Faculty Bibliography

OBJECTIVES/OBJECTIVE:Our objective was to identify gender differences in work-life balance, professional advancement, workload, salary, and career satisfaction among facial plastic and reconstructive surgeons. STUDY DESIGN/METHODS:Cross-Sectional Survey METHODS: American Academy of Facial Plastic and Reconstructive Surgery (AAFPRS) members were invited by email to respond to a confidential 25-question online survey. The survey had a response rate of 12%. There were a total of 139 participants; 23 participants were in training and 116 were either board-eligible or board-certified facial plastic surgeons. Collected variables included general demographics, personal life, academic involvement, career development, workload, and career satisfaction. RESULTS:Forty percent of participants were female. Fifty-nine percent of female participants were 25-35 years old compared with 15% of male participants. The majority of male participants were over 45 years old (63%) while only 19% of female participants fell into this age category (P < .0001). Women were more likely to be in a relationship with a physician (35% vs. 19%) or non-physician full-time professional (55% vs. 31%). The vast majority of men had children (89%) while only half of women (52%) had children. On average, women with children had fewer children than men (P < .0001). No gender difference was seen with respect to working full versus part-time (P = .81). Participants were equally satisfied with a surgical career regardless of gender. CONCLUSION/CONCLUSIONS:Although significant progress has already been made towards closing the gender gap, gender disparities remain both professionally and personally for facial plastic surgeons. With an increasing number of women in medicine, we should continue to strive to close the gender gap. LEVEL OF EVIDENCE/METHODS:4 Laryngoscope, 2020.

BACKGROUND:The misuse and abuse of opioids, including overprescription, has led to the current opioid epidemic and national crisis. There is a national effort to eliminate the unnecessary prescription of opioids for analgesia. METHODS:Seventy patients were randomized to receive postoperative analgesia with either 5 mg hydrocodone with 325 mg acetaminophen (opioid control group) or 400 mg of ibuprofen [nonsteroidal antiinflammatory drug (NSAID) experimental group]. Pain levels were assessed on postoperative days 1, 2, and 7. Outcome measures included numeric pain rating scores and assessments of frequency and amount of analgesic used. RESULTS:There was no significant difference in gender (p = 0.81) or age (p = 0.61) between groups. On postoperative day 0, the NSAID group (mean ± SD, 2.54 ± 1.57) was found to be noninferior to the opioid group (mean ± SD, 3.14 ± 1.75; p = 0.003). On postoperative day 1, the NSAID group showed a lower mean pain score (mean ± SD, 1.84 ± 1.29) than the opioid group (mean ± SD, 2.46 ± 1.90; p = 0.01). However, on postoperative day 7, the difference in pain scores between the NSAID (mean ± SD, 3.29 ± 2.14) and opioid (mean ± SD, 3.14 ± 2.12; p = 0.17) groups lost statistical significance. There was no significant difference in mean day of medication cessation between the NSAID (mean ± SD, 4.73 ± 1.57) and opioid (mean ± SD, 4.28 ± 2.23; p = 0.26) groups. Seventy-six percent of patients who were prescribed opioids took fewer than eight tablets. Five patients escalated from NSAIDs to opioids. There were no adverse effects related to NSAID use. CONCLUSIONS:NSAIDs are an acceptable and safe alternative to opioids for postoperative analgesia in rhinoplasty and potentially lead to better overall pain control in some patients. Significantly reducing or eliminating opioid prescriptions may be considered in light of the current opioid epidemic. CLINICAL QUESTION/LEVEL OF EVIDENCE/METHODS:Therapeutic, II.

Tissue inelasticity and the hair-bearing nature of the scalp and forehead pose unique challenges during reconstruction. A thorough understanding of the surgical anatomy of the scalp and forehead is paramount for optimal reconstructive outcomes. Primary wound closure is usually preferred over secondary intention healing and skin grafting. Use of dermal alternatives and tissue expansion are adjunctive therapies to facilitate scalp wound closure. Local skin and soft tissue flaps are commonly used for most small to medium defects; however, microsurgical free tissue transfer can be considered for large full-thickness skin defects of the forehead and scalp.

IMPORTANCE: Understanding age-related changes is important when considering cartilage-based implants or grafts during rhinoplasty and nasal reconstructive surgery. OBJECTIVE: To characterize the cellular and architectural changes in human nasal cartilage with aging. DESIGN: Laboratory study. PARTICIPANTS: Nasal septal cartilage was harvested from 50 consecutive patients undergoing septoplasty, rhinoplasty, or septorhinoplasty. INTERVENTION: Cartilage specimens were stained with hematoxylin-eosin (H&E) and safranin O for cartilage. MAIN OUTCOME MEASURES: A modified Mankin histologic grading scale was used to analyze each cartilage sample for H&E findings and safranin O staining. Higher H&E scores indicated more degenerative changes, while higher safranin O scores indicated reductions in proteoglycan content within the cartilage matrix, representing decreased active chondrocyte activity. Correlation between H&E and safranin O scores and patient age was determined. RESULTS: There was positive correlation between safranin O staining scores and age, with higher scores seen with advancing age (P = .01). A linear regression best-fit equation was determined to calculate a potential safranin O staining score for a given age. CONCLUSIONS AND RELEVANCE: We have quantitatively determined that advancing age is positively correlated with reductions in cartilage proteoglycan content and active cartilage growth. This finding not only enhances our current understanding of the natural changes that occur in cartilage with aging but may also affect surgical decision making when cartilage grafting is considered during functional, reconstructive, and aesthetic rhinoplasty. LEVEL OF EVIDENCE: NR.

OBJECTIVES: To describe our technique of using septal bone grafts for correction and stabilization of caudal septal deviation and to evaluate the effectiveness of this technique in the treatment of the deviated caudal septum. METHODS: A retrospective review of 81 patients who underwent open septorhinoplasty using septal bone grafts for correction of a caudal septal deviation or deformity and nasal obstruction. We reviewed medical records to determine postoperative outcomes in nasal obstruction and caudal septal position. RESULTS: Of the 81 patients, we included 66 with adequate follow-up information in the analysis. Follow-up duration ranged from 1 to 72 (mean, 8) months. Postoperative examination revealed a midline septum in 55 of the 66 patients (83%). Fifty-seven patients (86%) reported resolution of nasal obstruction; 49 (74%) had a midline septum and resolved nasal obstruction at the longest follow-up. Nine patients (14%) reported postoperative nasal obstruction, of whom only 3 required revision surgery. CONCLUSION: Nasal septal bone grafts can be an effective tool in stabilizing severe cartilaginous deformities or deviations and correcting caudal septal deviation.

Traditional upper blepharoplasty typically involves resection of excess upper eyelid skin and muscle with or without fat excision. Well-established concepts in periorbital aging have been challenged by newer morphologic and histologic studies that have characterized the changes that occur in the various periorbital soft tissue components. Several modified or adjunctive techniques have recently emerged to improve esthetic outcomes in upper blepharoplasty. The authors review surgical technique in detail: nasal fat repositioning, orbicularis oculi preservation, increasing lateral upper eyelid fullness, lacrimal gland resuspension, internal brow elevation, and glabellar myectomy, along with complications and aftercare involved with procedures.

OBJECTIVE: Radiotherapy, an essential modality in cancer treatment, frequently induces fibrotic processes in the skin, including accumulation of extracellular matrix. Transforming growth factor-beta is essential in regulating extracellular matrix gene expression and is dependent on Smad3, an intracellular mediator/transcription factor. Our study characterized the genetic expression involved in extracellular matrix accumulation during radiation-induced fibrosis. We performed Smad3 gene silencing in an attempt to abrogate the effects of radiation. STUDY DESIGN: Laboratory research. SETTING: University laboratory. SUBJECTS AND METHODS: C57 murine dermal fibroblasts were irradiated with 20 Gy RNA isolated (0, 6, 12, 24, 48, 72 hours postirradiation) and mRNA analyzed (reverse transcriptase polymerase chain reaction) for known regulators (Smad3, interleukin-13 [IL-13]), tumor necrosis factor-alpha [TNF-alpha]) and mediators of fibrosis (collagen 1A1 [Col1A1]), TGF-beta, matrix metalloprotease-1 and -2 (MMP-1, MMP-2), and tissue inhibitor of metalloprotease-1 (TIMP-1). Smad3 gene expression was silenced using siRNA in an effort to restore an unirradiated gene profile. RESULTS: Following irradiation, there was a steady increase in mRNA expression of Smad3, IL-13, TGF-beta, Col1A1, MMP-2, TIMP-1, with peak at 12 to 24 hours and subsequent decline by 72 hours. TNF-alpha expression remained elevated throughout. MMP-1 showed minimal expression initially, which decreased to negligible by 72 hours. Inhibition of Smad3 significantly decreased expression of Col1A1, TGF-beta, MMP-2, and TIMP-1. IL-13 and TNF-alpha expression was not affected by Smad3 silencing. CONCLUSION: We have characterized the early-phase mRNA expression profiles of the major mediators of radiation-induced fibrosis. Smad3 siRNA effectively abrogated the elevation of Col1A1, TGF-beta, TIMP-1, and MMP-2. IL-13 and TNF-alpha were unaffected by Smad3 silencing and appear to be minor regulators in fibrosis. These findings suggest a therapeutic rationale for Smad3 silencing in vivo

OBJECTIVE: To attempt to mitigate the effects of irradiation on murine skin after high-dose radiation using a novel transcutaneous topical delivery system to locally inhibit gene expression with small interfering RNA (siRNA) against Smad3. DESIGN: Laboratory investigation. SETTING: University laboratory. SUBJECTS: Twenty-five wild-type C57 mice. INTERVENTION: In an isolated skin irradiation model, the dorsal skin of C57 wild-type mice was irradiated (45 Gy). Just before irradiation, Smad3 and nonsense siRNA were applied to 2 separate dorsal skin areas and then reapplied weekly. Skin was harvested after 1 and 4 weeks. Smad3 expression were assessed by immunohistochemistry, and collagen deposition and architecture was examined using picrosirius red collagen staining. MAIN OUTCOME MEASURES: Epidermal thickness was measured semiquantitatively at 4 weeks. Radiation-induced fibrosis was measured quantitatively via tensiometry. The Young modulus, a measure of cutaneous rigidity inversely related to elasticity, was determined, with normal irradiated skin serving as a control specimen. RESULTS: Murine skin treated with topical Smad3 siRNA demonstrated effective Smad3 inhibition at 1 week and persistent suppression at 4 weeks. Collagen deposition and epidermal thickness were significantly decreased in skin treated with Smad3 siRNA compared with control irradiated skin. Tensiometry demonstrated decreased tension in Smad3 siRNA-treated skin, with a Young modulus of 9.29 MPa (nonirradiated normal skin, 7.78 MPa) compared with nonsense (control) siRNA-treated skin (14.68 MPa). CONCLUSIONS: Smad3 expression can be effectively silenced in vivo using a novel topical delivery system. Moreover, cutaneous Smad3 inhibition mitigates radiation-induced changes in tissue elasticity, restoring a near-normal phenotype