The "July effect": Outcomes in microvascular reconstruction during resident transitions.

OBJECTIVES/HYPOTHESIS: To evaluate the "July effect," as a possible risk factor for perioperative complications in otolaryngology microvascular reconstruction during the transitional period in the academic calendar. STUDY DESIGN: Retrospective database review. METHODS: Microvascular reconstruction outcomes in the National Surgical Quality Improvement Program (2005-2016) database were compared between the first academic quarter (July-September) to the last academic quarter (April-June). The primary outcome was 30-day morbidity, and secondary outcomes included 30-day mortality, operative complications, or postoperative adverse events. RESULTS: There were 612 and 580 patients who underwent microvascular reconstruction during the first and last academic quarters, respectively. There was no significant difference between the 30-day mortality between the first academic quarter (1.5%) and the last academic quarter (0.7%) (P = .194). There was no difference in 30-day morbidity (47.9% vs. 49.5%, P = .586), operative complications (wound disruption, P = .151; bleeding, P = .526; operative time, P = .162), or postoperative adverse events (deep vein thrombosis, P = .460; pneumonia, P = .737; reintubation, P = .201; pulmonary embolism, P = .452; ventilation for >48 hours, P = .769; acute renal failure, P = .500; urinary tract infection, P = .693; unplanned readmission, P = .202; and mean length of stay, P = .497). CONCLUSIONS: There appears to be no July effect in microvascular reconstruction. Further studies should identify the mechanisms that preserve the safety of this operation year-round for application to other areas of medicine who have observed the July effect. LEVEL OF EVIDENCE: NA Laryngoscope, 130:893-898, 2020.

Endoscopic Paramedian Forehead Flap Reconstruction of the Anterior Skull Base for Recalcitrant Cerebrospinal Fluid Leaks: Minimally Invasive Adaptation of Ancient Flap.

BACKGROUND: The anterior skull base (ASB) remains one of the greatest challenges for reconstructive surgeons. The current armamentarium includes endoscopic placement of free grafts, endonasal vascularized pedicled flaps, regional flaps, and microvascular free flaps. As the defect size increases, reconstruction complexity increases along with potential complications. Here, we report an endoscopic-assisted paramedian forehead flap, a novel adaptation of an age-old technique, for ASB reconstruction. CASE DESCRIPTION: A 66-year-old male underwent a dual bifrontal and transnasal endoscopic approach for the resection of a T4N0M0 sinonasal squamous cell carcinoma. The resulting ASB defect was repaired using simultaneous pericranial and nasoseptal flaps. Adjuvant radiation therapy resulted in delayed radiation necrosis in the right frontal lobe 3 years later requiring debridement via a supraorbital approach. Recovery from this operation was complicated by an ASB defect and cerebrospinal fluid (CSF) leak. The defect remained despite multiple attempts at endoscopic repairs. Due to multiple medical comorbidities, the patient was not a candidate for microvascular reconstruction. Prior surgeries had disrupted the traditional regional flaps (i.e., pericranial, nasoseptal, and temporoparietal fascia flaps) bilaterally. Therefore the novel endoscopic-assisted paramedian forehead flap was used to successfully repair the ASB defect. Postoperatively, the patient has done well with no recurrences in the CSF leak. CONCLUSIONS: The endoscopic-assisted paramedian forehead flap is a robust regional flap whose advantages include the utilization of muscle, low donor morbidity, and endoscopic placement with avoidance of craniotomies. Therefore it should be considered an important option for ASB reconstruction of recalcitrant CSF leaks when all other options are unavailable.

Craniofacial injuries related to motorized scooter use: A rising epidemic.

OBJECTIVES: Over the last decade, there has been increased interest in utilizing motorized scooters for transportation. The limited regulation of this modernized vehicle raises numerous safety concerns. This analysis examines a national database to describe the yearly incidence of craniofacial injuries and patterns of injury related to motorized scooter use. METHODS: The Consumer Product Safety Commission's National Electronic Injury Surveillance system was queried for craniofacial injuries associated with motorized scooter use. Patient demographics, injury type, anatomic location, injury pattern, and helmet status were extracted for analysis. RESULTS: From 2008 to 2017, there were 990 recorded events for craniofacial injuries secondary to motorized scooters extrapolating to an estimated 32,001 emergency department (ED) visits. The annual incidence was noted to triple over that 10-year period. The majority of patients were male (62.1%) and the common age groups at presentation were young children 6-12 years old (33.3%), adolescents 13-18 years old (16.1%) and young adults 19-40 years old (18.0%). The most common injury pattern was a closed head injury (36.1%) followed by lacerations (20.5%). Facial fractures were only present in 5.2% of cases. In cases in which helmet use was recorded, 66% of the patients were not helmeted. CONCLUSION: The incidence of motorized scooter related craniofacial trauma is rising, resulting in thousands of ED visits annually. Many patients are experiencing morbid traumatic injuries and may not be wearing appropriate protective equipment. This study highlights the importance of public awareness and policy to improve safety and primarily prevent craniofacial trauma.

Minimally Invasive Trigeminal Ablation: Long Buccal Nerve.

AIMS: To describe a technique of minimally invasive trigeminal nerve ablation of the long buccal nerve that was performed at a tertiary care academic medical center. METHODS: This case describes a 44-year-old woman with refractory left long buccal nerve neuropathy following a dental procedure. After failing medical management, she was taken for nerve exploration, which revealed no nerve discontinuity or neuroma formation. She was therefore counseled regarding the risks and possible benefits of a novel minimally invasive trigeminal nerve thermoablation of the long buccal nerve technique. RESULTS: Postoperatively, the patient experienced mild anesthesia along the long buccal nerve division and no longer experiences any allodynia or hypersensitivity. Additionally, she no longer requires any additional medical therapy or interventions. CONCLUSION: Minimally invasive trigeminal nerve ablation of the long buccal nerve may be effective surgical intervention in treating refractory neuropathic pain in cases of no structural nerve defects. However, long-term well-designed studies are required to fully define its role.

Religion and the Plastic Surgeon: an Imam, a Minister, and a Rabbi Walk into a Surgical Centre.

Cultural competency has become a keystone in forming a successful doctor-patient relationship to provide culturally appropriate services that respect patients' ethno-cultural beliefs, values, attitudes, and conventions. In cosmetic surgery, an often-overlooked aspect of a patient's cultural is his and her religious beliefs. In response to this paucity of resources for cosmetic surgeons to enable them to properly service their religious patients, this project was undertaken. This review article covers the three main Abrahamic religions (Judaism, Christianity, and Islam) and was written with the assistance of a prominent bioethicist from each religion (see Acknowledgements). In discussing each religion, the article has been divided into two sections. The first section is a general overview of the religion's relationship with cosmetic surgery as summary provided by the consulting bioethicist. The second portion is an annotated review of additional resources providing the reader further details on that religion. For example, our bioethicists provide a general perspective on Christianity as a whole, and the annotated review focuses on differences between Catholics and Protestants. We recognize the heterogeneity that is inherent in religion and the cultural and geographic biases that affect it. However, we aim to provide the reader a broad and basic foundation of the relationship between Judaism, Christianity, and Islam with cosmetic surgery to begin to create common ground between the physician and the patient and improve the process of shared decision-making and thus our outcomes. This paper should be seen as a foundation to build upon rather than an authoritative source, and specific patient concerns should be addressed with the patient's own religious advisor. LEVEL OF EVIDENCE V: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Outcomes in microvascular head and neck reconstruction in the setting of restricted residency hours.

BACKGROUND: Resident duty hour restrictions can limit the frequency of resident flap checks at smaller institutions with "home" call. Institutions are compensating with adjuvant nursing flap checks as well as incorporating technology; however, this management remains controversial. METHODS: A prospective cohort of 122 free flaps for reconstruction of the head and neck by a single surgeon. Demographic information, operative details, postoperative care, and flap outcomes were recorded. RESULTS: Over 42 months, 122 free flaps were performed on 115 patients. The overall flap success rate was 96%. The flap success rate at 72 h was 98% and 96% at the time of discharge with reexploration rates of 11.6%. The intraoperative and postoperative salvage rates were 71% and 64.3% respectively. CONCLUSION: Limited resident flap checks combined hourly nurse flap checks and an implantable Doppler is an effective monitoring protocol for academic programs in the setting of residency duty hour restrictions.