Search

Learning Objectives: After studying this article, the participant should be able to: 1. Understand the regional anatomy involved in facial feminization surgery, the key differences between the male and female face, and surgical approaches for modification. 2. Appreciate the integration of preoperative virtual planning and nonoperative approaches for facial feminization care. 3. Understand the perioperative process and potential complications and sequela. 4. Understand the importance of transgender care acceptance as it pertains to clinical outcomes., Summary: Facial feminization surgery (FFS) is composed of a broad spectrum of gender-affirming surgical procedures with the goal of modifying specific facial features to create a more feminine appearance. As FFS continues to evolve as a subspecialty of transgender care, it is important to consider the psychosocial evaluation, evolving aesthetic tastes, nonoperative facial feminization care, preoperative virtual planning, specialized instrumentation, and potential complications/sequelae when performing these procedures. Computed tomographic imaging and virtual preoperative planning may be used to assist the surgeon with morphologic typing of the brow, supraorbital rim, chin, and lateral mandible regions and aid in performing safer, more efficient procedures. The increasing number of FFS procedures performed on transwomen annually has been supported by objective outcome studies that demonstrate progress in minimizing both misgendering in social environments and reducing dysphoric feelings., (Copyright © 2023 by the American Society of Plastic Surgeons.)

Background: Improving perioperative efficiency helps reduce unnecessary surgical expenditure, increase operating room throughput, improve patient safety, and enhance staff and patient satisfaction. Lean Six Sigma (LSS) is a quality improvement model that has been successfully applied to eliminate inefficiencies in the business sector but has not yet been widely adopted in medicine. This study investigates the adaptation of LSS to improve operative efficiency for plastic surgery procedures., Methods: The authors followed the define, measure, analyze, improve, and control phases to implement LSS. The key outcome measures gathered were operative times, including the cut-to-close time, and the total time the patient spent in the operating room., Results: The study included a total of 181 patients who underwent immediate bilateral deep inferior epigastric perforator flap breast reconstruction between January of 2016 and December of 2019. The LSS interventions were associated with a decrease in total operative time from 636.36 minutes to 530.35 minutes, and a decrease in the time between incision to closure from 555.16 minutes to 458.85 minutes for a bilateral mastectomy with immediate deep inferior epigastric artery flap breast reconstruction., Conclusions: This study demonstrates that LSS is useful to improve perioperative efficiency during complex plastic surgery procedures. The workflow of the procedure was improved by determining the optimal spatial positioning and distinct roles for each surgeon and preparing surgeon-specific surgical trays. Two process maps were developed to visualize the positioning of the surgeons during each stage of the procedure and depict the parallel workflow that helped improve intraoperative efficiency., (Copyright © 2023 by the American Society of Plastic Surgeons.)

Objective: This study aimed to assess the durability of audiological outcomes after radiation and surgery in the management of vestibular schwannoma., Study Design: Retrospective review., Setting: Tertiary academic center., Patients: Adults with sporadic vestibular schwannoma and serviceable hearing at the time of intervention., Interventions: Gamma Knife, middle cranial fossa, or retrosigmoid approaches., Main Outcome Measures: Pure-tone audiometry and speech discrimination scores., Results: Postintervention serviceable hearing (class A/B) was preserved in 70.4% (n = 130; mean follow-up, 3.31 yr; range, 0-15.25 yr). Of the 49 patients treated with radiation, 19 (39.6%) had serviceable hearing at last follow-up, compared with 38 (46.9% of 81) who underwent retrosigmoid (n = 36 [44.4%]) and middle cranial fossa (n = 45 [55.6%]) approaches (odds ratio [OR], 1.40; 95% confidence interval [CI], 0.67-2.82; p = 0.47). A matched analysis by age, tumor volume, and preintervention hearing (n = 38) also found no difference in hearing preservation (HP) likelihood between surgery and radiation (OR, 2.33; 95% CI, 0.24-35.91; p = 0.59). After initial HP, 4 (9.5%) surgical versus 10 (37.0%) radiated patients subsequently lost residual serviceable (A/B) hearing (OR, 0.18; 95% CI, 0.06-0.69; p = 0.01) at a mean 3.74 ± 3.58 and 4.73 ± 3.83 years after surgery and radiation, respectively. Overall, 5- and 10-year HP rates (A/B) after initially successful HP surgery were 84.4 and 63.0%, respectively. However, survival estimates declined to 48.9% at 5 years and 32.7% at 10 years when patients with immediate postoperative serviceable hearing loss were also included, which were comparable to radiation-HP rates at 5 and 10 years of 28.0 and 14.2%, respectively ( p = 0.75)., Conclusions: After vestibular schwannoma intervention, overall HP was similar between radiated and surgical cohorts. However, when successful, surgical approaches offered more durable hearing outcomes at long-term follow-up., (Copyright © 2022, Otology & Neurotology, Inc.)

Object: Surgical site infection (SSI) after cranioplasty can result in unnecessary morbidity. This analysis was designed to determine the risk factors of SSI after cranioplasty in patients who received a decompressive craniectomy with the autologous bone for traumatic brain injury (TBI)., Methods: A retrospective review was performed at two level 1 academic trauma centers for adult patients who underwent autologous cranioplasty after prior decompressive craniectomy for TBI. Demographic and procedural variables were collected and analyzed for associations with an increased incidence of surgical site infection with two-sample independent t tests and Mann Whitney U tests, and with a Bonferroni correction applied in cases of multiple comparisons. Statistical significance was reported with a P value of < 0.05., Results: A total of 71 patients were identified. The mean interval from craniectomy to cranioplasty was 99 days (7-283), and 3 patients developed SSIs after cranioplasty (4.2%). Postoperative drain placement (P > 0.08) and administration of intrawound vancomycin powder (P = 0.99) were not predictive of infection risk. However, a trend was observed suggesting that administration of prophylactic preoperative IV vancomycin is associated with a reduced infection rate., Conclusions: The SSI rate after autologous cranioplasty in TBI patients is lower than previously reported for heterogeneous groups and indications, and the infection risk is comparable to other elective neurosurgical procedures. As such, the authors recommend attempting to preserve native skull and perform autologous cranioplasty in this population whenever possible., Competing Interests: The authors report no conflicts of interest., (Copyright © 2021 by Mutaz B. Habal, MD.)

Objective: To demonstrate successful surgical management of vestibular schwannomas via an exclusively endoscopic transcanal transpromontorial approach (EETTA)., Patients: Four patients with vestibular schwannomas., Interventions: Surgical excision via EETTA., Main Outcomes: Technique refinements, tumor access, complete tumor removal, and patient morbidity., Results: Three tumors were Koos grade I and one tumor was Koos grade II. All ears had non-serviceable hearing prior to surgery. The EETTA enabled access to the internal auditory canal and porus acousticus as well as limited access to the cerebellopontine angle. Gross total tumor resection was achieved in all cases. There were no intraoperative or postoperative complications and the mean hospital duration was 2.8 days. After a mean follow-up of 5.0 months, all cases had a good facial nerve outcome., Conclusions: The EETTA can be successfully used for the management of small vestibular schwannomas in ears without serviceable hearing. Additional studies are needed to fully elucidate the risk-benefit profile of this minimally invasive approach.

Objective: To analyze clinical outcomes after treatment of petroclival chondrosarcoma and to propose a novel staging system., Study Design: Retrospective case review, 1995 to 2015., Setting: Multicenter study., Patients: Consecutive patients with histopathologically proven petroclival chondrosarcoma., Intervention(s): Microsurgery, endoscopic endonasal surgery, radiation therapy, observation., Main Outcome Measures: Disease- and treatment-associated morbidity, recurrence, mortality., Results: Fifty-five patients (mean age 42 years; 56% women) presenting with primary or recurrent petroclival chondrosarcoma were analyzed. The mean duration of follow-up was 74 months. Among 47 primary cases, the most common presenting symptoms were headache (55%) and diplopia (49%) and the mean tumor size at diagnosis was 3.3 cm. Subtotal resection was performed in 33 (73%) patients and gross total resection in 12 (27%). Adjuvant postoperative radiation was administered in 30 (64%) cases. Preoperative cranial neuropathy improved in 13 (29%), worsened in 11 (24%), and remained stable in 21 (47%) patients; notably, 11 preoperative sixth nerve palsies resolved after treatment. Nine recurrences occurred at a mean of 42 months. The 1-, 3-, 5- and 10-year recurrence-free survival rate for all 45 patients who underwent primary microsurgery with or without adjuvant radiation therapy was 97%, 89%, 70%, and 56%, respectively. Higher tumor stage, larger categorical size (<4 versus ≥4 cm), lack of adjuvant radiation, and longer duration of follow-up were associated with greater risk of recurrence. The overall mortality rate was 2% for patients presenting with primary disease.Analyzing the cohort of 17 cases with 20 recurrences, 3 received salvage surgery alone, 5 radiation therapy alone, 11 multimodality treatment, and one patient has been observed. Tumor control was ultimately achieved in 15 of 17 patients with recurrent disease. One patient (6%) with grade 3 petroclival chondrosarcoma died as a result of rapidly progressive disease within 6 months of salvage treatment. The overall mortality rate was 6% for patients with recurrent disease., Conclusion: Gross total or subtotal resection with adjuvant radiation provides durable tumor control with minimal morbidity in most patients. Surgery may improve preoperative cranial nerve dysfunction, particularly in the case of cranial nerve 6 paralysis.

Background: Reconstructive surgeons may encounter patients presenting after intracranial facial nerve resection and grafting in the setting of skull base tumors, who inquire regarding progression, final facial function, and need for future operations. Study goals were to analyze global and regional facial function using established grading systems and videography, while examine variables possibly affecting outcomes., Methods: Between 1997 and 2012, 28 patients underwent intracranial nerve grafting. Fifteen were prospectively evaluated by three facial nerve physical therapists with the Facial Nerve Grading System 2.0 and the Sunnybrook Facial Grading Score for function and the Facial Disability Index for quality of life. Still photographs and videography were used to assess quality of motion and tone, while demographic and medical variables were analyzed regarding their effect on end results., Results: Average patient age was 41.9 years (range, 22 to 66 years), and there were 10 women and five men. Average time interval between nerve grafting and evaluations was 42.9 months (range, 12 to 146 months). Both grading scores demonstrated best outcomes in the periorbita and worst outcomes in the brow. Buccinator muscle tone also improved. The average total Facial Disability Index was 67.5 percent. Although not statistically significant, the data suggest that nerve gap length affected total resting symmetry and voluntary movement, whereas preoperative palsy and age may affect total resting symmetry. Perioperative radiation therapy, tumor type, donor nerve, and coaptation technique were not found to affect outcomes., Conclusions: Intracranial facial nerve grafting largely provides better resting tone and facial symmetry, potentially improving end results of future intervention; however, overall voluntary facial motion is poor., Clinical Question/level of Evidence: Therapeutic, IV.