Health Disparities Research in Facial Plastic and Reconstructive Surgery: A Scoping Review.

OBJECTIVE: Health disparities contribute significantly to disease, health outcomes, and access to care. Little is known about the state of health disparities in facial plastic and reconstructive surgery (FPRS). This scoping review aims to synthesize the existing disparities research in FPRS and guide future disparities-related efforts. DATA SOURCES: PubMed, Embase, Web of Science. REVIEW METHODS: We conducted a scoping review in adherence with the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews checklist. Our search included all years through March 03, 2023. All peer-reviewed primary literature of any design related to disparities in FPRS was eligible for inclusion. RESULTS: Of the 12283 unique abstracts identified, 215 studies underwent full-text review, and 108 remained for final review. The most frequently examined topics were cleft lip and palate (40.7%), facial trauma (29.6%), and gender affirmation (9.3%). There was limited coverage of other areas. Consideration of race/ethnicity (68.5%), socioeconomic status (65.7%), and gender/sex (40.7%) were most common. Social capital (0%), religion, occupation, and features of relationships were least discussed (0.01% each). The majority of studies were published after 2018 (59.2%) and were of nonprospective designs (95.4%). Most studies focused on disparity detection (80.6%) and few focused on understanding (13.9%) or reducing disparities (0.06%). CONCLUSION: This study captures the existing literature on health disparities in FPRS. Studies are concentrated in a few areas of FPRS and are primarily in the detecting phase of public health research. Our review highlights several gaps and opportunities for future disparities-related focus.

Perceptions and Understanding of Transgender Patient Care: A Survey of Practicing Facial Plastic Surgeons.

Transgender individuals face significant health disparities including deficiencies in physician education, knowledge, and comfort with care. The objective of this study was to determine the perceptions, practice patterns, and familiarity of facial plastic surgeons with transgender health care. An anonymous questionnaire was sent to facial plastic surgeons within the American Academy of Facial Plastic and Reconstructive Surgery list-serve. Primary datapoints included participant characteristics, transgender-related experience, and educational goals. Of the 66 facial plastic surgeons surveyed, 49% had treated 1 to 10 transgender patients during their career, and 70% were actively treating at least 1 transgender patient. The number of patients treated and surgeries performed was significantly associated with self-perceived competence, comfort counseling on gender-affirming surgeries, discussing gender identity, asking preferred pronouns, and a desire to learn more about transgender care. Most participants (61%) obtained transgender care training through real-world experience, with only 18% receiving formal training in residency or fellowship. In total, 50% of respondents believe transgender care training among facial plastic surgeons is inadequate and 60% support its incorporation into residency/fellowship curricula. Increased awareness is needed to address the disparities experienced by transgender patients. Many facial plastic surgeons desire to learn more and support incorporating transgender care into training. Understanding the current state of transgender care can assist the facial plastic community in promoting education that strengthens physicians' ability to deliver competent care that addresses the inequities faced by this diverse group.

The Changing Face of America.

The US population increases yearly and by 2050, experts predict the US population will be greater than 430 million. As the population has grown, it has diversified and includes the largest percentage of multiethnic Americans to date. Accessibility and popularity of aesthetic surgery also have increased. Approaches to rhinoplasty have evolved from a concept of cultural and ethnic transformation to concepts of ethnic preservation, with the goal of preserving features while harmonizing the nose with the rest of the face. To achieve this goal thoughtful consultation and consideration of the patient's self-defined ethnicity is paramount.

Facial Plastic Surgery Controversies: Keloids.

There are more than 11 million people in the world affected with keloids. Nevertheless, there is a lack of agreement in keloid management. Moreover, keloid research has left gaps in the understanding of its pathogenesis. Six questions are answered by 3 clinical scientists in an attempt to address common keloid controversies.

Creation of a head and neck Keloid quality of life questionnaire.

OBJECTIVES: Create a head-and-neck keloid quality of life (QOL) questionnaire. Demonstrate the reliability of the keloid-specific QOL scale according to test-retest and internal consistency standards. STUDY DESIGN: Prospective cohort study. METHODS: Patients presenting to a keloid clinic in a tertiary referral institution between April 2012 and February 2013 were enrolled on their first visit. They were administered a questionnaire assessing demographics and a 21-item Likert keloid-specific survey assessing symptomatology, self-esteem, social functioning, and therapeutic motivation during their first three visits. Reliability of the keloid questionnaire was assessed for internal consistency (Cronbach's alpha) and test-retest correlations. Patients were treated with Kenalog steroid injections at each visit. The 126-point total score from the questionnaire was then compared to each subscale (physical symptoms, self-esteem, social function, and medical motivation) using a Pearson coefficient. RESULTS: The keloid QOL questionnaire showed a Cronbach's alpha of 0.87 for the overall questionnaire and ranged from 0.66 to 0.86 for individual questions. The test-retest Pearson's R was 0.70 between visits 1 and 2 and 0.77 between visits 2 and 3. The Pearson correlation between symptoms, self-esteem, social functioning, and medical motivation subscales and the overall scale were 0.77, 0.73, 0.72, and 0.57, respectively. CONCLUSION: This head and neck keloid-specific QOL questionnaire proved to be a reproducible method of reliably assessing QOL burden on patients with head and neck keloids. LEVEL OF EVIDENCE: N/A.

Contemporary management of traumatic fractures of the frontal sinus.

This article discusses the classic and contemporary management strategies for treating frontal sinus fractures. The goals of management of frontal sinus fractures are to create a safe sinus by minimizing the likelihood of early and late complications while preserving the function of the sinus and maintaining the cosmetic appearance of the upper face. The assessment and classification of patients with frontal sinus injuries, their management, and the treatment of complications are reviewed.

Repairing angle of the mandible fractures with a strut plate.

IMPORTANCE: Despite multiple fixation techniques, the optimal method of repairing mandibular angle fractures remains controversial. OBJECTIVE: To evaluate the outcomes when using a 3-dimensional, curved strut plate in repair of angle of the mandible fractures. DESIGN: Retrospective cohort study. SETTING: Level I trauma center at an academic institution in Harris County, Texas. PARTICIPANTS: Patients with diagnostic codes involving angle of the mandible fractures that were repaired by the otolaryngology-head and neck surgery service from February 1, 2006, through February 28, 2011. EXPOSURE: Open reduction internal fixation using either a 3-dimensional curved strut plate or any other type of repair technique for angle of the mandible fractures. MAIN OUTCOMES AND MEASURES: Complication rates, postoperative complaints, and operative characteristics. RESULTS: Ninety patients underwent qualifying procedures during the study period. A total of 68 fractures (76%) were repaired using the 3-dimensional curved strut plate and 22 (24%) were repaired using other methods. The revision surgery rate was 10% for the strut plate group (7 patients) and 14% for the non-strut plate group (3 patients), with no significant differences in rates of infection (3 [4%] vs 2 [9%]), dehiscence (4 [6%] vs 2 [9%]), malunion (1 [1%] vs 2 [9%]), nonunion (3 [4%] vs 0), hardware failure (1 [1%] vs 1 [5%]), malocclusion (2 [3%] vs 2 [9%]), and injury to the inferior alveolar nerve (1 [1%] vs 1 [5%]). The most common postoperative complaints were pain (13 [19%] vs 6 [27%]), followed by numbness (5 [7%] vs 2 [9%]), trismus (4 [6%] vs 3 [14%]), edema (3 [4%] vs 3 [14%]), and bite deformity (2 [3%] vs 2 [9%]), with a mean (range) follow-up time of 54.7 (2-355) days for the strut plate group vs 46.8 (8-308) days for the non-strut plate group. CONCLUSIONS AND RELEVANCE: The 3-dimensional curved strut plate is an effective treatment modality for angle fractures, with comparable infection rates, low incidence of alveolar nerve injury, and trends for decreased length of operation, complications, and infections compared with other techniques.

Current concepts in the etiology and treatment of keloids.

Keloids are benign, fibroproliferative growths that occur as a result of dermal injury in ~15% of the population. They are characterized by their extension beyond the confines of the original injury and often present with pain and pruritus. Additionally, these growths may result in cosmetic deformities and contribute to significant emotional distress. It is thought that keloids form as a result of aberrancies in the normal wound-healing process, which is complex and involves an elegant interplay between multiple cell types, cytokines, and proteins. The exact etiology is unknown, but significant research efforts have been made. These efforts have revealed that various cell types in keloids are either hyperresponsive and/or overproductive of various growth factors. Additionally, keloid cell types respond differently to mechanical strain than skin cells in patients who do not form keloids. This lack of understanding of keloid pathophysiology has left the care provider with a lack of a single definitive treatment strategy. Instead, a multitude of therapies exist ranging from surgery to injectables to lasers and any combination thereof. This purpose of this article is to highlight our current knowledge and emerging scientific understanding of keloid pathology and the current management strategies.

Tip nuances for the nose of African descent.

Patients of African descent are seeking rhinoplasties today more than ever. As a result, the rhinoplasty surgeon must be aware of the ethnic, cultural, anatomic, and surgical issues pertaining to this patient population. In this article, the nuances of rhinoplasty as it pertains to the nasal tip in patients of African descent are discussed.

Increased in vitro differentiation of fibrocytes from keloid patients is inhibited by serum amyloid P.

Keloid scarring is a form of fibroproliferative dermal wound healing characterized by growth beyond the confines of the original wound. Fibrocytes, derived from peripheral blood mononuclear cells and inhibited by serum amyloid P (SAP), have been linked to other fibroproliferative diseases. We hypothesized that peripheral blood mononuclear cells of keloid formers have a higher propensity to differentiate into fibrocytes and are more resistant to the effects of SAP. To test this hypothesis, plasma was isolated from peripheral blood samples of keloid (n = 10) and age/sex/race-matched control (n = 10) subjects, and SAP levels were measured by enzyme-linked immunosorbent assay. Equal numbers of peripheral blood mononuclear cells were also isolated from these samples and fibrocytes cultured in serum-free media with increasing concentrations of SAP. No difference in plasma SAP levels was found between keloid and control subjects. In the absence of SAP, keloid patients (n = 7) had almost 20 times more fibrocytes than controls (n = 7) in culture (median: 1,087 cells vs. 60 cells; p < 0.01). SAP inhibited the differentiation of keloid fibrocytes in vitro, although a higher concentration of SAP was needed when compared with controls (20 µg/mL keloid vs. 5 µg/mL control). Fibrocytes may contribute to the pathogenesis of keloids, and SAP has potential as a therapeutic agent in the prevention of these lesions.

Ethnic trends in facial plastic surgery.

The appearance of patients seeking cosmetic surgery is changing to reflect our multicultural society. Integral to addressing the desires of a cross-cultural patient population is an understanding of one's perception of race, ethnicity, and culture. Race is an objective description, whereas ethnicity is a subjective description of a person's social group. Culture, on the other hand, defines the behaviors, beliefs, and values of a group. How a person perceives their place within these groups affects his or her self-image and approach to cosmetic surgery. These cultural perceptions are important, as patients of Asian, Hispanic, and African descent make up the fastest growing groups that desire cosmetic surgery. Factors contributing to this trend include population growth, especially within multicultural communities, improvements in social status, and increasing disposable income, combined with a positive perception of cosmetic surgery. Surgical philosophies have also changed, shifting from the perspective of racial transformation, defined as the use of a common set of surgical goals for all ethnicities, toward a view of racial preservation, with the goal of preserving one's racial and ethnic features.

The aging African-American face.

With the desire to create a more youthful appearance, patients of all races and ethnicities are increasingly seeking nonsurgical and surgical rejuvenation. In particular, facial rejuvenation procedures have grown significantly within the African-American population. This increase has resulted in a paradigm shift in facial plastic surgery as one considers rejuvenation procedures in those of African descent, as the aging process of various racial groups differs from traditional models. The purpose of this article is to draw attention to the facial features unique to those of African descent and the role these features play in the aging process, taking care to highlight the differences from traditional models of facial aging. In addition, this article will briefly describe the nonsurgical and surgical options for facial rejuvenation taking into consideration the previously discussed facial aging differences and postoperative considerations.

Keloids: pathogenesis, clinical features, and management.

Cutaneous wound healing is a complex response to skin injury. Deregulation of this process can lead to excessive scar formation, as seen in keloids. Keloids are common skin lesions that are difficult to treat and are associated with high recurrence rates despite the large number of available treatment options. With increased knowledge of the disease process and further scientific advancements, future approaches will hopefully improve keloid treatment. In this article, we review the epidemiology, genetic basis, etiology, clinical features, pathogenesis, and management of keloids.

Rhinoplasty: the african american patient.

Over the past three decades, an increasing number of African American patients have undergone rhinoplasty, and many continue to present to surgeons for rhinoplasty evaluation. The reality is that rhinoplasty is no longer an uncommon procedure in the African American population. Most patients desire nasal refinement while preserving their cultural identity. The African American nose has many unique features that have to be appreciated and understood to provide the desired outcome. In this paper, we present an overview of the unique anatomic features of the African American nose, rhinoplasty techniques tailored to this patient population, and complications encountered postoperatively.

HIV-associated facial lipoatrophy: establishment of a validated grading scale.

OBJECTIVE: HIV-associated lipodystrophy is considered a sequela of highly active antiretroviral treatment. We describe the characteristics, possible etiology, and pathophysiology of HIV-associated lipodystrophy and facial lipoatrophy and establish a validated grading scale for HIV-associated facial lipoatrophy using evidence-based techniques. DESIGN/METHODS: A grading scale was designed based on the severity of each patient's facial lipoatrophy. Preoperative photographs of HIV-infected patients seeking treatment for facial lipoatrophy and control subjects were reviewed by physicians qualified in facial plastic surgery. With use of the devised grading scale, each patient was assigned a severity score. These scores were then compared for interrater variability, and the distribution of scores was analyzed. RESULTS: Preoperative photographs of 39 HIV-infected individuals with facial lipoatrophy and 6 normal subjects were obtained and reviewed. All patients were males. A Cohen kappa of 0.73 was calculated, and there was a fairly equal distribution of all severity grades throughout the 39 patients. CONCLUSION: HIV-associated facial lipoatrophy is a major stigma for HIV patients that can have dramatic effects on their self-esteem, social habits, and medication compliance. This current study introduces a validated evidence-based grading scale that can be implemented to categorize disease severity. Using this scale will hopefully generate improved treatment plans directed to each patient, which should produce enhanced postoperative results.

Botulinum toxin to improve facial wound healing: A prospective, blinded, placebo-controlled study.

OBJECTIVE: To test whether botulinum toxin-induced immobillzation of facial lacerations enhances wound healing and results in less noticeable scars. PATIENTS AND METHODS: In this blinded, prospective, randomized clinical trial, patients were randomized from February 1, 2002, until January 1, 2004, to botullnum toxin vs placebo injection into the musculature adjacent to the wound within 24 hours after wound closure. Blinded assessment of standardized photographs by experienced facial plastic surgeons using a 10-cm visual analog scale served as the main outcome measure. RESULTS: Thirty-one patients presenting with traumatic forehead lacerations or undergoing elective excisions of forehead masses were included in the study. The overall median visual analog scale score for the botulinum toxin-treated group was 8.9 compared with 7.2 for the placebo group (P=.003), indicating enhanced healing and Improved cosmesis of the experimentally immobilized scars. CONCLUSIONS: Botullnum toxin-induced Immobilization of forehead wounds enhances healing and is suggested for use in selected patients to improve the eventual appearance of the scar.

Preoperative assessment of the aging patient.

The issues related to preoperative evaluation and facial analysis for patients undergoing facial rejuvenation procedures are discussed in this article. A key component of the preoperative evaluation begins with a thorough understanding of the patient's concerns and desires for improvements. Other components of the evaluation should include a detailed assessment of the patient's medical and psychiatric history, informed consent, and photographic documentation. Additionally, we discuss facial changes associated with aging, paying special attention to some of the differences that occur between male and female patients. Different aesthetic scales and their applications in facial plastic surgery are also presented. Finally, we consider the process of facial analysis in the context of common facial plastic procedures including rhytidectomy, blepharoplasty, browlift, and minimally invasive techniques.

Male face-lift.

Middle-aged men represent an emerging group expressing an interest in facial rejuvenation procedures. One must understand the complex differences in motivation, psychosocial factors, and aspects associated with anatomy and facial aging that are unique to men. To maximize postoperative results and increase patient satisfaction, the facial plastic surgeon must adjust perioperative management and surgical techniques when performing a male face-lift.