Transconjunctival Lower Eyelid Blepharoplasty with Volume Augmentation for Correction of the Lower Eyelid and Cheek Junction.

Aesthetic surgical management of the inferior periorbital region should include an approach to volume augmentation of the midface and infraorbital hollow, reduction of fat pseudoherniation in the lower eyelids, and treatment of the overlying skin. A combined approach using volume augmentation with fat grafting, a transconjunctival approach to the lower eyelid fat pads, and conservative management of the lower eyelid skin can produce optimal aesthetic results while minimizing complications. Fat harvest from the thigh and abdominal region allows for ample grafting material to the lateral cheek, midface, and orbital rim. The treatment paradigm is to restore volume optimally while minimizing fat resection in the lower eyelids. Volume augmentation is used to restore youthful contours, as well as to counter deflation and laxity in the periorbital and midfacial regions.

Alloplastic malar implants in aesthetic facial surgery.

PURPOSE OF REVIEW: To examine the recent literature on aesthetic alloplastic malar implants. RECENT FINDINGS: Alloplastic implantation is heavily favored in the oromaxillofacial literature. Recent articles have examined porous polyethylene and silicone implantation. Overall patient satisfaction is high and complications are low. Outcomes are likely comparable with alternative modalities to rejuvenate the face in the appropriate hands. SUMMARY: Alloplastic implantation continues to be a reliable tool for malar augmentation.

Quality of recovery and safety of deep intravenous sedation compared to general anesthesia in facial plastic surgery: A prospective cohort study.

BACKGROUND: Facial plastic surgical procedures are performed under either general anesthesia (GA) or sedation. GA is often associated with post-operative nausea and longer recovery, while deep sedation is thought to greatly facilitate perioperative patient comfort and expedite recovery. The objective of this study was to compare these two anesthetic techniques in a relatively healthy patient population undergoing facial plastic surgery and to discuss optimizing patient safety with a deep sedation technique. METHODS: A non-randomized, prospective cohort study was conducted to evaluate patients undergoing facial plastic surgery with a focus on rhinoplasty under either deep intravenous sedation (DIVS) in an ambulatory surgery center or under GA in a community hospital. Patients were between ages 18-65 and agreed to participate in the study and complete a quality of recovery (QoR-40) survey. Two-tailed Student's t-test was done for numerical data and Chi-squared test for categorical data. RESULTS: Twenty-three patients and 16 patients had surgery under DIVS and GA, respectively. Compared to the GA group, the DIVS group had less post-operative nausea and vomiting (21.7% vs 50%, P = 0.04; 4.3% vs 37.5%; P = 0.004, respectively), shorter emergence time (4 vs 13 min, P < 0.001), and higher QoR-40 scores for almost all the categories except for physical independence. There were no post-operative medical or surgical complications. CONCLUSION: DIVS appeared to be safe in the office-based setting and provided a higher quality recovery after a predominantly rhinoplasty-based practice compared to the GA group. Vigilant monitoring of the patient is crucial for careful titration of sedation to avoid respiratory depression and possible compromise of the surgical result from having to rescue the airway.

The Impact of COVID-19 on Patient Interest in Facial Plastic Surgery.

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic has led to an unforeseen surge in demand for facial plastic surgery (FPS). The objective of this study was to survey patients who pursued cosmetic FPS during COVID-19 to better understand how changes in lifestyle, digital media usage, and their facial self-image influenced their decision to pursue surgery. METHODS: A web-based survey was sent to 150 patients who had undergone FPS at an outpatient clinic between May 1 and July 30, 2020. Questions included changes in patients' lifestyle habits, use of video conferencing and social media, Likert scale ratings of motivational factors to pursue FPS, and changes in perception of their own facial aesthetics during COVID-19. RESULTS: The survey response rate was 41%. Overall increases in video conferencing for social (79% of respondents) and occupational (73%) purposes, and social media usage (82%) were noted. The most commonly cited motivating factors to pursue FPS during COVID-19 were having ample privacy from family, friends, and co-workers (77%) and not requiring extended leave of absence from work (69%) during the postoperative recovery period. Patients were more aware of their nose than any other facial feature during COVID-19 compared to prior. CONCLUSIONS: The popularity of FPS during COVID-19 can be partially attributed to increased usage of video conferencing and social media, digital applications which often accentuate personal and idealized facial aesthetics. As surgeons adjust to increased demand for FPS, a better understanding of patient perspectives and motivations can help optimize doctor-patient relations and the delivery of care.

Perspectives of Facial Plastic Surgeons on Opioid Dependence in Rhinoplasty Patients.

Understanding the perspectives and opinions of facial plastic surgeons on opioid dependence is critical in a national epidemic of opioid overuse. Findings may encourage surgeon education so that facial plastic surgeons may be able to judiciously prescribe opioids, improving patient outcomes and reducing healthcare opioid-related spending. The objective of this study is to understand facial plastic surgeons' perspectives on opioid dependence in rhinoplasty patients. A key secondary objective was to quantify facial plastic surgeons' opioid prescribing patterns. This was a prospective survey study. A nine-question survey was sent to all members of the American Academy of Facial Plastic and Reconstructive Surgery in July of 2018, and analysis of the data was completed in August of 2018. The primary study outcome measurement was surgeon perspectives on opioid dependence. This was measured by an online survey. A total of 164 facial plastic surgeons responded to the survey (response rate: 6.6%). The majority were experienced surgeons in practice for more than 10 years (61.96%) who perform less than five rhinoplasties per week (84.15%). Of the facial plastic surgeons, 89.51% prescribe some variation of opioids following rhinoplasty. Most surgeons believe that opioid dependence is not a problem in rhinoplasty patients (86.96%), but that it is a problem among surgical patients in general (61.11%). The majority (52.45%) of surgeons prescribe between 11 and 25 tablets of opioids following rhinoplasty, with 25.17% of surgeons prescribing > 25 tablets of opioids. Facial plastic surgeons do not believe opioid dependence to be a problem among rhinoplasty patients. Resultantly, many facial plastic surgeons can prescribe more than 25 tables of opioids following rhinoplasty. The findings suggest that facial plastic surgeons may require further education and complete more research regarding opioid dependence among the rhinoplasty population. Additionally, the findings are important for health policy in that they encourage the creation of rhinoplasty specific opioid prescription guidelines.

Patient assessment of psychosocial dysfunction following nasal reconstruction.

BACKGROUND: Postoperative psychosocial distress is a critical aspect of surgery, particularly in aesthetically sensitive areas. In this study, the authors assess the level of psychosocial distress associated with nasal reconstruction. The authors also compare postoperative distress levels associated with different reconstructive techniques throughout the healing process. METHODS: The authors conducted a prospective study of patients undergoing nasal reconstruction following excision of cutaneous malignancy. The main outcome measure was the Derriford Appearance Scale 24, a measure of psychosocial distress. The Derriford Appearance Scale was administered at preoperative assessment, 1 < x < 4 weeks, 4 ≤ x < 12 weeks, and x ≥ 12 weeks. The entire cohort was analyzed with respect to distress levels before and after surgery. Reconstructions were categorized as interpolated, local tissue, or full-thickness skin graft. Analyses were performed for reconstruction type, patient, and defect data. RESULTS: Fifty-nine patients were enrolled. Reconstructions included 14 interpolated flaps, 17 local tissue flaps, and 28 full-thickness skin grafts. For the entire cohort, distress levels were significantly higher at the first postoperative visit (p < 0.05), with normalization at subsequent follow-up evaluations. At the first assessment, the interpolated flap group had significantly higher levels of distress in comparison with the full-thickness skin graft group (p < 0.05). At late follow-up, levels of distress were equivalent. CONCLUSIONS: Nasal reconstruction is associated with short-term increases in psychosocial distress that corrects by approximately 12 weeks after surgery. Interpolated flaps cause significantly higher distress at early assessment. Distress levels at late follow-up appear to be equivalent to those following a full-thickness skin graft despite larger and deeper initial defects. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, II.

Key issues in nasal reconstruction.

PURPOSE OF REVIEW: To review recent research and advances in nasal reconstruction over the last 12 months. RECENT FINDINGS: Although the major principles of replacing surgically ablated tissues with like tissue and respecting the nasal aesthetic subunits have not changed, recent advances in nasal reconstruction have focused on producing superior aesthetic and functional results, while minimizing deformity and morbidity. Future directions may also include the application of allotransplantation and tissue engineering. SUMMARY: A large variety of sophisticated techniques continue to emerge with the goal of producing increasingly natural results for patients undergoing nasal reconstruction.

Undergraduate otolaryngology education in Canadian medical schools.

OBJECTIVES: To examine the quantity and nature of undergraduate otolaryngology instruction in the Canadian medical school system and to present the management of the undergraduate otolaryngology curriculum at the University of Toronto medical school with a yearly enrolment of 224 students. STUDY DESIGN: Survey questionnaire and narrative description. METHODS: A structured one-page survey was administered to the education directors of all 16 Canadian medical schools. The administration of core learning material, scheduling, patient encounter logging, and student and instructor evaluations with computerized, on-line systems at the University of Toronto was described. RESULTS: Rotations in otolaryngology were highly variable across medical schools. Mandatory rotations in otolaryngology were identified in only 6 of the 16 undergraduate curricula. The average length of clinical experience in schools with mandatory rotations was 4.6 days. CONCLUSIONS: The majority of Canadian medical graduates complete their undergraduate training with minimal clinical experience in otolaryngology. There is a clear discrepancy between the quantity and perceived need for training. To provide a thorough and equitable exposure to otolaryngology, a curriculum with standardized lectures and evaluation procedures is required.

Retrospective review of 242 consecutive patients treated surgically for parotid gland tumours.

OBJECTIVE: To compare the trends and specific outcomes of patients treated surgically for parotid neoplasms between 1994 and 2005 with those of patients who were treated between 1985 and 1993 at Mount Sinai Hospital in Toronto and to identify preoperative indicators of malignancy. METHODS: A retrospective chart review was performed that included all patients who received treatment from 1994 to 2005 at Mount Sinai Hospital. The results of this review was compared with those of another group at the same institution. RESULTS: The study included 242 patients. Of these patients, 183 (75.6%) had benign neoplasms, 51 (21.1%) had malignant neoplasms, and 8 (3.3%) had inflammatory or lymphatic lesions. The most common associated symptoms were swelling (17.4%) and pain (16.5%). Only 5.8% of patients presented with facial weakness; however, the likelihood of malignancy was high (64.3%). Total parotidectomy was reserved for 26.4% of patients; the majority (68.2%) received a subtotal parotidectomy. Common postoperative complications included temporary facial nerve palsy (23.6%), Frey syndrome (12.4%), and salivary fistula (5.0%). Analysis of the correlation between fine-needle aspiration and final cytology revealed that fine-needle aspiration sensitivity and specificity were 60.0% and 96.1%, respectively. Comparison of these results with the other study at our institution revealed no significant differences in patient predictors or outcomes. CONCLUSIONS: These results were compared with those of a previous study conducted at the same institution between 1985 and 1993. There was no significant deviation from former trends. The presenting symptoms of facial nerve weakness and lymphadenopathy were found to be strong indicators of malignant disease. Facial pain was found not to be a reliable prognostic feature for malignancy.

The ten-year rule revisited: accuracy of clinicians' estimates of life expectancy in patients with localized prostate cancer.

OBJECTIVES: To determine the accuracy of clinicians' predictions of life expectancy in patients with localized prostate cancer, when provided with information about age and comorbidity, and to determine whether life expectancy estimates predict the choice of initial treatment. METHODS: A survey was sent by facsimile to 191 Canadian urologists and radiation oncologists asking them to estimate the life expectancy and choose the initial therapy (radical prostatectomy, radiation, or watchful waiting) for 18 patient scenarios: two prostate cancer scenarios, each with three ages and three levels of comorbidity. RESULTS: Life expectancy estimates were accurate within 1 year of the projections of a Markov model for 31% of the clinicians' responses and accurate within 3 years for 67% of the responses. The average prediction error ranged from 2.4 to 5.2 years. The life expectancy was correctly estimated as being greater than or less than 10 years in 82% of responses. Ten years was the minimal life expectancy for recommending surgery and within the range (5 to 15 years) in which radiation was recommended. CONCLUSIONS: Clinicians can use age and comorbidity to predict the life expectancy of patients with localized prostate cancer with a modest degree of overall accuracy, but with sufficient accuracy to use the "10-year rule." Life expectancy estimates are strongly associated with treatment choice. The appropriateness of the 10-year rule remains to be determined.