Patterns of Filler-Induced Facial Skin Ischemia: A Systematic Review of 243 Cases and Introduction of the FOEM Scoring System and Grading Scale.

BACKGROUND: The incidence of facial skin necrosis has increased considerably because of the growth in the popularity of dermal fillers. This study describes the patterns and severity of facial skin ischemia, along with associated neuro-ophthalmologic injuries, in the published literature through the introduction of the facial artery, ophthalmic artery, distal external carotid artery, internal maxillary artery (FOEM) facial angiosome scoring system and grading scale. METHODS: A systematic review of all photographic cases of facial skin ischemia attributable to vascular occlusion with dermal fillers and injectable materials was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. RESULTS: A total of 243 cases were identified, with 738 digital clinical photographs retrieved. The facial artery (58% of cases) and ophthalmic artery (48% of cases) angiosomes were most commonly affected. The frontonasal and angulonasal territories were the most common facial skin segments injured by filler-induced vascular occlusion. Cutaneous involvement of the ophthalmic angiosome was significantly associated with neuro-ophthalmologic complications [vision loss, 39% versus 0.8% ( P = 0.00001); stroke, 8% versus 0.8% ( P = 0.0085)]. Injuries with greater cutaneous surface area or cross-angiosome involvement were associated with a higher incidence of severe visual deficits and bilateral stroke. CONCLUSIONS: Facial skin necrosis attributable to vascular occlusion is a rapidly growing problem that has remained poorly characterized in the literature. This study provides the largest descriptive analysis of published photographic reports of skin ischemia to date and proposes a novel scoring system and grading classification to aid in future reporting.

Orbital post-septal hyaluronic acid: An iatrogenic etiology compounding lower eyelid steatoblepharon.

The stark rise in the incidence of dermal filler-related adverse sequelae has given rise to a variety of cosmetic distortions related to improper filler placement that include dynamic and static contour deformities of the face. In this article, we describe two instances of post-septal hyaluronic acid filler aggravating existing steatoblepharon and outline potential causative mechanisms responsible for this condition.

RealSelf Social Media Analysis of Rhinoplasty Patient Reviews.

BACKGROUND: Social media has become increasingly important for patients when deciding whether they should undergo rhinoplasty. The purpose of this study is to analyze patient satisfaction of rhinoplasty procedures through RealSelf social media reviews. METHODS: We collected data from 583 rhinoplasty reviews published on the RealSelf portal. In posts dated between 2016 and 2020, we included those which were labeled as "Worth It" and "Not Worth It." Posts that were labeled as "Unsure" or were left unlabeled were excluded from the study. In addition, posts not including the cost of their rhinoplasty were excluded. Taking into account patient demographics and cost of the procedure, we analyzed reasons for choosing to undergo surgery, reasons for choosing surgeons, and reasons for liking or disliking their procedure. RESULTS: Of the 583 reviews analyzed, most (45.4%) were categorized from the 18-24 years age group and there was an overall 93.8% satisfaction rate. While there was no statistically significant difference in the cost of rhinoplasty surgeries between "Worth It" and "Not Worth It" groups, the average cost of recorded rhinoplasties was US$ 8043 with a standard deviation ± $3296. According to our analysis, younger patients aged 18-24 years relied more on social media to choose their surgeons and desired a more natural appearance to their nose while older ones preferred compatible physician personalities and increased self-esteem for rhinoplasty. CONCLUSION: This study offers a unique perspective into the distinguishing characteristics of different age groups and the values they place in pursuing rhinoplasty, choosing their surgeons, and why they like/dislike their surgical outcomes.

Acute Pain Management Following Facial Plastic Surgery.

Facial plastic surgery, including septorhinoplasty, aging face procedures, otoplasty, and oculoplastic procedures, has varying levels of evidence for the management of acute pain after surgery. This article discusses the available evidence in these procedures and discusses the authors' recommendations for the treatment of postoperative pain, with a focus on decreasing the reliance on opioid pain medication.

Rattled: Analysis of Facial Trauma Among Toddlers.

OBJECTIVE: The aim of this study was to determine the national incidence of facial trauma among toddlers and delineate patterns of injury and their causes. METHODS: A retrospective review was designed to explore patterns of maxillofacial trauma within toddler-aged children using the National Electronic Injury Surveillance System from the Consumer Product Safety Commission. The database was searched for emergency department visits involving facial trauma sustained by children 12 months through 3 years of age from 2010 through 2014 and analyzed for patient demographics, primary diagnosis, and associated products/activities. Subset analyses were performed between age groups to determine the relationship between causes of injury and age using extrapolated national incidences. RESULTS: A sample of 45,249 patients extrapolated to an estimated 1.3 million emergency department visits for facial trauma in toddlers from 2010 to 2014, averaging 260,000 annually. Injuries involving foreign bodies and fractures had a higher incidence in toddlers 2 years or older, and fractures comprised fewer than 1% of facial injuries in any age group. Furniture was the most common source of trauma overall, with a higher frequency among toddlers aged 12 to 17 months. Trauma in the setting of sports was more common in toddlers aged 3 years. CONCLUSIONS: The low incidence of facial fractures further supports recommendations against routine imaging in toddler facial trauma and suggests that more focus should be placed on investigating for concurrent traumas and soft tissue injuries where fractures are involved. Our findings highlight prevention opportunities, particularly in furniture-related injuries for toddlers aged 12 to 17 months and sports-related traumas in toddlers aged 3 years. Our study also suggests restricting certain toys from 3-year-old toddlers to decrease the risk of aspiration.

Functional and Aesthetic Outcomes of Extracorporeal Septoplasty: A Systematic Review and Meta-Analyses.

OBJECTIVE: The safety and efficacy of extracorporeal septoplasty (ECS) has long been debated. Our objective was to determine this technique's functional and aesthetic outcomes and complications through a systematic review of the literature. DATA SOURCES: PubMed/MEDLINE, Embase, Cochrane Library, and Web of Science databases were evaluated for studies detailing functional or aesthetic outcomes of ECS. REVIEW METHODS: Bias was evaluated using the Cochrane Risk of Bias Tool and the Methodological Index for Non-randomized Studies (MINORS) score. Aesthetic and functional outcomes in addition to complications were evaluated using subjective and objective measures. Meta-analyses were performed when appropriate. RESULTS: Seventeen studies encompassing 1418 patients were included. The average MINORS score for observational studies was 9.2. Overall there was a significant improvement in subjective nasal function with a preoperative average Nasal Obstruction Symptom Evaluation (NOSE) score of 75 (±16) decreasing to 19.5 (±16.5) postoperatively for a mean difference (MD) of -55 (95% confidence interval (CI): -60 to -49.5). In terms of objective nasal function, at 6 months postoperatively, there was an improvement of nasal flow measured by rhinometry ranging from 70 to 71% across studies. Anthropometric measurements were utilized for objective aesthetic outcomes. There was a significant improvement in I-shaped deviations (MD: -2.7°, 95% CI: -5.6 to -0.16) and C-shaped deviations improved by 11.9° (95% CI +2.8-+21.2). Complication rates ranged from 0 to 18%. CONCLUSION: ECS can achieve significant improvements in the subjective and objective function of the nose. The associated complication rate is low but variable between surgeons.

Perioperative Analgesia for Patients Undergoing Septoplasty and Rhinoplasty: An Evidence-Based Review.

OBJECTIVES/HYPOTHESIS: Opioid misuse and diversion is a pressing topic in today's healthcare environment. The objective of this study was to conduct a review of non-opioid perioperative analgesic regimens following septoplasty, rhinoplasty, and septorhinoplasty. STUDY DESIGN: Evidence-based systematic review. METHODS: PubMed, MEDLINE, Cochrane Library, and Embase databases were reviewed for articles related to perioperative analgesic use in septoplasty, rhinoplasty, and septorhinoplasty. Quality of studies were assessed via the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) criteria, Jadad scores, and the Cochrane bias tool. Patient demographic data and clinical outcomes, including medication type, dose, administration time, pain scores, and adverse events, were obtained from included studies. Summary tables detailing the benefits and harms of each investigated regimen are included. RESULTS: Thirty-seven studies met inclusion criteria for this evidence-based review. The quality of the studies was determined to be of moderate quality based off of GRADE standardized criteria with a mean Jadad score of 3.1. A preponderance of evidence showed reduced perioperative pain scores and rescue analgesic requirements, supporting the use of local anesthetics for analgesic control. Nonsteroidal anti-inflammatory drugs (NSAIDs) demonstrated similar decreased visual analog scores and postoperative analgesic demand; however, increased adverse events in this class warrant caution. CONCLUSIONS: Contemporary literature supports the use of NSAIDs, gabapentin, local anesthetics, and α-agonists as effective perioperative analgesic opioid alternatives for septoplasty and septorhinoplasty. Local anesthetic use is a cost-effective option resulting in decreased postoperative pain scores and rescue analgesic requirements. Further large-scale, multi-institutional, controlled studies are needed to provide definitive recommendations. LEVEL OF EVIDENCE: NA Laryngoscope, 129:E200-E212, 2019.

A Cross-sectional Analysis of Adverse Events and Litigation for Injectable Fillers.

IMPORTANCE: Injectable fillers are increasing in popularity as a noninvasive option to address concerns related to facial aging and volume loss. To our knowledge, there have been no large-scale analyses of adverse events and associated litigation related to filler injections. OBJECTIVES: To determine risks of injectable fillers and analyze factors raised in litigation related to injectable fillers. DESIGN, SETTING, AND PARTICIPANTS: In this cross-sectional review, the US Food and Drug Administration's (FDA) manufacturer and user facility device experience (MAUDE) database was evaluated for complications from the use of the following fillers: Juvederm, Restylane, Belotero, Sculptra, Radiesse, Artefill, Bellafill, and Juvederm Voluma from 2014 to 2016. The Westlaw Next database was used to identify jury verdicts. MAIN OUTCOMES AND MEASURES: Complications were organized by type of filler used, location of injection, and severity. Intra-arterial injections without sequelae and those resulting in blindness or necrosis were considered severe complications. Factors raised during the litigation process were also analyzed. RESULTS: Of 1748 adverse events analyzed, most cases stemmed from cheek (751 [43.0%]) or lip (524 [30.0%]) injection. Commonly reported adverse events reported included swelling (755 [43.2%]) and infection (725 [41.5%]). Among FDA-reported complications, blindness was significantly associated with dorsal nasal injections (P < .001). Vascular compromise with and without sequela of dermal necrosis and blindness were significantly associated with Radiesse injections P < .001. Of the 9 malpractice cases identified, two-thirds involved allegations of inadequate informed consent, and the median award in cases resolved with payment was $262 000. CONCLUSIONS AND RELEVANCE: Although specific complication profiles vary by material and injection site, common adverse events associated with injectable fillers include swelling and infection. More serious events include vascular compromise, resulting in necrosis and blindness; these events are also raised in cases involving litigation. This analysis illustrates the importance of outlining these risks in a comprehensive preoperative informed consent process. LEVEL OF EVIDENCE: NA.

Traumatic Facial Injuries Among Elderly Nursing Home Residents: Never Event or Frequent Occurrence?

Importance: As the nursing home population continues to increase, an understanding of preventable injuries becomes exceedingly important. Although other fall-related injuries have been characterized, little attention has been dedicated to facial trauma. Objectives: To estimate the incidence of facial trauma among nursing home residents and detail mechanisms of injury, injury characteristics, and patient demographic data. Design, Setting, and Participants: The National Electronic Injury Surveillance System was used to calculate a weighted national incidence of facial trauma among individuals older than 60 years from a nationally representative collection of emergency departments from January 1, 2011, through December 31, 2015. Entries were screened for nursing home residents, and diagnosis, anatomical site, demographic data, and mechanism of injury were analyzed. Results: There were 109 795 nursing home residents (median age, 84.1 years; interquartile range, 79-89 years; 71 466 women [65.1%]) who required emergency department care for facial trauma. Women sustained a greater proportion of injuries with increasing age. The most common injuries were lacerations (48 679 [44.3%]), other soft-tissue injuries (45 911 [41.8%]; avulsions, contusions, and hematomas), and fractures (13 814 [12.6%]). Nasal (9331 [67.5%]) and orbital (1144 [8.3%]) fractures were the most common sites. The most common injury causes were direct contact with structural housing elements or fixed items (62 604 [57.0%]) and transfer to and from bed (24 870 [22.6%]). Conclusions and Relevance: Despite falls being considered a Centers for Medicare & Medicaid Services preventable never event in hospitals, our analysis in the nursing home setting found more than 100 000 facial injuries during 5 years, suggesting these underappreciated injuries contribute substantially to health care expenditures. Although structural elements facilitated the greatest number of falls, transfer to and from bed remains a significant mechanism, suggesting an area for intervention.

Analysis of Factors Associated With Rhytidectomy Malpractice Litigation Cases.

IMPORTANCE: This study investigates the financial burden of medical malpractice litigation associated with rhytidectomies, as well as factors that contribute to litigation and poor defendant outcomes, which can help guide physician practices. OBJECTIVE: To comprehensively evaluate rhytidectomy malpractice litigation. DATA SOURCES AND STUDY SELECTION: Jury verdict and settlement reports related to rhytidectomy malpractice litigations were obtained using the Westlaw Next database. Use of medical malpractice in conjunction with several terms for rhytidectomy, to account for the various procedure names associated with the procedure, yielded 155 court cases. Duplicate and nonrelevant cases were removed, and 89 cases were included in the analysis and reviewed for outcomes, defendant specialty, payments, and other allegations raised in proceedings. Data were collected from November 21, 2015, to December 25, 2015. Data analysis took place from December 25, 2015, to January 20, 2016. RESULTS: A total of 89 cases met our inclusion criteria. Most plaintiffs were female (81 of 88 with known sex [92%]), and patient age ranged from 40 to 76 years (median age, 56 years). Fifty-three (60%) were resolved in the defendant's favor, while the remaining 36 cases (40%) were resolved with either a settlement or a plaintiff verdict payment. The mean payment was $1.4 million. A greater proportion of cases involving plastic surgeon defendants were resolved with payment compared with cases involving defendants with ear, nose, and throat specialty (15 [36%] vs 4 [24%]). The most common allegations raised in litigation were intraoperative negligence (61 [69%]), poor cosmesis or disfigurement (57 [64%]), inadequate informed consent (30 [34%]), additional procedures required (14 [16%]), postoperative negligence (12 [14%]), and facial nerve injury (10 [11%]). Six cases (7%) involved alleged negligence surrounding a "lifestyle-lift" procedure, which tightens or oversews the superficial muscular aponeurosis system layer. CONCLUSIONS AND RELEVANCE: In this study, although most cases of rhytidectomy malpractice litigation were resolved in the defendant's favor, cases resulting in payments created substantial financial burden for the defendants. Common factors cited by plaintiffs for pursuing litigation included dissatisfaction with cosmetic outcomes and perceived deficits in informed consent. These factors reinforce the importance of a comprehensive, preoperative informed consent process in which the specific potential risks and outcomes are presented by the surgeon to the patient to limit or avoid postsurgical allegations. Intraoperative negligence and facial nerve injury were significantly more likely to result in poor defendant outcomes. LEVEL OF EVIDENCE: NA.

Forgetful but not forgotten: Bathroom-related craniofacial trauma among the elderly.

OBJECTIVES/HYPOTHESIS: As our population ages, injuries attributable to falls continue to increase, impacting healthcare delivery. Evaluation of craniofacial trauma with focus on elderly patients remains an underappreciated concern. Our objectives were to evaluate injury trends associated with elderly bathroom falls, as this information may be useful for counseling and preventive purposes. STUDY DESIGN: Database review. METHODS: The National Electronic Injury Surveillance System was evaluated for craniofacial trauma among patients 60 years and older presenting to the emergency department (ED) (2010-2014). Injury descriptions were reviewed for mechanism of injury, patient demographics, and other injury characteristics. RESULTS: In total, 7.2% of the estimated 3.4 million ED visits for elderly craniofacial trauma were bathroom related. Females comprised the majority (60.9%) of patients, and a plurality of patients were in their 80s. A greater proportion of facial injuries resulted from syncope (16.6% vs. 10.9% compared to head injuries). Toilets facilitated a greater proportion of facial insults and were more likely to require admission; the most common mechanism was "falling off." Showers contributed a majority of head injuries and had a lower median age than toilet injuries. Fractures comprised 12.6% of facial injuries; of craniofacial fractures, common sites included the nose (54%), mandible (6%), and orbit (6%). Admitted patients were significantly older than those who were released. CONCLUSIONS: Bathroom falls result in a significant proportion of elderly traumatic injury. The trends we present offer the opportunity for targeted preventative measures to decrease the occurrence of these events. Additionally, this information may adjunct a detailed history and physical to ensure appropriate patient management. LEVEL OF EVIDENCE: 4 Laryngoscope, 127:820-827, 2017.

Critical Analysis of the Quality, Readability, and Technical Aspects of Online Information Provided for Neck-Lifts.

IMPORTANCE: The number of patients using the internet to obtain health information is growing. This material is unregulated and heterogeneous and can influence patient decisions. OBJECTIVE: To compare the quality, readability, and technical aspects of online information about neck-lifts provided by private practice websites vs academic medical centers and reference sources. DESIGN, SETTING, AND PARTICIPANTS: In this cross-sectional analysis conducted between November 2015 and January 2016, a Google search of the term neck-lift was performed, and the first 45 websites were evaluated. The websites were categorized as private practice vs other. Private websites (PWs) included sites created by private practice physicians. Other websites (OWs) were created by academic medical centers or reference sources. MAIN OUTCOMES AND MEASURES: Quality, readability, and technical aspects of online websites related to neck-lifts. Quality was assessed using the DISCERN criteria and the Health on the Net principles (HONcode). Readability was assessed using 7 validated and widely used criteria. Consensus US reading grade level readability was provided by a website (readabilityformulas.com). Twelve technical aspects were evaluated based on criteria specified by medical website creators. RESULTS: Forty-five websites (8 OWs [18%] and 37 PWs [82%]) were analyzed. There was a significant difference in quality between OWs and PWs based on the DISCERN criteria and HONcode principles. The DISCERN overall mean (SD) scores were 2.3 (0.5) for OWs and 1.3 (0.3) for PWs (P < .001). Of a total possible score of 14 using the HONcode analysis, the mean (SD) was 8.6 (1.8) (range, 5-11) for OW, and the mean (SD) was 5.8 (1.7) (range, 2-9) for PW. The mean (SD) readability consensus reading grade level scores were 11.7 (1.9) for OWs and 10.6 (1.9) for PWs. Of a total possible score of 12, the mean (SD) technical scores were 6.3 (1.8) (range, 4-9) for OWs and 6.4 (1.5) (range, 3-9) for PWs. CONCLUSIONS AND RELEVANCE: Compared with PWs, OWs had a significantly higher quality score based on both the DISCERN criteria and HONcode principles. The mean readability for OWs and PWs was grade 11 and grade 10, respectively, significantly higher than the grade 7 level recommended by the National Institutes of Health. Assessment of technical criteria demonstrated room for improvement in providing links to social media and blogs and reducing advertisements. Improving the quality and readability of online information may result in increased patient understanding, more active patient involvement, and ultimately better outcomes. Enhancing the technical aspects of websites may increase website traffic and patient volume. LEVEL OF EVIDENCE: NA.

A critical analysis of melanoma malpractice litigation: Should we biopsy everything?

OBJECTIVES/HYPOTHESIS: The aim of this study was to evaluate factors raised in malpractice litigation related to the diagnosis and management of melanoma and to further assess issues impacting outcome. STUDY DESIGN: Retrospective chart review. METHODS: The Westlaw legal database was searched for malpractice litigation resolved over the last 20 years relating to melanoma. Cases were evaluated for allegations, defendant specialty, outcome, and other issues raised. RESULTS: Of the 80 cases evaluated, 49% were resolved in the defendants' favor. In greater than 80% of cases, there was alleged misdiagnosis. In 35% of cases, the patient had expired secondary to melanoma at the time of litigation. There was no statistical difference in payments upon comparison of cases with and without mortality. A greater proportion of cases with dermatologists and pathologists as defendants involved alleged misdiagnosis. The most common locations for melanoma were the extremities and the head-and-neck region, at 32.5% and 22.5%, respectively. Location did not significantly impact the outcome of cases. CONCLUSION: Malpractice litigation relating to melanoma involves numerous physicians, including dermatologists, pathologists, and otolaryngologists. Alleged misdiagnosis of a pigmented lesion was the most common cause of litigation and involved physicians from numerous specialties. Patients who were misdiagnosed had a significantly higher likelihood of having active disease at the time of litigation. Ultimately improved methods of detecting concerning pigmented lesions need to be developed. Factors such as death and poor cosmetic outcome did not significantly impact litigation outcome. LEVEL OF EVIDENCE: NA Laryngoscope, 127:134-139, 2017.

Race and Sex Differences in Adult Facial Fracture Risk.

IMPORTANCE: There are well-described racial, sex, and age differences related to osteoporosis and hip and/or extremity fractures. Nonetheless, there has been virtually no inquiry evaluating whether these findings carry over to facial fracture. OBJECTIVE: To characterize the incidence of facial fractures by patient demographics and injury mechanism, focusing on whether differences are noted with race, sex, and advancing age. MAIN OUTCOMES AND MEASURES: Retrospective analysis of the National Electronic Injury Surveillance System (NEISS) was performed in October and November 2015, specifically evaluating adult emergency department (ED) visits from 2012 to 2014 related to facial trauma. Entries were organized by age groups (both individual decades as well as younger adults [18-59 years] vs older adults [60-89 years]), sex, and race (white, black, Asian, other/unspecified). Incidence of facial fractures and mechanism of injury were also evaluated. RESULTS: There were 33 825 NEISS entries correlating to 1 401 196 ED (range, 1 136 048-1 666 344) visits for adult facial injury, with 14.4% involving fracture. A greater proportion of facial injuries among younger men (<60 years) were fractures relative to younger women (15.5% vs 12.5%; difference of the mean [DOM], 3.0%; 95% CI, 2.8%-3.1%; P < .001); however, on comparison by sex in elderly populations (≥ 60 years), women had an increased fracture predilection (15.0% vs 14.0%; DOM, 1.0%; 95% CI, 0.8%-1.2%; P < .001). Also, older women had a significantly greater risk of fracture relative to those younger than 60 years (15.0% vs 12.5%; DOM, 2.5%; 95% CI, 2.4%-2.7%; P < .001), a comparison that was significant among whites and Asians. Black women had a significantly decreased risk of fracture in the older aged population. (8.4% vs 9.1%; DOM, 0.7%; 95% CI, 0.2%- 1.3%; P = .001). Both on individual comparisons of younger and older cohorts, white and Asian individuals of either sex had significantly greater rates of facial fracture injury than blacks. Among younger cohorts in either sex, injuries sustained during participation in recreational activities were a significant factor, replaced largely by injuries due to housing structural elements and falls among older cohorts. CONCLUSIONS AND RELEVANCE: There is an increase in the risk of facial fracture among postmenopausal women sustaining facial injuries, with these results significant among whites and Asians. In contrast, a decreased risk was noted on comparison of younger and older black women. Mechanism of injuries also varied significantly by age, race, and sex. LEVEL OF EVIDENCE: 4.

The Vicious Cycle: Pediatric Facial Trauma from Bicycling.

OBJECTIVES: Although prevention of head injuries through helmet use is widespread, there has been a paucity of inquiry and publicity regarding the potential for facial injury stemming from cycling. Our objectives included estimating the incidence of emergency department (ED) visits for bicycle-related facial trauma among the pediatric population and detailing injury patterns. STUDY DESIGN AND SETTING: Analysis of a nationwide database. METHODS: The National Electronic Injury Surveillance System, offered by the Consumer Product Safety Commission, was accessed for ED visits related to bicycle-related facial trauma among individuals 21 years old and younger. These data were used to estimate national incidence and examine patient demographics and injury characteristics. RESULTS: From 2010 to 2014, there were 5420 entries extrapolating to an estimated 178,457 ED visits for pediatric bicycle-related facial trauma. Median age was 8 years, and 71.9% of patients were male. Lacerations (63.1%), abrasions/contusions (27%), and fractures (7%) were most common, with fractures dramatically increasing in prevalence with age. Nasal fractures were the most common fracture type. Injury patterns varied by age. CONCLUSION: Bicycle-related facial trauma is prevalent among the pediatric population, with nearly 180,000 visits to EDs between 2010 and 2014. Soft tissue injuries predominated among all age groups, although fractures increased significantly with age. Knowledge of injury patterns described may be a useful adjunct assisting history, examination, and decision making regarding the use of medical imaging. There is a clear void in inquiry regarding the use of facial protection, reinforcing the need for further study into prevention and efforts to raise public awareness among youth.

Protecting the airway and the physician: Aspects of litigation arising from tracheotomy.

BACKGROUND: In recent decades, medical malpractice costs have increased and have led to a change in the way physicians practice medicine. Tracheotomies are cases in which complications have a high risk of morbidity and mortality and the potential for litigation. METHODS: The Westlaw legal database was used to gather data on 43 jury verdicts and settlements from 1987 to 2013. Various factors included outcome, defendant specialty, and the reason for litigation. RESULTS: Median settlements were $500,000 and median verdict awards were $2,000,000. Postoperative negligence was alleged most often (81%) followed by intraoperative negligence (27.9%) and permanent injury (18.6%). Otolaryngologists were named as defendants most often (25.6%), with nurses named second most often. Pediatric cases had significantly higher awards and were more often named in favor of the plaintiff. CONCLUSION: An awareness of tracheotomy malpractice litigation has the potential to both help physicians avoid future litigation and improve patient safety.

"Beaned": A 5-Year Analysis of Baseball-Related Injuries of the Face.

OBJECTIVES: Baseball remains one of the most popular and safest games played by children and adults in America and worldwide. Rules and equipment changes have continued to make the game safer. For youth leagues, pitching restrictions, safety balls, helmets, and face mask equipment continue to make the game safer. With increased utilization of safety equipment, the objective was to analyze recent trends in baseball-related facial injuries. STUDY DESIGN: Cross-sectional analysis of a national database. METHODS: The National Electronic Injury Surveillance System was searched for baseball-related facial injuries with analysis of incidence, age, and sex and specific injury diagnoses, mechanisms, and facial locations. RESULTS: From 2009 to 2013, there were 5270 cases entries, or 187,533 estimated emergency department (ED) visits, due to baseball-related facial injuries. During this time, there was a significant decline in the incidence of ED visits (P = .014). Inclusion criteria were met by 3208 visits. The majority of injuries occurred in patients ≤18 years old (81.5%). The most common injury was laceration (33.2%), followed by contusion (29.7%) and fracture (26.9%), while the most common injury site on the face was the nose (24.9%). The injuries were most commonly due to impact from a baseball (70%) or a bat (12.5%). CONCLUSION: The overall incidence of ED visits due to baseball-related facial injuries has decreased over the past 5 years, concurrent with increased societal use of protective equipment. Nonetheless, these injuries remain a common source for ED visits, and a continued effort to utilize safety measures should be made, particularly in youth leagues.

Impact of Postreconstitution Room Temperature Storage on the Efficacy of IncobotulinumtoxinA Treatment of Dynamic Lateral Canthus Lines.

BACKGROUND: The efficacy of botulinum neurotoxin type A after prolonged storage at room temperature is currently unknown. This randomized, double-blinded, split-face study investigated the impact of postreconstitution 25°C storage for 1 week on the clinical efficacy of incobotulinumtoxinA in the treatment of lateral canthus lines. PATIENTS AND METHODS: Twenty-one participants with at least mild to moderate crow's feet at maximum contraction on the Crow's Feet Grading Scale (CFGS) underwent injection to each lateral canthus area with 10 U of freshly reconstituted and room temperature-stored product and followed for 4 months. Responders were defined as those demonstrating at least a 1-point improvement on their CFGS score. RESULTS: At each visit (2 weeks and 1, 2, 3, and 4 months), there was no statistical difference in the rate of responders between the fresh and the stored products. In addition, the percentage of responders displaying a 2-point versus a 1-point improvement and response longevity did not statistically differ between both products for the entire 4-month study duration. CONCLUSION: Prolonged storage of incobotulinumtoxinA at room temperature does not appear to significantly alter its efficacy or longevity in the treatment of dynamic lateral canthus lines.

Trauma patterns, symptoms, and complications associated with external auditory canal fractures.

OBJECTIVES/HYPOTHESIS: External auditory canal (EAC) trauma, although rare, can have significant long-term adverse outcomes. This study aims to investigate the frequency, treatment, and complications of external ear canal injury in association with mandibular and temporal bone trauma. STUDY DESIGN: Retrospective chart review. METHODS: Computed tomography images with mandibular or temporal bone trauma were reviewed for EAC fractures. Patient data were collected from initial presentation and subsequent follow-up clinic visits. RESULTS: Thirty-nine percent of temporal bone fractures and 3.3% of mandible trauma involved the EAC. In particular, 10% of condylar or subcondylar trauma included an EAC fracture (P = 0.0006). One patient sustained bilateral EAC fractures despite an isolated, unilateral condylar fracture. The most common presenting sign was blood in the external auditory canal. Two patients underwent exam under anesthesia and removal of debris and stenting as treatment, whereas 42% of the patients were placed on otic drops and 5% received packing or a stent. Follow-up data were only available for 16% of the patients. Hearing loss from otic capsule involvement or ossicular chain disruption were follow-up complaints, and one patient had persistent canal stenosis. CONCLUSIONS: External auditory canal trauma is present in a significant proportion of mandibular and temporal bone trauma, including both condylar and noncondylar fractures with a higher incidence of condylar fractures. One case was seen with bilateral EAC fractures despite a unilateral mandibular fracture. Complications of these fractures can include hearing loss and canal stenosis; however, additional outpatient follow-up is needed to further elucidate long-term complications and shape treatment recommendations.