State of the Evidence for Preservation Rhinoplasty: A Systematic Review.

Preservation rhinoplasty encompasses a number of techniques that minimize disruption of the native cartilaginous and soft tissue nasal architecture. These techniques have gained popularity resulting in an increase in publications relevant to preservation rhinoplasty. However, many studies that present patient outcomes are of low-level evidence and do not incorporate validated patient-reported outcome measures. While these studies do consistently report positive outcomes, there are few high-level comparative studies that support the theoretical benefits of preservation relative to structural rhinoplasty. As contemporary preservation rhinoplasty techniques will continue to evolve and become incorporated into clinical practice, there will be the need for parallel emphasis on robust clinical studies to delineate the value of these methods.

The single-stage melolabial flap for internal lining of full thickness defects of the nasal ala.

BACKGROUND: Full-thickness defects of the nasal ala necessitate composite repair of the nasal lining, cartilage and soft tissue envelope. Repair of the nasal lining is particularly challenging due to access and geometry of this area. OBJECTIVE: To evaluate the melolabial flap as a single stage operation for repair of full-thickness nasal ala defects. METHODS: Retrospective study of seven adult patients with full-thickness nasal ala defects who underwent melolabial flap repair. Complications and operative technique were recorded and described. RESULTS: Of the seven patients who underwent melolabial flap repair, each had excellent coverage of the defect postoperatively. There were two cases of mild ipsilateral congestion, and no revision procedures performed. CONCLUSION: The melolabial flap is a versatile reconstructive option for repair of the internal lining of the nasal ala, and in our series there were no significant complications or revision procedures performed.

Difference in Perception of Nasal Aesthetic Appearance Between Surgeons and Rhinoplasty Patients: A Single-Center Perspective.

BACKGROUND: Patient satisfaction is an essential outcome measure after a rhinoplasty. Yet it is not known whether the opinions of rhinoplasty patients and surgeons on nasal aesthetic appearance differ. OBJECTIVES: The aim of this study was to determine the differences between patients and surgeons in their perception of nasal aesthetic appearance. METHODS: A retrospective cohort of 300 patients seen in consultation for cosmetic, functional, or combined cosmetic and functional rhinoplasty at a single tertiary care center from June 2017 to June 2020 was studied. Based on preoperative patient images, 6 surgeons with varying levels of expertise assessed nasal aesthetics utilizing a modified Standardized Cosmesis and Health Nasal Outcomes Survey for nasal cosmesis (SCHNOS-C). These scores were then compared to the patient-reported SCHNOS-C scores. RESULTS: The cosmetic, functional, and combined subgroups consisted of 100 patients each. The mean [standard deviation] age was 35.4 [13.7] years and 64% were women. The modified SCHNOS-C scores were well-correlated among the 6 surgeons but showed only weak correlations of 0.07 to 0.20 between patient-reported scores and scores assessed by the surgeons. Compared with the surgeon's scores, patients in the cosmetic subgroup perceived their nasal aesthetic problems to be more severe whereas the those in the functional subgroup perceived their nasal aesthetic problems to be milder compared with the surgeons' assessment. CONCLUSIONS: Our findings suggest that patients and surgeons perceive nasal cosmesis differently. This difference should be considered carefully when planning rhinoplasty or assessing its outcome.

Synkinesis and Communicative Participation.

Background: Facial palsy (FP) impacts verbal and nonverbal communication, but the effect of synkinesis on communicative ability is unknown. Objective: Among patients with nonflaccid FP, or synkinesis, is there a correlation between disease-specific quality-of-life and communicative ability or dysfunction? Methods: Retrospective study of a series of adult patients with unilateral synkinesis. Subjects were evaluated using the Communicative Participation Item Bank (CPIB) Short Form, Facial Clinimetric Evaluation (FaCE) scale, and Synkinesis Assessment Questionnaire (SAQ). Associations between these scales were evaluated by computing Pearson correlation coefficients. Results: A total of 69 confirmed synkinesis patients were included. Synkinesis patient mean (standard deviation) CPIB score was 20.68 (±8.27; range of scale 0-30), indicative of communication restriction. A strong correlation was observed between total CPIB and FaCE scores (r = 0.66), indicating patients with synkinesis who reported better facial function also reported greater communicative ability. There was a weak correlation between CPIB and SAQ scores (r = -0.27). Conclusion: Synkinesis is associated with significant deficits in communicative ability. Communication restrictions track strongly with the FaCE scale.

Dual Nerve Transfer for Facial Reanimation.

This article describes a method of performing a dual nerve transfer procedure and provides illustrative cases for analysis and discussion. Clinical indications, technical pearls, and pitfalls are discussed. Dual nerve transfer for facial reanimation efficiently combines the strengths of the hypoglossal and masseteric nerve transfers and builds on existing nerve transfer techniques.

Risk of Venous Thromboembolism Following Rhinoplasty.

BACKGROUND: Although prior studies have identified a low risk of venous thromboembolism (VTE) in rhinoplasty, these studies are limited by small samples and associated risk factors remain unknown. OBJECTIVES: The aim of this study was to discern the incidence of VTE following rhinoplasty in a large patient population through analysis of a nationwide insurance claims database. METHODS: This study involved a population-based retrospective analysis of insurance claims made by patients who underwent rhinoplasty between 2007 and 2016. Established risk factors for VTE, demographic data, procedural details, and absolute incidence of VTE were collected. RESULTS: We identified a total of 55,287 patients who underwent rhinoplasty from 2007 to 2016. Mean age [standard error of the mean] was 38.74 [0.06] years (range, 18-74 years), and 54% were female. The overall incidence of VTE was 111, of which 70 were DVT and 41 were PE. From multivariate regression analysis, previous VTE (odds ratio [OR], 52.8; 95% confidence interval [CI], 35.2-78.6; P < 0.0001), peripherally inserted central catheter (PICC)/central line placement (OR, 19.6; 95% CI, 9.8-153; P < 0.05), rib graft (OR, 4.6; 95% CI, 2.3-8.5; P < 0.0001), age 41 to 60 years (OR, 2.65; 95% CI, 1.7-4.3; P < 0.01), inflammatory bowel disease (IBD) (OR, 2.6; 95% CI, 1.0-5.5; P < 0.05), and age 61 to 74 years (OR, 2.4; 95% CI, 1.2-4.8; P < 0.05) were associated with an increased risk of VTE. CONCLUSIONS: We demonstrate a low overall incidence of VTE in rhinoplasty patients. Previous VTE, PICC/central line, advancing age, IBD, and intraoperative rib graft harvest were most strongly associated with VTE in this population cohort.

Using Nasal Self-Esteem to Predict Revision in Cosmetic Rhinoplasty.

BACKGROUND: It would be useful if existing tools or outcomes measures could predict which patients are at greater risk of revision surgery following rhinoplasty. OBJECTIVES: The authors sought to determine if a single question assessing nasal self-esteem could be utilized to predict which patients are at greatest risk of revision surgery following rhinoplasty. METHODS: The authors conducted a retrospective chart review of 148 patients who underwent cosmetic rhinoplasty. Results of pre- and postoperative Standardized Cosmesis and Health Nasal Outcomes Survey questionnaires and rates of revision or patient-initiated revision discussions (RD) were collected. Patients were stratified based on answers to Standardized Cosmesis and Health Nasal Outcomes Survey question 5 (SQ5), "Decreased mood and self-esteem due to my nose." RESULTS: Of the 148 patients included in the analysis, 72.9% were women, and the mean age was 30.9 (15-59, standard deviation = 10.3) years. Those patients who selected 4 or 5 on SQ5 had an overall revision rate of 16.7% and 18.8%, respectively, and a RD rate of 27.8% and 31.25%, respectively. Those patients who selected 0 through 3 on SQ5 had an overall revision rate of 0% and an overall RD rate of 10.4%. Only SQ5 was predictive of revision and RD on logistic regression analysis (P = 0.0484 and P = 0.0257) after Bonferroni correction. CONCLUSIONS: SQ5 appears to offer a useful adjunct to guide surgical management of the cosmetic rhinoplasty patient. Those patients who reported worse nasal self-esteem and associated mood preoperatively were more likely to request and undergo revision.

How do we teach surgical residents in the COVID-19 era?

OBJECTIVE: In response to ongoing concerns regarding transmission of the novel coronavirus (COVID-19), surgical practice has changed for the foreseeable future. Practice guidelines recommend only urgent or emergent surgical procedures be performed to minimize viral transmission. This effectively limits standard training and practice for surgical residents. The purpose of this article is to describe opportunities in surgical simulation, and highlights the challenges associated with training in the COVID-19 era. DESIGN: This is a perspective summarizing the potential role of surgical simulation to target training gaps caused by decreased surgical caseloads. CONCLUSIONS: This manuscript concisely discusses simulation options available to training programs, including the novel concept of "surgical kits." These kits include all instruments necessary to simulate a procedure at home, effectively pairing safety and utility.

The Bilobe Flap for Nasal Reconstruction.

Repair of nasal defects is technically challenging due to inelastic nasal skin and unforgiving nasal geometry. The bilobe flap is a double transposition flap that can transpose skin from cephalad to caudad to repair defects of the lower third of the nose. However, pincushioning may complicate this flap, yielding untoward aesthetic outcomes. We review our single surgeon series of patients who underwent bilobe flap reconstruction of nasal defects, and describe our surgical technique to minimize pincushioning and poor aesthetic outcomes. This was a retrospective chart review of patients who underwent bilobe flap reconstruction of nasal defects at a tertiary referral facial plastic and reconstructive surgery clinic between January 1, 2010 and February 12, 2019. All postoperative clinic notes were analyzed for complications, reports of unfavorable cosmetic outcome, and rates of revision procedures. Surgical technique is described. In the analysis, 125 patients were included, of whom 84 (67%) patients were women, and the mean (standard deviation) age was 60.7 (12.5) years. Complications were reported in 20 (16%) patients, including scars, pincushioning, and nasal obstruction. Five patients underwent revision surgery (4%), including scar revision and z-plasty. Pincushioning was reported in four patients (3.2%), of whom three underwent scar revision procedures. One patient had alar notching requiring correction. There was no statistically significant association between ear cartilage graft and complications (p = 0.84) or requirement of intervention (p = 1.0). Univariate and multivariate logistic regression did not show statistically significant association between size of the defect and the presence of complications (p > 0.05). The bilobe flap is an excellent transposition flap for the repair of small nasal tip defects. By adequately thinning the transposition flap of excess subcutaneous tissue prior to inset, rates of poor aesthetic outcomes, revision procedures, and pincushioning are minimized.

Evidenced-Based Practice Among Trainees: A Survey on Facial Trauma Wound Management.

OBJECTIVE: Assess whether facial trauma wound care and antibiotic use recommendations are guided by evidence-based practice (EBP) or practice patterns, and investigate strategies to improve EBP adoption among surgical trainees. DESIGN: We conducted a survey of all trainees who manage facial trauma (general surgery, emergency medicine, plastic surgery, otolaryngology) to assess clinical knowledge and sources of treatment recommendations. Clinical questions were based on Oxford Center for Evidence-Based Medicine Level 1 or 2 evidence. We measured internal validity of questions using Cronbach's α. Results were weight-adjusted for nonresponse and then analyzed using Welch t test and descriptive statistics. STUDY SETTING: Stanford Hospital and Clinics, a Level I trauma center. RESULTS: Response rate was 50.3% overall (78/155). For recommendations on facial trauma wound and antibiotic use, nonspecialty junior residents most frequently relied on their own senior or specialty residents (79.1%); nonspecialty senior residents relied on specialty residents (67.9%). Specialty junior residents most often relied on their own senior residents (51.0%), the majority of whom made recommendations based on their own knowledge (73.2%). Questions assessing EBP knowledge had Cronbach's α of 0.98; response accuracy was similar between specialty and nonspecialty residents (54.6% vs 55.5%, p = 0.96). When provided recommendations that conflict with EBP, both nonspecialty and specialty residents more frequently followed recommendations rather than EBP; junior residents reported doing so to avoid conflict with superiors. Total 92.6% of surveyed residents felt cross-departmental EBP guidelines would improve patient care. CONCLUSIONS: Facial trauma wound care and antibiotic recommendations disseminate down seniority and from craniofacial specialty to nonspecialty residents, yet knowledge of EBP among senior specialty and nonspecialty residents was weak. EBP may be difficult to adopt in the absence of consensus society guidelines. To address this gap, we published a review of EBP for facial trauma and plan to update our trauma manual with cross-departmental guidelines to facilitate EBP adoption among trainees.

Facial Paralysis and Communicative Participation: The Importance of Facial Symmetry at Rest.

OBJECTIVE: There is a paucity of research devoted to understanding the communication restrictions encountered by facial paralysis patients. We aim to explore the relationship between patient-reported restrictions in communicative participation and objective facial paralysis severity using validated scales of facial movement. METHODS: We performed a pilot retrospective study using a consecutive series of adult patients with a diagnosis of unilateral facial paralysis. In addition to baseline demographics, subjects were evaluated using the Communicative Item Participation Bank Short Form (CPIB), Electronic Facial Assessment by Computer Evaluation (eFACE), and Sunnybrook Facial Grading System (SFGS). RESULTS: Twenty patients were included, 10 (50%) of whom were female with a mean age of 61 ± 13 years and mean duration of facial paralysis of 53 ± 82 months. The mean CPIB score was 14.6 ± 10.0 (range 0-29) and was comparable to scores of patients with conditions known to cause significant communicative disability. The mean eFACE scores were 67.4 ± 29.2, 44.2 ± 30.1, and 73.8 ± 30.0 for the static, dynamic, and synkinesis domains, respectively, with a composite smile score of 58.5 ± 16.9. After adjusting for age, gender, and duration of facial paralysis, significant moderate correlations were observed between the CPIB and the static eFACE domain (r = -0.51, P = .03) and smile composite score (r = 0.48, P = 0.0049), in addition to between the CPIB and SFGS synkinesis domain (r = 0.48, P = 0.04). CONCLUSIONS: Patients with unilateral facial paralysis experience significant limitations in communicative participation. These restrictions demonstrate moderate to strong correlations with objective assessments of facial paralysis and quality of life measures. Communicative participation may be a helpful means of tracking response to treatment. LEVEL OF EVIDENCE: IV.

Prospective Evaluation of the Safety and Efficacy of THRIVE for Children Undergoing Airway Evaluation.

Transnasal Humidified Rapid-Insufflation Ventilatory Exchange (THRIVE) is a humidified high-flow nasal cannula capable of extending apneic time. Although THRIVE is assumed to stent upper airway soft tissues, this has not been objectively evaluated. Also, there are no prior studies providing safety and efficacy data for those patients undergoing upper airway evaluation using THRIVE. METHODS: This report is a prospective study of the safety and efficacy of THRIVE in pediatric patients younger than 18 years old undergoing drug-induced sleep endoscopy. We positioned a flexible laryngoscope to view the larynx, and photographs were taken with no THRIVE flow (control) and with THRIVE flow at 10 and 20 liters per minute (LPM). Upper airway patency was measured using epiglottis to posterior pharynx distance, laryngeal inlet area, and modified Cormack-Lehane score at the trialed parameters. Vomiting and aspiration were our primary safety endpoints. RESULTS: Eleven patients (6 women) with a mean age of 5.3 ± 2.1 years (2-8 years; SD, 2.05) were enrolled. Measurements of upper airway patency showed a significant THRIVE flow-associated increase in epiglottis to posterior pharynx distance (105 ± 54 at 10 L/min and 199 ± 67 at 20 L/min; P = 0.007) and nonsignificant increase of laryngeal inlet area (206 ± 148 at 10 L/min and 361 ± 190 at 20 L/min; P = 0.07). Cormack-Lehane score improved significantly at higher THRIVE volumes (P = 0.006). CONCLUSIONS: THRIVE appears to safely improve upper airway patency during sleep endoscopy in the pediatric patient. In this study, we objectively document the flow-dependent increase in laryngeal patency associated with THRIVE.

Otolaryngology Education: Recent Trends in Publication.

Objectives (1) Evaluate peer-reviewed publications regarding education in otolaryngology since 2000. (2) Analyze publication trends as compared with overall otolaryngology publications. Study Design Bibliometric analysis. Setting Academic medical center. Subjects and Methods A search for articles regarding education in otolaryngology from 2000 to 2015 was performed with MEDLINE and EMBASE databases, yielding 1220 articles; 362 relevant publications were categorized by topic, subspecialty, subject, article type, and funding source. Impact factors for each journal by year were obtained, and trends of each category over time were analyzed. These were then compared with publication numbers and impact factors for all otolaryngology journals. Results From 2000 to 2015, publications in otolaryngology education increased more rapidly than the field of otolaryngology overall. The most published topics included operative skills training, surgical simulation, and professionalism/career development. Recently there has been a decline in publications related to residency administration and duty hours relative to other topics. Only 12.2% of publications reported a funding source, and only 12.2% of studies were controlled. Conclusion Recent trends in otolaryngology literature reflect an increasing focus on education; however, this work is underfunded and often lacks high-quality evidence.