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SUMMARY The American Society of Plastic Surgeons, the American Academy of Otolaryngology-Head and Neck Surgery, and the American Academy of Facial Plastic and Reconstructive Surgery commissioned the multidisciplinary Rhinoplasty Performance Measure Development Work Group to identify and draft quality measures for the care of patients undergoing both functional and aesthetic rhinoplasty. One outcome measure and three process measures were identified. The outcome looked at patient satisfaction with rhinoplasty procedures. The process measures look at motivations and expectations of the procedure, airway assessment, and nonnarcotic shared decision-making strategies for pain management. All measures in this report were approved by the American Society of Plastic Surgeons Quality and Performance Measures Work Group and Executive Committee, and the American Academy of Otolaryngology-Head and Neck Surgery Foundation, the American Academy of Facial Plastic and Reconstructive Surgery, The Rhinoplasty Society, and the American Association of Oral and Maxillofacial Surgeons. The Work Group recommends the use of these measures for quality initiatives, Continuing Medical Education, Maintenance of Certification, Qualified Clinical Data Registry reporting, and national quality reporting programs.

Background and objectives With the resumption of elective ophthalmic surgery during COVID-19, revised protocols were mandated to protect both staff and patients from transmission while increasing case numbers. We discuss a widely generalizable and in-depth protocol intended to safely allow the restart of elective procedures in 2 dedicated ophthalmic ambulatory surgical centers (ASCs) using monitored anesthesia care. Methods A single-center review of protocols and practices designed to limit COVID-19 transmission. Results All patients were tested within 72 hours prior to the procedure with a COVID-19 nasal swab to assess for active disease. A distance of 6 ft between each stretcher and the staff within the ASC was maintained when possible. Preoperative anesthetizing and dilating eye drops were administered from multiuse bottles without contact with surfaces. Surgical cases were restarted at a reduced capacity of a maximum of 7 per day to distance patient arrivals. Removal of waiting room chairs and the creation of new break areas allowed for social distancing. Conclusion As recommendations change on the basis of an increased understanding of the COVID-19 virus, ophthalmologists and ASC staff need to tailor protocols and workflows to limit transmission of virus with resumption of ocular surgery.

Purpose: Surgery involves modifying anatomy to achieve a goal. Reconstructing anatomy can facilitate surgical care through surgical planning, real-time decision support, or anticipating outcomes. Tool motion is a rich source of data that can be used to quantify anatomy. Our work develops and validates a method for reconstructing the nasal septum from unstructured motion of the Cottle elevator during the elevation phase of septoplasty surgery, without need to explicitly delineate the surface of the septum. Approach: The proposed method uses iterative closest point registration to initially register a template septum to the tool motion. Subsequently, statistical shape modeling with iterative most likely oriented point registration is used to fit the reconstructed septum to Cottle tip position and orientation during flap elevation. Regularization of the shape model and transformation is incorporated. The proposed methods were validated on 10 septoplasty surgeries performed on cadavers by operators of varying experience level. Preoperative CT images of the cadaver septums were segmented as ground truth. Results: We estimated reconstruction error as the difference between the projections of the Cottle tip onto the surface of the reconstructed septum and the ground-truth septum segmented from the CT image. We found translational differences of 2.74(2.06-2.81) mm and a rotational differences of 8.95(7.11-10.55) deg between the reconstructed septum and the ground-truth septum [median (interquartile range)], given the optimal regularization parameters. Conclusions: Accurate reconstruction of the nasal septum can be achieved from tool tracking data during septoplasty surgery on cadavers. This enables understanding of the septal anatomy without need for traditional medical imaging. This result may be used to facilitate surgical planning, intraoperative care, or skills assessment.

IMPORTANCE: Standardization of outcome measurement using a patient-centered approach in pediatric facial palsy may help aid the advancement of clinical care in this population. OBJECTIVE: To develop a standardized outcome measurement set for pediatric patients with facial palsy through an international multidisciplinary group of health care professionals, researchers, and patients and patient representatives. DESIGN, SETTING, AND PARTICIPANTS: A working group of health care experts and patient representatives (n = 21), along with external reviewers, participated in the study. Seven teleconferences were conducted over a 9-month period between December 3, 2016, and September 23, 2017, under the guidance of the International Consortium for Health Outcomes Measurement, each followed with a 2-round Delphi process to develop consensus. This process defined the scope, outcome domains, measurement tools, time points for measurements, and case-mix variables deemed essential to a standardized outcome measurement set. Each teleconference was informed by a comprehensive review of literature and through communication with patient advisory groups. Literature review of PubMed was conducted for research published between January 1, 1981, and November 30, 2016. MAIN OUTCOMES AND MEASURES: The study aim was to develop the outcomes and measures relevant to children with facial palsy as opposed to studying the effect of a particular intervention. RESULTS: The 21 members of the working group included pediatric facial palsy experts from 9 countries. The literature review identified 1628 papers, of which 395 (24.3%) were screened and 83 (5.1%) were included for qualitative evaluation. A standard set of outcome measurements was designed by the working group to allow the recording of outcomes after all forms of surgical and nonsurgical facial palsy treatments among pediatric patients of all ages. Unilateral or bilateral, congenital or acquired, permanent or temporary, and single-territory or multiterritory facial palsy can be evaluated using this standard set. Functional, appearance, psychosocial, and administrative outcomes were selected for inclusion. Clinimetric and psychometric outcome measurement tools (clinician-, patient-, and patient proxy–reported) and time points for measuring patient outcomes were established. Eighty-six independent reviews of the standard set were completed, and 34 (85%) of the 40 patients and patient representatives and 44 (96%) of the 46 health care professionals who participated in the reviews agreed that the standard set would capture the outcomes that matter most to children with facial palsy. CONCLUSIONS AND RELEVANCE: This international collaborative study produced a free standardized set of outcome measures for evaluating the quality of care provided to pediatric patients with facial palsy, allowing benchmarking of clinicians, comparison of treatment pathways, and introduction of value-based reimbursement strategies in the field of pediatric facial palsy. LEVEL OF EVIDENCE: NA.

Facial nerve deficits cause significant functional and social consequences for those affected. Existing techniques for dynamic restoration of facial nerve function are imperfect and result in a wide variety of outcomes. Currently, there is no standard objective instrument for facial movement as it relates to restorative techniques.To determine what objective instruments of midface movement are used in outcome measurements for patients treated with dynamic methods for facial paralysis.Database searches from January 1970 to June 2017 were performed in PubMed, Embase, Cochrane Library, Web of Science, and Scopus. Only English-language articles on studies performed in humans were considered. The search terms used were ("Surgical Flaps"[Mesh] OR "Nerve Transfer"[Mesh] OR "nerve graft" OR "nerve grafts") AND (face [mh] OR facial paralysis [mh]) AND (innervation [sh]) OR ("Face"[Mesh] OR facial paralysis [mh]) AND (reanimation [tiab]).Two independent reviewers evaluated the titles and abstracts of all articles and included those that reported objective outcomes of a surgical technique in at least 2 patients.The presence or absence of an objective instrument for evaluating outcomes of midface reanimation. Additional outcome measures were reproducibility of the test, reporting of symmetry, measurement of multiple variables, and test validity.Of 241 articles describing dynamic facial reanimation techniques, 49 (20.3%) reported objective outcome measures for 1898 patients. Of those articles reporting objective measures, there were 29 different instruments, only 3 of which reported all outcome measures.Although instruments are available to objectively measure facial movement after reanimation techniques, most studies do not report objective outcomes. Of objective facial reanimation instruments, few are reproducible and able to measure symmetry and multiple data points. To accurately compare objective outcomes in facial reanimation, a reproducible, objective, and universally applied instrument is needed.

IMPORTANCE: A multivector functional muscle flap that closely simulates the biomechanical effects of facial muscle groups is essential for complete smile restoration after facial paralysis. OBJECTIVE: To determine the feasibility of a multivector gracilis muscle flap design for reanimation after facial paralysis and to analyze the effect on the smile display zone. DESIGN, SETTING, AND PARTICIPANTS: Prospective analysis of patients who underwent a double paddle multivector gracilis flap for complete facial paralysis between June 2015 and December 2016 was carried out in a tertiary hospital. INTERVENTIONS: The gracilis muscle was harvested as a double paddle flap and inserted along 2 vectors for facial reanimation. MAIN OUTCOMES AND MEASURES: The primary outcome measures were: (1) dental display (the number of maxillary teeth displayed on paralyzed vs normal sides), (2) exposed maxillary gingival scaffold width, (3) interlabial gap at midline and canine, (4) facial asymmetry index (FAI), and (5) dynamic periorbital wrinkling. RESULTS: There were 10 women and 2 men between ages 20 and 64 years (mean [SD], 46 [15] years). Five flaps were reinnervated with facial and masseteric nerves, 5 with masseteric nerve only, and 2 with crossfacial nerve only. There was functional muscle recovery in all cases. On average there was additional 3.1 maxillary teeth exposed posttreatment when smiling (5.5 vs 8.6; CI, 7.9 to 16.6; P

Body dysmorphic disorder (BDD) is a relative contraindication for facial plastic surgery, but formal screening is not common in practice. The prevalence of BDD in patients seeking facial plastic surgery is not well documented.To establish the prevalence of BDD across facial plastic and oculoplastic surgery practice settings, and estimate the ability of surgeons to screen for BDD.This multicenter prospective study recruited a cohort of 597 patients who presented to academic and private facial plastic and oculoplastic surgery practices from March 2015 to February 2016.All patients were screened for BDD using the Body Dysmorphic Disorder Questionnaire (BDDQ). After each clinical encounter, surgeons independently evaluated the likelihood that a participating patient had BDD. Validated instruments were used to assess satisfaction with facial appearance including the FACE-Q, Blepharoplasty Outcomes Evaluation (BOE), Facelift Outcomes Evaluation (FOE), Rhinoplasty Outcomes Evaluation (ROE), and Skin Rejuvenation Outcomes Evaluation (SROE).Across participating practices (9 surgeons, 3 sites), a total of 597 patients were screened for BDD: 342 patients from site 1 (mean [SD] age, 44.2 [16.5] years); 158 patients, site 2 (mean [SD] age, 46.0 [16.2] years), site 3, 97 patients (mean [SD] age, 56.3 [15.5] years). Overall, 58 patients [9.7%] screened positive for BDD by the BDDQ instrument, while only 16 of 402 patients [4.0%] were clinically suspected of BDD by surgeons. A higher percentage of patients presenting for cosmetic surgery (37 of 283 patients [13.1%]) compared with those presenting for reconstructive surgery (21 of 314 patients [6.7%]) screened positive on the BDDQ (odds ratio, 2.10; 95% CI, 1.20-3.68; P = .01). Surgeons were only able to correctly identify 2 of 43 patients (4.7%) who screened positive for BDD on the BDDQ, and the positive likelihood ratio was only 1.19 (95% CI, 0.28-5.07). Patients screening positive for BDD by the BDDQ had lower satisfaction with their appearance as measured by the FACE-Q, ROE, BOE, SROE, and FOE.Body dysmorphic disorder is a relatively common condition across facial plastic and oculoplastic surgery practice settings. Patients who screen positive on the BDDQ have lower satisfaction with their facial appearance at baseline. Surgeons have a poor ability to screen for patients with BDD when compared with validated screening instruments such as the BDDQ. Routine implementation of validated BDD screening instruments may improve patient care.NA.

Alopecia is a common condition with varying levels of severity that affects both men and women. Hair loss can have a negative psychosocial effect with detriments to self-esteem, social success, and perceived attractiveness. Recent evidence has proven a significant reduction in the quality of life (QOL) in patients with this condition. Health-state utility studies have demonstrated the value of treating alopecia and reveal the motivations for patients seeking treatment [1]. Surgical hair restoration is now among the most highly sought cosmetic procedures. According to the International Society for Hair Restoration Surgery (ISHRS), the number of surgical hair restoration patients increased by 109% from 2012 to 2016 and by 67% from 2014 to 2016 alone [3]. Hair restoration aims to stimulate regrowth of lost hair and unlike many medical therapies, is not limited to prevention of hair loss [2]. Tremendous advancements in hair restoration techniques have led to greatly improved outcomes since restoration was first attempted in the early 1800s [2]. Procedures in the current era include hair transplantation with follicular unit extraction (FUE) or follicular unit transplant (FUT), use of platelet-rich plasma (PRP), tissue expansion, local tissue rearrangement, and hairline lowering surgery.

Background: Women in academic medicine are not attaining parity with men in several domains. This issue is not only one of fairness; some funding agencies are requesting data on gender ben...

An increasing volume of ambulatory surgeries has led to an increase in the number of ambulatory surgery centers (ASCs). Some academic health systems have aligned with ASCs to create a more integrated care delivery system. Yet, these centers are diverse in many areas, including specialty types, ownership models, management, physician employment, and regulatory oversight. Academic health systems then face challenges in integrating these ASCs into their organizations.Johns Hopkins Medicine created the Ambulatory Surgery Coordinating Council in 2014 to manage, standardize, and promote peer learning among its eight ASCs. The Armstrong Institute for Patient Safety and Quality provided support and a model for this organization through its quality management infrastructure. The physician-led council defined a mission and created goals to identify best practices, uniformly provide the highest-quality patient-centered care, and continuously improve patient outcomes and experience across ASCs.Council members built trust and agreed on a standardized patient safety and quality dashboard to report measures that include regulatory, care process, patient experience, and outcomes data. The council addressed unintentional outcomes and process variation across the system and agreed to standard approaches to optimize quality. Council members also developed a process for identifying future goals, standardizing care practices and electronic medical record documentation, and creating quality and safety policies.The early success of the council supports the continuation of the Armstrong Institute model for physician-led quality management. Other academic health systems can learn from this model as they integrate ASCs into their complex organizations.

BACKGROUND The Mohs histotechnologist (MH) performs tissue preparation, sectioning, and staining, which are critical tasks in ensuring a successful Mohs micrographic surgery (MMS). OBJECTIVE To assess current norms in MH training, practice setting, and utilization of specific histologic techniques. MATERIALS AND METHODS A 16-question survey was created and distributed using Survey Monkey to all members of the American Society for Mohs Histotechnology. RESULTS Response rate was 30%. Most MHs received on-the-job training from other MHs or the Mohs surgeon. Mohs histotechnologists largely performed tasks related to tissue processing while Mohs surgeons generally illustrated the Mohs layer map. Automated routine staining was used in most laboratory tests, and laboratory tests used similar staining techniques. Most respondents worked in private offices verses academic centers. Total staining time was significantly longer at academic medical centers versus private offices (7 vs 5 minutes, p = .01). CONCLUSION These findings provide an updated profile of current laboratory training and tissue preparation techniques at MMS practices across the country. Understanding the roles of the MH in laboratory functioning may help laboratories adopt best practices.

Consistent and objective evaluation of the paralyzed face is imperative for documenting preoperative findings and assessing postoperative outcomes of reanimation techniques. Static and dynamic facial asymmetry are the key features of the paralyzed face. To date, there is no consensus among surgeons on how best to document facial asymmetry. The authors propose a Facial Asymmetry Index (FAI) as an objective measure of facial asymmetry and validate its use and reliability across numerous reanimation techniques. Frontal photographs of patients with unilateral facial nerve paralysis were analyzed. The length from the medial canthus to the ipsilateral oral commissure was compared between affected and nonaffected sides. The FAI is the difference between the two values, with a higher value reflecting poorer facial symmetry. Validation and reliability testing was then performed. There was a consistent decrease in the FAI with procedural intervention (FAI pre = 10.1, FAI post = 3.17; p

The Merit-based Incentive Payment System provides for new ways to pay for care, including bundled payment programs, which pay a fixed amount for the total cost of care during a defined period surro...

Nail apparatus melanomas are rare and may present with a wide variety of clinical presentations. In particular, the amelanotic subtype can pose a diagnostic challenge, often leading to a poor prognosis related to a delayed diagnosis. We report a 69-year-old man with an unusual subungual amelanotic melanoma presenting as a persistent single nail dystrophy that was repeatedly treated as onychomycosis. Owing to the delayed diagnosis of the melanoma and to minimize recurrence risk, the patient underwent a partial amputation of his left thumb.

Objectives To measure the attentional distraction to the facial paralysis deformity using eye-tracking, and to distinguish between attention paid to the upper and lower facial divisions in patients with complete paralysis. We hypothesized that features affected by the paralysis deformity would distract the casual observer, leading to an altered pattern of facial attention as compared to normals. Study Design Randomized controlled experiment. Methods Sixty casual observers viewed images of paralyzed faces (House-Brackmann [HB] IV–VI) and normal faces smiling and in repose. The SMI iView X RED (SensoMotoric, Inc., Boston, MA) eye-gaze tracker recorded eye movements of observers gazing on the faces. Fixation durations for predefined areas of interest were analyzed using three separate multivariate analyses. Results Casual observers gazing on both paralyzed and normal faces directed the majority of their attention to the central triangle (CT) region. Significant differences occurred in the distribution of attention among individual features in the CT and to individual sides of the face. Observers directed more attention to the mouth of paralyzed faces, smiling (analysis of variance [ANOVA] > F 0.0001) and in repose (ANOVA > F 0.0000). Attention was asymmetrically distributed between the two halves of paralyzed faces (paralyzed smiling minus normal smiling P > |z| 0.000). Conclusions Casual observers directed attention in a measurably different way when gazing on paralyzed faces as compared to normal faces, a finding exacerbated with smiling. These findings help explain society's perceptions of attractiveness and affect display that differ for paralyzed and normal faces and can be used to direct our reconstructive efforts. Level of Evidence N/A. Laryngoscope, 126:334–339, 2016

To perform a systematic review and meta-analysis to determine if isolated nasal surgery in patients with obstructive sleep apnea and nasal airway obstruction improves obstructive sleep apnea.Computerized searches were performed in PubMed, EMBASE, and the Cochrane Library through October 2014. Manual searches and subject matter expert input was also solicited.A search protocol was defined a priori, and 2 independent investigators performed the data extraction, focusing on relevant data, including quality data polysomnography data, and taking note of methodological quality and risk for bias.The 10 studies meeting criteria included a total of 320 patients. There were 2 randomized controlled trials, 7 prospective studies, and 1 retrospective study. There was a significant improvement in the pooled results of both Epworth Sleepiness Scale (ESS; difference 3.53, 95% confidence interval [CI] [0.64, 6.23]) and Respiratory Disturbance Index (RDI; 11.06, 95% CI [5.92, 16.19]) scores with isolated nasal surgery. There was no significant improvement in the Apnea Hypopnea Index (AHI) in the random effects model (4.83, 95% CI [-1.6, 11.62]).The pooled results showed that isolated nasal surgery for patients with nasal obstruction and obstructive sleep apnea improved some sleep parameters, as shown by significant improvements in ESS and RDI, but had no significant improvements on AHI. Future controlled studies with larger groups are needed to confirm the benefits of isolated nasal surgery in this patient population.

Nail apparatus melanomas are rare and may present with a wide variety of clinical presentations. In particular, the amelanotic subtype can pose a diagnostic challenge, often leading to a poor prognosis related to a delayed diagnosis. We report a 69-year-old man with an unusual subungual amelanotic melanoma presenting as a persistent single nail dystrophy that was repeatedly treated as onychomycosis. Owing to the delayed diagnosis of the melanoma and to minimize recurrence risk, the patient underwent a partial amputation of his left thumb.

We describe an approach to reanimation of complete, prolonged facial paralysis using minimally invasive temporalis tendon transfer (MIT3) by the melolabial or transoral approach. Objective outcome measures are evaluated based on symmetry, and grading of preoperative/post-operative results and the scar at the melolabial fold.Retrospective cohort study.Twenty-five patients undergoing the MIT3 technique were studied. Photographic analysis was used to determine the percentage of difference between the 2 sides (symmetry). Using the Delphi method to achieve consensus, a panel of experts graded pre/post-operative photos using the Terzis' Facial Grading System and a 1 to 10 Likert-type scale and the melolabial scar using the Beausang Scar Scale.Percentage of difference (symmetry) with smiling improved from 18.6% ± 1.5% (mean ± standard error of the mean [SEM]) preoperatively to 5.0 ± 0.9% (mean ± SEM) post-operatively. Expert grading by the Terzis system showed improvement post-operatively (mean 3.7/5; median 3.6/5) versus preoperatively (mean 1.5/5; median 1.2/5). Perceived improvement was also largely favourable (mean 8.1/10; median 8.0/10). Melolabial scar grading was favourable in terms of colour (mean 1.53/4), surface character (mean 1.05/2), contour (mean 1.60/4), and distortion (mean 1.74/4).The MIT3 technique offers immediate, predictable, and symmetrical return of smile function. Objective symmetry analysis and favourable expert grading of both pre-/post-operative photographs and the scar at the melolabial fold demonstrate applicability for facial reanimation in patients where other procedures have failed, or when a direct return to function is desired. Both the melolabial approach and transoral approach were found to be acceptable and effective, although applicability varies.Les auteurs décrivent une approche de la réanimation d’une paralysie faciale complète et prolongée par transfert mini-invasif du tendon temporal (MIT3) par l’abord mélolabial ou transoral. Les mesures objectives de résultats sont évaluées en fonction de la symétrie, du classement des résultats préopératoires et postopératoires et de la cicatrice au pli mélolabial.Étude rétrospective de cohorte.Les chercheurs ont étudié 25 patients qui avaient subi la technique MIT3. L’analyse photographique a déterminé la différence en pourcentage entre les deux côtés (symétrie). À l’aide de la méthode Delphi pour parvenir à un consensus, un groupe d’experts a classé les photos préopératoires et postopératoires à l’aide du système de classement facial de Terzis et de l’échelle de Likert de 1 à 10. Il a aussi classé la cicatrice mélolabiale à l’aide de l’échelle de cicatrices de Beausang.La différence du sourire en pourcentage (symétrie) est passée de 18,6±1,5 % (moyenne±erreur-type) avant l’opération à 5,0±0,9 % (moyenne±erreur-type) après l’opération. Le classement par les experts à l’aide du système de Terzis a démontré une amélioration après l’opération (moyenne 3,7/5; médiane 3,6/5) par rapport à l’aspect préopératoire (moyenne 1,5/5; médiane 1,2/5). De plus, l’amélioration perçue était largement favorable (moyenne 8,1/10; médiane 8,0/10). Le classement de la cicatrice mélolabiale était positif sur le plan de la couleur (moyenne 1,53/4), de l’aspect de la surface (moyenne de 1,05/2), du contour (moyenne de 1,60/4) et de la distorsion (moyenne de 1,74/4).La technique MIT3 assure un retour immédiat, prévisible et symétrique du sourire. L’analyse de symétrie objective, un classement favorable par des experts d’après des photos avant-après l’opération et la cicatrice au pli mélolabial démontrent la possibilité de réanimation faciale des patients lorsque d’autres interventions ont échoué ou qu’un retour direct à la fonction est souhaité. Tant l’abord mélolabial que transoral étaient acceptables et efficaces, même si leur applicabilité varie.

Hyper IgE Syndrome (HIES) is an inherited immunodeficiency syndrome with an increased susceptibility to cutaneous fungal infections. While systemic antifungals are often the therapy of choice, many non-pharmacologic treatment options have been shown to improve clearance of these infections. We report the treatment course of cutaneous Fusarium Solani infection in an 8-year-old male with HIES with progression despite a series of systemic antifungals.

Objective To determine how patients seeking cosmetic rhinoplasty analyze themselves compared to their surgeon's analysis. Simply stated, “Does your surgeon view your nose the same as you?” Study design Prospective, blinded study. Methods All primary rhinoplasty consultations completed a nasal analysis questionnaire. The patients’ facial plastic surgeons completed an identical questionnaire. The results were compared and analyzed. Results Data underwent statistical analysis and subsequent factor analysis was performed. 132 patients participated in the study. Questions were grouped together based on factors: overall appearance, skin quality, tip dimensions, straightness, nostril show, and width. The only factor with reasonable surgeon/patient correlation was factor 1, overall appearance, with correlation 0.6473, p Conclusions Surgeons and patients are in agreement with the overall appearance of the nose, but differ in their analysis regarding the details. This information can be used to guide future discussions during consultations and most importantly help to better gauge and manage patient expectations.

Academic medical centers (AMCs)--which include teaching hospital(s) and additional care delivery entities--that form accountable care organizations (ACOs) must decide whether to partner with other provider entities, such as community practices. Indeed, 67% (33/49) of AMC ACOs through the Medicare Shared Savings Program through 2014 are believed to include an outside community practice. There are opportunities for both the AMC and the community partners in pursuing such relationships, including possible alignment around shared goals and adding ACO beneficiaries. To create the Johns Hopkins Medicine Alliance for Patients (JMAP), in January 2014, Johns Hopkins Medicine chose to partner with two community primary care groups and one cardiology practice to support clinical integration while adding approximately 60 providers and 5,000 Medicare beneficiaries. The principal initial interventions within JMAP included care coordination for high-risk beneficiaries and later, in 2014, generating dashboards of ACO quality measures to facilitate quality improvement and early efforts at incorporating clinical pathways and Choosing Wisely recommendations. Additional interventions began in 2015.The principal initial challenges JMAP faced were data integration, generation of quality measure reports among disparate electronic medical records, receiving and then analyzing claims data, and seeking to achieve provider engagement; all these affected timely deployment of the early interventions. JMAP also created three regional advisory councils as a forum promoting engagement of local leadership. Network strategies among AMCs, including adding community practices in a nonemployment model, will continue to require thoughtful strategic planning and a keen understanding of local context.

To measure the attentional distraction to the facial paralysis deformity using eye-tracking, and to distinguish between attention paid to the upper and lower facial divisions in patients with complete paralysis. We hypothesized that features affected by the paralysis deformity would distract the casual observer, leading to an altered pattern of facial attention as compared to normals.Randomized controlled experiment.Sixty casual observers viewed images of paralyzed faces (House-Brackmann [HB] IV-VI) and normal faces smiling and in repose. The SMI iView X RED (SensoMotoric, Inc., Boston, MA) eye-gaze tracker recorded eye movements of observers gazing on the faces. Fixation durations for predefined areas of interest were analyzed using three separate multivariate analyses.Casual observers gazing on both paralyzed and normal faces directed the majority of their attention to the central triangle (CT) region. Significant differences occurred in the distribution of attention among individual features in the CT and to individual sides of the face. Observers directed more attention to the mouth of paralyzed faces, smiling (analysis of variance [ANOVA]F 0.0001) and in repose (ANOVAF 0.0000). Attention was asymmetrically distributed between the two halves of paralyzed faces (paralyzed smiling minus normal smiling P|z| 0.000).Casual observers directed attention in a measurably different way when gazing on paralyzed faces as compared to normal faces, a finding exacerbated with smiling. These findings help explain society's perceptions of attractiveness and affect display that differ for paralyzed and normal faces and can be used to direct our reconstructive efforts.N/A.

Previous work on surgical skill assessment using intraoperative tool motion has focused on highly structured surgical tasks such as cholecystectomy and used generic motion metrics such as time and number of movements. Other statistical methods such as hidden Markov models (HMM) and descriptive curve coding (DCC) have been successfully used to assess skill in structured activities on bench-top tasks. Methods to assess skill and provide effective feedback to trainees for unstructured surgical tasks in the operating room, such as tissue dissection in septoplasty, have yet to be developed. We proposed a method that provides a descriptive structure for septoplasty by automatically segmenting it into higher-level meaningful activities called strokes. These activities characterize the surgeon’s tool motion pattern. We constructed a spatial graph from the sequence of strokes in each procedure and used its properties to train a classifier to distinguish between expert and novice surgeons. We compared the results from our method with those from HMM, DCC, and generic metric-based approaches. We showed that our method—with an average accuracy of 91 %—performs better or equal than these state-of-the-art methods, while simultaneously providing surgeons with an intuitive understanding of the procedure. In this study, we developed and evaluated an automated approach to objectively assess surgical skill during unstructured task of tissue dissection in nasal septoplasty.

Objective To present a modified technique in the harvest and application of split-thickness skin graft (STSG) from the primary flap donor site in forearm fasciocutaneous free flaps. Methods A prospective review was performed on 16 consecutive patients who had undergone a radial forearm free flap procedure for reconstruction of head and neck defects with a hinged forearm STSG used to reconstruct the flap donor site defect. Results Sixteen patients with a mean (SD) defect size of 53.7 (29.9) cm 2 underwent the hinged STSG procedure. A hinged STSG was successfully harvested from all patients without disruption. Graft take was greater than 90% in all patients by postoperative day 7. A secondary skin graft donor site was avoided in all but 2 patients. Good color match of the deepithelialized flap with surrounding oral and pharyngeal mucosa was observed. Visible scarring along the graft hinge margin was absent. No bridging scars resulted from the deepithelialized flaps. Conclusions The hinged STSG from the forearm is a reliable method of repairing radial forearm free flap donor site defects and offers the advantages of reduced suture line scarring, minimal STSG disruption, low or no secondary donor site morbidity, and good color match at the donor and recipient flap sites.

We observe that expert surgeons performing MIS learn to minimize their tool path length and avoid collisions with vital structures. We thus conjecture that an expert surgeon's tool paths can be predicted by minimizing an appropriate energy function. We hypothesize that this reference path will be closer to an expert with greater skill, as measured by an objective measurement instrument such as objective structured assessment of technical skill (OSATS). To test this hypothesis, we have developed a surgical path planner (SPP) for functional endoscopic sinus surgery (FESS). We measure the similarity between an automatically generated reference path and surgical motions of subjects. We also develop a complementary similarity metric by translating tool motion to a coordinate-independent coding of motion, which we call the descriptive curve coding (DCC) method. We evaluate our methods on surgical motions recorded from FESS training tasks. The results show that the SPP reference path predicts the OSATS scores with 88% accuracy. We also show that motions coded with DCC predict OSATS scores with 90% accuracy. Finally, the combination of SPP and DCC identifies surgical skill with 93% accuracy.

We describe a novel design and application of the vascularized scapular tip flap in the reconstruction of a temporomandibular joint and mandibular defect.

Objectives/Hypothesis: There is a paucity of data showing the perception penalty caused by facial paralysis. Our objective was to measure society's perception of facial paralysis on the characteristic of beauty. We hypothesized that patients with paralysis would be considered by society as less attractive than normals, a difference amplified by smiling. Study Design: Randomized controlled experiment. Methods: Forty subjects viewed photographs of normal and paralyzed faces. They rated attractiveness, identified paralysis if present, its severity, and the feature most affected. Results: There were significant differences in attractiveness scores for normal and paralyzed faces (Wilcoxon rank sum test, z = 16.912; P < .001). A mixed effects regression model was used to explain differences in the scores. The fixed portion of the model shows paralyzed faces were 1 standard deviation less attractive than normal faces. Smiling increased attractiveness for normals (constant, 5.9; smile effect, 0.735; P < .001). The smile × paralysis interaction term was −0.892; P < .001, but not significantly different from the smile term (χ2(1) = 0.87; P = .352). The random effects model showed an intersubject rating variability of 1.32. Conclusions: The attractiveness penalty imposed by facial paralysis is significant, with paralyzed faces considered markedly less attractive than normals. However, the ratings did not change significantly when patients smiled, despite the increased asymmetry that occurs through smiling. Observers were moderately good at identifying the presence of facial paralysis, but less good at distinguishing side of involvement. These results have important implications for patient counseling and management of facial paralysis patients in an evidence-based manner.

Objective To determine if clinical data and Nasal Obstruction Symptom Evaluation (NOSE) scores can be used to identify patients at risk for obstructive sleep apnea (OSA). Design Intake surveys using the NOSE, Epworth Sleepiness Scale (ESS), and Snore Outcomes Scale (SOS) were administered to new patients visiting a facial plastic surgery practice and a rhinology practice. Setting An academic facial plastic surgery practice and an academic rhinology practice. Patients New patients to both practices. Main Outcome Measures NOSE score and presence of septal deviation. Results The odds ratio (OR) for an ESS score higher than 10 was 2.98 (95% confidence interval [CI], 1.17-7.57) when snoring was present; 5.5 (95% CI, 1.35-22.58) when the NOSE score was 10 or higher; and 3.3 (95% CI, 0.98-11.0) when a deviated septum was found on clinical examination. The probability of an elevated ESS score was 88% when all 3 factors were present and 56% when the NOSE score was not elevated. Receiver operating characteristic analysis with predictors “snore” and NOSE score of 10 or higher had an area under the curve of 0.72. With a probability cutoff of 0.5, the sensitivity was 30%, and the specificity 90%. Conclusions Sinonasal surgery is among the most common outpatient procedures performed in the United States each year. Many patients undergoing sinonasal surgery have undiagnosed OSA or nasal obstruction, a known risk factor for OSA. Patients with OSA have unique perioperative needs. In patients with nasal obstruction, a deviated septum, and/or snoring, there is an association between the NOSE score and the ESS score. The NOSE survey may serve as a simple screening instrument instead of the ESS for patients at risk for undiagnosed OSA and special perioperative needs.

Objective To describe a minimally invasive approach of the temporalis tendon transposition technique for dynamic reanimation in patients with long-standing facial paralysis. Methods We report a case series of 17 consecutive patients with facial paralysis who underwent minimally invasive temporalis tendon transposition surgery for dynamic facial reanimation between January 1, 2006, and December 31, 2008. The minimally invasive technique is described. Preoperative and postoperative records, photographs, and videos were reviewed for feasibility of the technique, symmetry, oral competence, and dynamic oral commissure movement. Results All the patients tolerated the procedure well, and none developed procedure-related complications. All the patients achieved improved symmetry at rest and voluntary motion of the oral commissure. In all the patients, the temporalis tendon was transposed to the modiolus without the need for fascial extension or lengthening myoplasty. Conclusions The temporalis tendon can be transposed for immediate dynamic reanimation of the paralyzed lower face using a minimally invasive approach. This procedure involves a single small incision and minimal dissection, with no major osteotomies. Acquisition of desired facial movement requires intensive physiotherapy and a motivated patient.

In the context of minimally invasive surgery, clinical risks are highly associated with surgeons' skill in manipulating surgical tools and their knowledge of the closed anatomy. A quantitative surgical skill assessment can reduce faulty procedures and prevent some surgical risks. In this paper focusing on sinus surgery, we present two methods to identify both skill level and task type by recording motion data of surgical tools as well as the surgeon's eye gaze location on the screen. We generate a total of 14 discrete Hidden Markov Models for seven surgical tasks at both expert and novice levels using a repeated k-fold evaluation method. The dataset contains 95 expert and 139 novice trials of surgery over a cadaver. The results reveal two insights: eye-gaze data contains skill related structures; and adding this info to the surgical tool motion data improves skill assessment by 13.2% and 5.3% for expert and novice levels, respectively. The proposed system quantifies surgeon's skill level with an accuracy of 82.5% and surgical task type of 77.8%.

Objectives: Introduce a novel method for objectively evaluating attentional bias to peripheral facial deformities using an established metric of attention. Methods: The SMI eye-tracker system (SensoMotoric Inc., Boston, MA) was used to record the eye movement patterns, called scanpaths, of eight naive observers gazing at pictures of faces with or without peripheral surgical deformities. The scanpaths of observers gazing on those novel faces were compared, and the fixation durations for different facial regions were compared between faces. Results: There were statistically significant differences in the mean fixation times between the faces considered normal and those considered abnormal (those with an obvious defect). When multivariate analysis of variance was performed with dependent variables total fixation time, fixation time in central triangle, and fixation time in the defect region and the independent variable face, all four tests were highly statistically significant. When univariate analysis of variance was performed to test the hypothesis that defect fixation times varied by face, the results were highly statistically significant (F = 8.79, P = .0003). Conclusions: Observers gazing on faces typically focus their attention on discriminating features, such as eyes, nose, and mouth. The well-established method of eye movement recordings was applied in a novel way to provide quantitative data showing changes in observer gaze patterns to focus on deformities. These gaze patterns are a direct reflection of observer attention. This is the first objective method to quantify the amount of distraction caused by peripheral facial deformities and may provide insight into the perception of facial deformity. Laryngoscope, 119:459–465, 2009

Article-at-a-Glance Background Clinical communities are an emerging approach to quality improvement (QI) to which several large-scale projects have attributed some success. In 2011 the Armstrong Institute for Patient Safety and Quality established clinical communities as a core strategy to connect frontline providers from six different hospitals to improve quality of care, patient safety, and value across the health system. Clinical Communities Fourteen clinical communities that presented great opportunity for improvement were established. A community could focus on a clinical area, a patient population, a group, a process, a safety-related issue, or nearly any health care issue. The collaborative spirit of the communities embraced interdisciplinary membership and representation from each hospital in each community. Communities engaged in team-building activities and facilitated discussions, met monthly, and were encouraged to meet in person to develop relationships and build trust. After a community was established, patients and families were invited to join and share their perspectives and experiences. Enabling Structures The clinical community structure provided clinicians access to resources, such as technical experts and safety and QI researchers, that were not easily otherwise accessible or available. Communities convened clinicians from each hospital to consider safety problems and their resolution and share learning with workplace peers and local unit safety teams. Conclusion The clinical communities engaged 195 clinicians from across the health system in QI projects and peer learning. Challenges included limited financial support and time for clinicians, timely access to data, limited resources from the health system, and not enough time with improvement experts.