01)., Conclusion: EMLA and EC did not mitigate LA-associated pain in patients undergoing cutaneous head and neck surgery and as such practitioners should reconsider their use of these in this regard. Patients' operative experience remains excellent regardless of topical anesthetic use., Level of Evidence: Ib., (© 2024 American Academy of Otolaryngology–Head and Neck Surgery Foundation.)

Objective: Otolaryngologists are at a significantly greater risk of being sued than most other physicians. To date, there is a lack of studies characterizing trends in otolaryngology malpractice claims. To assess these trends and risk variables, this study examined malpractice claims against otolaryngologists., Study Design: Retrospective database review., Setting: LexisNexis Jury Verdicts and Settlements., Methods: The LexisNexis legal database was used to locate jury verdicts and settlements related to medical malpractice in otolaryngology, from 2018 to 2024. The study did not include any claims covered by the Social Security Disability Insurance, Workers' Compensation, Healthcare Law, or Criminal Law and Procedure categories. Temporal trends were evaluated, and logistic regression was used to identify independent risk factors., Results: Out of 903 items, 79 reported malpractice cases were included (mean age 44.5; 60.3% female). The most sued subspecialty was head and neck oncology (32.5%). Negligence (93.7%) was the primary cause of action. Of cases sent to the jury, 87.7% of them resulted in a verdict in favor of the defendant. The mean plaintiff verdict payout was $7,432,508.06 and the mean identified settlement amount was $1,562,500.00. Physical injury (62.0%) was the highest type of harm. Regional analysis indicated a higher percentage of cases from New York favored the defendant (21.1% vs 13.6%; P = .034)., Conclusion: This study highlights key trends in otolaryngology malpractice claims, emphasizing the prevalence in cases of head and neck surgery, primarily attributed to negligence. By identifying trends and risk factors, otolaryngologists can get a better understanding of the dynamics surrounding malpractice., (© 2024 American Academy of Otolaryngology–Head and Neck Surgery Foundation.)

Different techniques exist to provide tip support in rhinoplasty. There is little evidence to provide a consensus on the most effective choice. Evaluating columellar strut graft (CSG) and septal extension grafts (SEG) for their influence on airway function, patient satisfaction and tip support. A retrospective cohort study was undertaken on 165 adult patients who underwent open rhinoplasty with either a CSG or SEG, from February 2012 to August 2019 in a single tertiary facial-plastic practice in Sydney, Australia. Operations were for both cosmetic and functional indications, and both primary and revision cases were assessed. Airway testing and patient-reported outcomes (PROMs) were performed preoperatively and at least 6 months following the procedure. Photographic tip analysis was taken from approximately 4 and 12-month postoperative photographs. Nasal peak inspiratory flow (NPIF) and total nasal airway resistance (NAR) were the primary airway functional outcomes. The primary PROMs analysed were a visual analogue scale (VAS) for nasal obstruction and 13-point Likert scale for global cosmesis, the Nose Outcome Symptom Evaluation (NOSE), and the nasal obstruction score. Tip support was determined by the nasolabial angle (NLA) and Simon's ratio as assessed by Rhinobase developed by Apaydin et al. on lateral Frankfort plane photographs. Data normalised as an improvement over preoperative baseline, accounting for individual variability. A total of 165 patients was assessed (35.2 ± 12.9 yrs, 72% female), 100 (61%) of which received SEG. There were similar nasal airway assessments between CSG and SEG groups, with ΔNPIF (20.0 ± 42.1 L/min v 19.9 ± 44.9 L/min, p = 0.983) and Δ "obstructed" NAR (-1.13 ± 1.90 v -1.02 ± 4.33 Pa/cm3/s, p = 0.849). Amongst PROMs, a greater cosmetic outcome was seen in the SEG group (7.20 ± 2.97 v 5.69 ± 3.45, p < 0.01) with all other assessments similar between CSG and SEG techniques. Photographic analysis of tip projection showed reduced NLA distortion in the SEG. While greater patient-perceived cosmesis was seen in patients with a SEG, there were similar airflow and patient-reported nasal function between groups. Photographic analysis of tip projection showed SEG patients additionally benefited from less NLA distortion and greater tip maintenance. [ABSTRACT FROM AUTHOR]

Objectives/Hypothesis: Despite increasing the numbers of women entering the field, underrepresentation of women in otolaryngology has been reported. In the subspecialty of facial plastic and reconstructive surgery (FPRS), female representation and academic leadership have not been formally characterized. Our study aims to identify female representation and academic leadership roles in FPRS. Study Design: Cross sectional analysis. Methods: Analysis was performed using the 2020 American Academy of Facial Plastic and Reconstructive Surgery (AAFPRS) membership directory. Board‐eligible and board‐certified FPRS surgeons were included. Data regarding academic rank, leadership position, academic productivity, and years in practice were collected from publicly available departmental websites. Academic productivity was measured using h‐index. Results: Of 1,421 members queried in the 2020 AAFPRS membership directory, 13.0% were female and 86.9% were male. Most practitioners (87.0%) work in a private practice setting, but of the 13.0% of academic FPRS surgeons, 25.9% were female. Most female facial plastic surgeons in academic practice were Assistant Professors (72.9%), whereas ranks were evenly distributed among male FPRS surgeons. Three (4.3%) of 69 AAFPRS fellowship directors were women, and 1 (1.8%) of 56 present or past AAFPRS presidents was female. Female FPRS surgeons had fewer years in practice and lower h‐indices compared with male surgeons. Conclusions: Female FPRS surgeons hold fewer academic leadership positions and have lower academic productivity in comparison to male FPRS surgeons. Future studies are needed to elucidate the etiology of these gender differences. Level of Evidence: NA Laryngoscope, 132:781–785, 2022 [ABSTRACT FROM AUTHOR]

The surgical reconstruction of nose also termed 'Rhinoplasty' is as old as human civilisation. While major contribution of total nasal reconstruction originated in India by Sushrutha in around 600 B.C and later paved its way to the modern facial plastic surgery in North America and Europe in 18th century and popularised the Indian methods of nasal reconstruction to develop cosmetic and corrective rhinoplasty. This article aims to take you through the journey of evolution of rhinoplasty.

This technique has been developed with the aim of expanding the well documented pre-auricular flap to help reconstruct pinna lesions that extend into the external auditory canal. This area can be a challenge to reconstruct effectively to minimise morbidity and there are limited published techniques. This flap is a reproducible, one-stage technique that is readily available to most ENT surgeons, avoiding stenosis and allowing for adequate reconstruction of the external auditory canal. [ABSTRACT FROM AUTHOR]

Study Design: Retrospective review., Objective: Auricular hematomas are generally associated with sports-related injuries, with studies predominantly in white populations and high neighborhood socioeconomic status (NSES) compared to our county. A previous population-based study of trauma patients in our county, Shelby County, Tennessee, shows that those who live in high vs low NSES experienced socioeconomic variation in injury. We aim to determine if differences exist in clinical management and outcomes in this population., Methods: Patients from two hospital systems diagnosed with auricular hematomas from 2008-2023 were reviewed retrospectively. Inclusion criteria included adequate follow-up, clinical description of the hematoma, and comment on any complications or recurrence., Results: 48 patients, with a median age of 28 (range: 0-83), with the most common etiology being assault/non-accidental trauma (NAT) at 41.7%, equally distributed across all NSES ( P = .30), with one sports-related injury. Facial trauma consults were associated with lower recurrence rates, 25% vs 62.5% ( P = .003) and were less likely to be placed for self-pay patients ( P = .019). Bolster placement resulted in lower recurrence rates, 23.3% compared to 58.3% ( P = .030)., Conclusions: Higher rates of assault/NAT etiologies existed in our population, independent of NSES. Our study reiterates the importance of facial trauma consultation and bolster usage to reduce recurrence., Competing Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© The Author(s) 2024.)

Introduction: In Singapore, fractures of the mandible are common and of which, 32% occur at its angle. Current TwoDimensional (2D) imaging methods are lacking in accuracy, leading to increased surgical morbidity. Aim: To determine the Length (L), Diameter (D), Width (W) and Height (H) measurements in fractured and non-fractured mandibles by using Three-Dimensional (3D) Computed Tomography (CT). Materials and Methods: A single centre retrospective CT based study of 23 subjects (46 mandibular angles and M3s) was conducted and subjects below 16 years, conservatively managed fractures, mandibles without M3s and cases with inadequate CT scan data were excluded. Intraosseous M3 L and D and mandibular H and W were measured and ratios L/H and D/W were calculated. Results: Average mean (Standard Deviation, SD) L, D, H and W was 8.58 (2.089), 11.63 (2.156), 29.17 (4.830) and 16.94 (1.967) mm respectively. Average mean L/H and D/W were 0.30 (0.070) and 0.69 (0.126) respectively. There was a trend towards greater osseous volume occupied horizontally in fractured mandibles. Measurements demonstrated good reliability (CA 0.999-1.000) and good intra and inter-observer variability (ICC 0.998-1.000, p

Objective: Assess the effects of American Council for Graduate Medical Education (ACGME) resident work hour restrictions on the preparedness of incoming facial plastic surgery fellows as assessed by American Academy of Facial Plastic and Reconstructive Surgery (AAFPRS) fellowship directors. Methods: Observational survey study evaluating the perception of ACGME resident duty hour change on resident surgical and clinical skills from fellowship directors of AAFPRS fellowship programs in the US. A cross-sectional survey was sent to 47 fellowship directors of AAFPRS fellowship programs. Perceived change in resident clinical and surgical skills were measured using a 5-point Likert scale (1 = significantly improved, 2 = improved, 3 = neither improved nor worsened, 4 = worsened, 5 = significantly worsened) to evaluate 15 benchmarks. Results: Responses received from 36 fellowship directors. The results indicate no statistically significant perceived trend of ACGME duty hour reform on fellows for AAFPRS fellowships among fellowship directors. However, cohort analysis demonstrated that fellowship directors with more than 10 years of service perceived a more negative impact in 2 clinical benchmarks (assessment/planning and basic exposure) over time. Conclusions: The study results appear to show no significant perceived trend over time on the effect of duty hour reform on fellows for AAFPRS fellowships among fellowship directors. However, there are some apparent opinion differences between fellowship directors separated by years of service, with more negative perceptions noted in 2 clinical areas by those with more than 10 years of service. This study is in line with the more recent literature that suggests a trend toward a less negative perception of the duty hour change. This may suggest resident education is adapting to the ACGME duty hour regulations. [ABSTRACT FROM AUTHOR]

Introduction: In Singapore, fractures of the mandible are common and of which, 32% occur at its angle. Current Two- Dimensional (2D) imaging methods are lacking in accuracy, leading to increased surgical morbidity. Aim: To determine the Length (L), Diameter (D), Width (W) and Height (H) measurements in fractured and non-fractured mandibles by using Three-Dimensional (3D) Computed Tomography (CT). Materials and Methods: A single centre retrospective CT based study of 23 subjects (46 mandibular angles and M3s) was conducted and subjects below 16 years, conservatively managed fractures, mandibles without M3s and cases with inadequate CT scan data were excluded. Intraosseous M3 L and D and mandibular H and W were measured and ratios L/H and D/W were calculated. Results: Average mean (Standard Deviation, SD) L, D, W and H was 8.58 (2.089), 11.63 (2.156), 29.17 (4.830) and 16.94 (1.967) mm respectively. Average mean L/H and D/W were 0.30 (0.070) and 0.69 (0.126) respectively. There was a trend towards greater osseous volume occupied horizontally in fractured mandibles. Measurements demonstrated good reliability (CA 0.999-1.000) and good intra and inter-observer variability (ICC 0.998-1.000, p<0.001). Conclusion: A 3D reconstruction with OsiriX offers greater insight at little additional cost. However, this can be further streamlined and automated. [ABSTRACT FROM AUTHOR]

Digital patient photography and morphing software have become an important part of rhinoplasty over the past few decades. Presented is a novel technology incorporating 3D photography and printing to produce life-size models for use in patient evaluation and treatment. Surveys were conducted to assess patient response and were universally positive. Early surgeon experience also indicates benefit for intraoperative use. Three-dimensional printing and modeling is a new technology that has exciting applications for rhinoplasty and facial plastic surgery. [ABSTRACT FROM AUTHOR]

Objectives Microsurgical techniques are essential for vessel anastomosis in free flap reconstructive surgery. However, teaching these skills intraoperatively is difficult. The chicken thigh microvascular model is a high-fidelity model that has been previously validated to differentiate between skill levels of surgeons. This study aims to determine if this model objectively improves microsurgical skills. Study Design Validation study Methods Thirteen residents were given a tutorial on microvascular anastomosis and asked to perform anastomoses on the microvascular model. Anastomoses were video-recorded and the time required for trainees to complete the first stitch of their first anastomosis was compared to the time required for the first stitch of their last anastomosis. Comparison of first and last stitch times was completed using a paired student t-test. All participants completed a survey regarding their experience with the simulator. Results There was a statistically significant decrease between the time required for the first stitch (235 s, 95%CI 198-272 s) compared to last stitch (120 s, 95%CI 92-149 s), and an average 48.7% (115 s) decrease in time ( p < 0.001). Junior (PGY 2/3) and senior (PGY 4/5) residents had similar decreases in time, 49.1% and 48.21%, respectively. One hundred percent of residents felt they improved during the session and 92% of residents agreed or strongly agreed that their final stitch was better than their last stitch. All residents agreed or strongly agreed that the simulation is realistic, effective in teaching the procedure, and would translate to improved intraoperative performance. Conclusions The chicken thigh model demonstrates objective improvements in resident microvascular surgical skills. Level of Evidence NA [ABSTRACT FROM AUTHOR]

Botulinum toxin is a potent neuromodulator commonly used for cosmetic applications in the clinic. In this article, we reviewed the various formulations of botulinum toxin type A commercially available in the United States, as well as clinical pearls for preprocedural planning, common in-office injections, and management of complications., Competing Interests: The authors declare no conflict of interest., (© 2023 The Authors. World Journal of Otorhinolaryngology ‐ Head and Neck Surgery published by John Wiley & Sons Ltd on behalf of Chinese Medical Association.)

Objectives/hypothesis: To show that, for patients with few medical comorbidities and at low risk for airway compromise or fistula formation, early discharge after free tissue transfer for head and neck reconstruction is a safe and viable option.Study Design: Retrospective chart review.Methods: A cohort of patients who underwent free tissue transfer for head and neck reconstruction between February 2010 and December 2014 and who were discharged from the hospital by postoperative day 3 were reviewed.Results: Fifty patients undergoing 51 free-tissue transfer surgeries were discharged by postoperative day 3. The surgeries performed included anterolateral thigh free flaps (ALT) (n = 46), radial forearm free flaps (n = 2), latissimus myogenous and myocutaneous free flaps (n = 1), supraclavicular free flap (n = 1), and serratus free flap (n = 1). All ALT flaps were harvested exclusively as perforator free flaps; and the vast majority used superficial temporal, angular, or facial vessels. All free flaps were viable without evidence of vascular compromise at discharge and the initial follow-up appointment. One patient required take-back for successful flap salvage. One patient experienced late flap failure (between 2-3 weeks postoperatively), requiring another surgery. This resulted in an overall success rate of 98% in this cohort. No other postoperative complications related to early discharge were identified.Conclusion: In a carefully selected subset of patients undergoing free tissue transfer, early discharge has been shown to be possible without compromising patient safety or surgery success rates.Level Of Evidence: 4. Laryngoscope, 126:2679-2683, 2016. [ABSTRACT FROM AUTHOR]

Risk factors for the formation of facial scars include skin type, ethnicity, scar location, and certain medical conditions that contribute to poor or delayed healing. Risk of scar can be reduced with appropriate surgical planning, including proper placement and design of incisions, meticulous skin closure, aseptic technique, and wound care to improve healing. Common pathologic scars include hypertrophic scars and keloid scars, each of which has unique approaches to surgical revision and medical treatment due to their respective risks of recurrence. Topical scar therapies, medical therapies, and surgical revision techniques for improvement in final scar appearance are discussed., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: Patients often seek help to redress aging that affects various regions of the face (subunits). The purpose of this study was to determine how aging of different facial subunits impacts perception of age, attractiveness, and tiredness. Method: Frontal and lateral view facial photographs of a middle-aged woman were modified using imaging software to independently age different facial features. Sixty-six subjects were administered with a questionnaire, and presented with a baseline unmodified picture and others containing different individual or grouped aging of facial subunits. Test subjects were asked to estimate the age of the subject in the image and quantify (0-10 scale) how 'tired' and 'attractive' they appeared. Facial subunits were organized following rank assignment regarding impact on perception of age, attractiveness, and tiredness. Results: The correlation coefficient between age and attractiveness had a strong inverse relationship of approximately −0.95 in both lateral and frontal views. From most to least impact in age, the rank assignment for frontal view facial subunits was full facial aging, middle third, lower third, upper third, vertical lip rhytides, horizontal forehead rhytides, jowls, upper eyelid ptosis, loss of malar volume, lower lid fat herniation, deepening glabellar furrows, and deepening nasolabial folds. From most to least impact in age, the rank assignment for lateral view facial subunits was severe neck ptosis, jowls, moderate neck ptosis, vertical lip rhytides, crow's feet, lower lid fat herniation, loss of malar volume, and elongated earlobe. Conclusion: This study provides a preliminary template for further research to determine which anatomical subunit will have the most substantial effect on an aged appearance, as well as on the perception of tiredness and attractiveness. Level of Evidence IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors . [ABSTRACT FROM AUTHOR]

Apocrine carcinoma is a rare and potentially highly aggressive cutaneous adenocarcinoma, normally seen in areas rich in apocrine glands. An apocrine carcinoma was diagnosed following excisional biopsy of a nasal rim lesion and expert review of the histology. It represents the first reported case in this area. Following exclusion of further lesions by PET CT, a wide local excision was performed curatively, followed by a three-stage reconstruction with a nasolabial flap to correct the defect. Management of such rare lesions is difficult and is best directed, as in this case, by specialist pathological input and through a specialist MDT. Level of Evidence: Level V, diagnostic study. [ABSTRACT FROM AUTHOR]

Objectives/hypothesis: Extirpation via expanded endonasal approaches (EEA) to the skull base can result in defects requiring vascularized rotational flap reconstruction. The buccal fat pad (BFP) is a vascularized graft described in open skull base resections, but its harvest and adequacy of vascular supply have not been examined for use with EEA. Study Design: A transfacial cadaveric dissection was carried forth in a latex-injected specimen to characterize the BFP blood supply. Then a cadaveric dissection series was performed involving the endoscopic harvest and rotation of 10 buccal fat pads in five cadaveric specimens to assess defect coverage. Methods: An endoscopic medial maxillectomy combined with an anterior maxillotomy was performed prior to endoscopic harvest in cadaveric specimens. The BFP was rotated to assess its capability to reconstruct seven possible ventral skull base defects. Finally, the BFP vascular anatomy was further characterized following harvest and transposition. Results: The BFP reconstructed defects at the greater sphenoid wing, inferior and superior clivus, sella, planum, and bilateral ethmoids in all cadaveric specimens. In some cases it covered two sites concurrently. Conclusions: The BFP pedicled rotational flap is a potential alternate flap following EEA in select cases. Level Of Evidence: NA [ABSTRACT FROM AUTHOR]

Objective:This study assesses the efficacy of alar suspension sutures in the management of nasal valve collapse causing nasal obstruction. These sutures are inserted between the vestibular skin and lateral crura and hitched to the periosteum of the medial inferior orbital margin; this is a variation of the alar (change everywhere) suspension suture technique.Method:A retrospective review of patients who underwent alar suspension suture insertion between January 2009 and December 2010 in the management of nasal obstruction was undertaken. Symptoms of nasal obstruction were assessed using the Visual Analogue Scale (VAS) and peak inspiratory flow rate (PIFR). This was measured preprocedure and repeated at 3, 6, and 12 months postoperatively.Results:A total of 35 patients were identified, and 26 were included in the study; 90% of patients were satisfied with the outcome of surgery, supported by improvement in the VAS and PIFR scores. The mean difference in VAS preprocedure and postprocedure was 4.97 (P value = 0.00), and the average improvement in PIFR was 25.5 L/min (P value = 0.00).Conclusion:Our study shows a significant improvement in patient’s symptoms following insertion of alar suspension sutures. It is, therefore, a reliable, safe, and effective technique in treating nasal obstruction secondary to nasal valve collapse. [ABSTRACT FROM AUTHOR]

Lateral osteotomies are essential to rhinoplasty and are performed through percutaneous or intranasal approaches. Both techniques are difficult to teach as they rely on tactile feedback. Thus, it is critical to understand trainee learning curves to minimize complications. Herein, we aim to (1) demonstrate an educational module for teaching lateral osteotomies and (2) examine potential differences in outcomes between the 2 surgical approaches when performed by trainees. After a hands-on cadaveric laboratory, trainees (n = 24) reported increased confidence in performing both types of osteotomies ( P < .0001). Completion of the bony cut was similar between intranasal and percutaneous osteotomies (96% vs 75%, P = .097), as was correct placement of the osteotomy (75% vs 67%, P = .53). Intranasal osteotomies were more likely to cause periosteal disruption ( P = .02). This pilot study demonstrates that cadaveric laboratories are an effective way to teach lateral osteotomies and that percutaneous osteotomies may be less likely to cause periosteal disruption in trainees' hands. [ABSTRACT FROM AUTHOR]

Objectives/Hypothesis: Timing for repair of mandible fractures is a significant factor with regard to the rate of complication. Study Design: Retrospective chart review of the previous 5 years (January 2005–January 2010). Methods: All patients undergoing mandible fracture fixation performed in the study period and having complete records were analyzed (n ¼ 83). Patients were stratified by time to fixation following initial injury. Subjects were then separated by the presence or absence of any of the following complications: infection, malunion, and nonunion. Logistical regression was then performed. Results: Out of 83 patients there were 4 patients with six complications including malunion (n ¼ 4) and infection (n ¼ 2). There were no cases of nonunion. Delay in surgical intervention did not influence the complication rate. Conclusions: Complications from repair of mandible fractures are rare; it is difficult to detect significant variables that may impact outcomes. We found no relationship between complications and timing to repair. [ABSTRACT FROM AUTHOR]

Sino-orbital cutaneous fistulas are a well-documented complication of orbital exenteration and sinonasal carcinoma resection. Challenges to successful closure of this common complication include complex anatomy, communication with sinonasal mucosa, persistent mucopurulent drainage, compromised wound healing due to previous irradiation, and wound infection. We describe a novel approach for closure of sino-orbital cutaneous fistulas in two patients using a galeopericranial flap. The galeopericranial flap is ideal due to its thin, pliable nature and predictable, abundant vascularity. Additionally, it obviates the need for a more cosmetically disfiguring closure. Although used successfully in a variety of skull base and ophthalmologic surgeries, the galeopericranial flap has not been previously described for closure of sino-orbital cutaneous fistulas. Both patients' defects have remained closed at follow-up with excellent cosmetic results. Laryngoscope, 2011 [ABSTRACT FROM AUTHOR]

Objective. In the setting of known facial nerve sacrifice or injury, patients require precautions to prevent exposure keratitis and the morbidity that follows. One recommended treatment is surgical placement of a gold weight with or without lateral tarsal strip. In patients in whom the facial nerve has been sacrificed, it is unknown whether rehabilitation should be simultaneous or in the perioperative period.Study Design and Setting. Case series with chart review of patients who underwent immediate rehabilitation of the eye (gold weight and lateral tarsal strip) following facial nerve resection.Subjects and Methods. From 1998 to 2009, 52 patients were studied. Postoperative ophthalmologic complications and the need for revision surgeries were measured.Results. A gold weight was placed in all patients, and 48 of 52 (92%) simultaneous lateral tarsal strips were performed. The facial nerve was sacrificed in 51 of 52 (88%) patients, and the remaining patient had a known preoperative facial nerve paralysis. Thirty-six of 52 (69%) required free tissue transfer for reconstruction, underscoring the extensive resections performed. A 1.2-g gold weight was placed in 50 of 52 (96%) patients. Three (6%) patients required gold weight revision with a larger weight and 3 (6%) for extrusion. Eight (16.7%) patients underwent revision of the lateral tarsal strip for ectropion.Conclusions. No patients developed ophthalmologic complications. Patients undergoing radical surgical resections with known or suspected injury of the facial nerve should be considered for simultaneous rehabilitation of the upper and lower eye. [ABSTRACT FROM PUBLISHER]

Objectives/Hypothesis: To document the long-term advantages and disadvantages of cartilage grafts used to correct traumatic saddle nose deformity. Additionally, to demonstrate functional improvement and cosmetic satisfaction with the use of this graft. Study Design: Retrospective chart review and prospective follow-up telephone survey of 20 patients after dorsal augmentation of saddle nose deformity secondary to trauma. Methods: This is a single-surgeon, single-institution investigation within an academic tertiary care medical center. All patients presented for correction of saddle nose deformity after trauma, and cartilage grafts were used for augmentation of the dorsum. Minimum postoperative follow-up period of 1 year was required. A modified and expanded Nasal Obstructive Symptoms Evaluation survey, which included questions pertaining to the appearance of their nose, was used to assess both functional and cosmetic changes after surgery. Results: Only 1 of the 20 patients was dissatisfied with the overall outcome. Three (15%) were extremely satisfied, 12 (60%) were very satisfied, three (15%) were somewhat satisfied, and one (5%) was indifferent. In terms of function, four (20%) experienced excellent relief in nasal obstruction, five (25%) moderate relief, four (20%) mild relief, and seven (35%) noted no difference. Regarding cosmesis, two (10%) noted excellent improvement, three (15%) moderate improvement, nine (45%) mild improvement, and five (25%) noted no significant change. One (5%) patient reported worsening due to tip edema. Mean follow-up time was 6.8 years. Conclusions: Autogenous cartilage grafts are useful in the correction of mild to moderate traumatic saddle nose deformity. The graft is readily available, preserves long-term structural stability, and achieves functional and cosmetic satisfaction in most patients. Laryngoscope, 2009 [ABSTRACT FROM AUTHOR]

Objective: The reconstruction of large scalp defects poses both functional and cosmetic challenges. While free tissue transfer remains the standard for defects larger than 30 cm 2 , prolonged anesthesia and postoperative complications remain significant limitations. The purpose of this study is to evaluate the use of O-Z flaps for the reconstruction of large scalp defects and to describe the techniques employed., Methods: This is a retrospective analysis of ten patients who underwent reconstructive surgery using an O-Z flap approach for large scalp defects between July 2017 and June 2019. The parameters included in this study were patient demographics, tumor characteristics, and postoperative management, collected for at least a year after surgery., Results: In this cohort, the mean age was 76.1 years and 90% were male. All patients were treated for neoplastic skin lesions, with 70% located on the vertex and 30% located on the temporoparietal region. The mean size of defect was 52.0 cm 2 (range: 38.6 to 63.8 cm 2 ). The maximum hospital stay was two days, and no patients were readmitted within 30 days of surgery. There were no cases of wound infection or flap necrosis. All patients reported pain control with acetaminophen and ibuprofen. Four patients received adjuvant radiation, and there was no delay to receiving treatment following surgery., Conclusions: The O-Z flap is a reliable alternative for the reconstruction of non-irradiated scalp defects in the vertex and temporoparietal regions up to 63 cm 2 . This technique provides advantages for patients, including hairline preservation, shorter hospital stays, and decreased postoperative complications., Competing Interests: Informed consent was obtained for publication of photographs., (© 2022 The Authors. World Journal of Otorhinolaryngology ‐ Head and Neck Surgery published by John Wiley & Sons Ltd on behalf of Chinese Medical Association.)

Objectives/Hypothesis: The objectives were to describe our experience with a bolsterless technique for the management of auricular hematomata and discuss the management options for auricular hematomata and the comparative benefits of the bolsterless technique. Study Design: Retrospective case series. Methods: Patients presented with recurrent auricular hematomata following traditional treatment with incision and drainage and bolster placement. Revision incision and drainage were performed, and then auricular skin was stabilized using through-and-through absorbable horizontal mattress sutures. Patients were seen in follow-up to evaluate for recurrence and assess cosmetic results. Results: Twenty-eight patients were treated for recurrent auricular hematomata using the bolsterless technique. There were no recurrences in follow-up, and cosmetic results were judged to be excellent by both patient and surgeon. Conclusions: Bolsterless management for auricular hematomata using absorbable mattress sutures has been described intermittently in the otolaryngology literature since 1991 but is not widely utilized. In this series, patients presenting with recurrent auricular hematomata following failure of traditional bolster management were effectively managed with the bolsterless technique. This technique is well tolerated by patients and allows for early return to athletic activity. [ABSTRACT FROM AUTHOR]