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Given the significance of forehead aesthetics to facial gender identification, frontal sinus setback and brow contouring are frequent components of facial feminization surgery (FFS) in transgender female patients. This study presents a safe and reliable technique for corrugator muscle resection during FFS to provide enhanced feminization of the forehead. This technique was performed in 12 patients between 27 and 58 years of age. Following bone reduction and sinus setback, the corrugator is located on the undersurface of the forehead flap and dissected through the reflected soft tissue of the forehead, with care taken to protect the supraorbital nerve. Patient satisfaction and complications, such as infection, poor wound healing, scarring, and desire for revision surgery, were assessed at follow-up visits. All patients showed improved feminization of the forehead. No complications were reported intraoperatively or postoperatively, and no patients required hospitalization beyond the expected overnight admission. No patients reported anesthesia or hypoesthesia in the distribution of the supraorbital nerve at 6 months postoperatively. Patients reported high satisfaction with their FFS outcomes. In conclusion, performing corrugator resection in conjunction with FFS is a safe and rapid technique that may significantly enhance the feminizing effects on the forehead of frontal sinus setback and brow contouring., (© The Author(s) 2024. Published by Oxford University Press on behalf of The Aesthetic Society.)

Facial feminization surgery (FFS) can be an important part of an individual's transition; however, outcomes have not been well explored in the literature. This study aims to elucidate trends in FFS with a focus on drivers of secondary FFS to further improve care for TGNB patients. A manual chart review was conducted on patients from a single institution from 2012 to 2023 with a diagnosis of transsexualism (F64) who had undergone one or more surgeries associated with any 1 or more of 95 CPT codes related to gender-affirming surgery. Patients who underwent >1 FFS procedure were separated into staged, unplanned, and revision FFS. Three hundred twenty-seven patients were included in the analysis, with 111 of these patients undergoing FFS. Those who underwent FFS were significantly older (P<0.001), had a lower BMI (P<0.001), and began socially transitioning and hormone therapy at an older age (P<0.001 and P=0.001) than those who did not undergo FFS. 44.1% of patients who underwent FFS also underwent secondary FFS, with 26.1% of FFS patients undergoing unplanned secondary FFS. Patient factors, including BMI, age at first FFS, smoking status, race, ethnicity, and order of FFS in relation to other gender-affirming surgeries, were not significantly associated with differences in rates of unplanned secondary FFS. These findings highlight the importance of tailoring the surgical approach to a patient's transition to their unique situation, as well as the need for future studies to identify factors influencing the need for revision FFS and to enhance surgical outcomes for patients undergoing gender-affirming procedures., Competing Interests: M.A. consults for Johnson & Johnson and LifeNet Health. The remaining authors report no conflicts of interest., (Copyright © 2024 by Mutaz B. Habal, MD.)

Genioplasty is frequently performed in facial feminization surgery, typically aiming to reduce chin height and projection for more feminine appearance. Quantification of the bony changes occurring during surgery have to date not been published. This study presents a method for segmentation of the chin using CT imaging to quantify changes to the chin after feminization genioplasty. CT scans of 21 patients before and after feminization genioplasty were segmented in Mimics to isolate the chin region. Surface area, volume, vertical chin projection, and horizontal chin projection were measured before and after surgery. Patient outcomes were evaluated using the FACE-Q and World Health Organization Quality of Life patient-reported outcome measures. Surface area, volume, and vertical chin projection demonstrated statistically significant decreases after surgery. The magnitude of changes in surface area and vertical chin projection were significantly associated with their presurgical values. In particular, patients with greater presurgical vertical projections experienced greater decreases in vertical projection after surgery, with some patients having increases in postsurgical vertical projection. Patient FACE-Q scores improved significantly on all scales, including chin, jawline, and neck satisfaction. This study demonstrates a method for evaluating bony changes on CT scan after feminization genioplasty. The measured changes cohere with the changes expected to create a more feminine chin. Furthermore, changes created by feminization genioplasty are in the context of the patient's overall facial harmony and are not uniform across all patients., Competing Interests: The authors report no conflicts of interest., (Copyright © 2024 by Mutaz B. Habal, MD.)

No consensus exists on the standard of intraoperative airway management approach to prevent endoscopy complications in acute gastrointestinal (GI) bleeding. Eight years after our initial meta-analysis, we reassessed the effect of prophylactic endotracheal intubation in acute GI bleeding in hospitalized patients. Multiple databases were reviewed in 2024, identifying 10 studies that compared prophylactic endotracheal intubation (PEI) versus no intubation in acute upper GI bleeding in hospitalized patients. Outcomes of interest included pneumonia, length of hospital stay, aspiration, and mortality. The odds ratio (OR) or mean difference (MD) using the random effects model was calculated for each outcome. In total, 11 studies (10 retrospective, one prospective) were included in the meta-analysis (n = 7,332). PEI demonstrated statistically significant higher odds of pneumonia (OR = 5.83; 95% confidence interval (CI) = 3.15-10.79; p < 0.01) and longer length of stays (MD = 0.84; 95% CI = 0.12-1.56; p = 0.02). However, mortality (OR = 1.68; 95% CI = 0.78-3.64; p = 0.19) and aspiration (OR = 2.79; 95% CI = 0.89-8.7; p = 0.08) were not statistically significant. PEI before esophagogastroduodenoscopy for hospitalized upper GI bleeding patients is associated with an increased incidence of pneumonia within 48 hours and prolonged hospitalization but no statistically significant increased risk of mortality or aspiration., Competing Interests: Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: Matthew Bechtold MD declare(s) personal fees from Medtrition. Advisory Board. Matthew Bechtold MD declare(s) personal fees from Nestle Nutrition Institute. Nutrition lectures. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Pasha et al.)

Objective: To elucidate trends in publication productivity over the past 50 years and how they correlate with the stage of training as well as the competitiveness of residency and fellowship programs. The authors hypothesize that research qualifications play an important role in obtaining a competitively ranked craniofacial surgery fellowship and that over the past 50 years, there has been an upward shift in the research qualifications held by applicants at the time of application., Design: A cross-sectional study was performed involving all 121 academic craniofacial surgeons in the United States for whom sex, years since fellowship, current institution rank, current academic position, and years since graduation were available., Main Outcome Measures: The relationship between research qualifications, as determined by the overall number of publications, number of first authorship publications, H-index scores, and years since fellowship completion, was examined. The study also analyzed the placement of surgeons at programs ranked in the top 25 versus the lower 25., Results: As the number of decades since beginning craniofacial fellowship decreased, the average number of first authorship publications and average H-index increased. Those who attended higher-ranking residency and fellowship programs had a higher average number of publications, number of first authorship publications, and H-index., Conclusions: Over the past 5 decades, research productivity at all stages of medical training has surged, potentially fueled by the trend toward pass/fail grading in medical school evaluations and standardized exams and the need to differentiate oneself in an increasingly competitive field., Competing Interests: The authors report no conflicts of interest., (Copyright © 2023 by Mutaz B. Habal, MD.)

Background: Rhinoplasty is one of the most commonly performed facial gender-affirming surgeries (FGASs) for transgender females, but well-established morphometric parameters describing feminizing nasal changes do not exist., Objectives: Describe the author's technique for feminization rhinoplasty, analyze the changes in 3-dimensional nasal anthropomorphic parameters, and describe patient-reported outcomes., Methods: Three-dimensional photogrammetric evaluation was performed both preoperatively and postoperatively in transgender female patients who underwent FGAS. Measurements assessed included the nasofrontal angle, nasolabial angle, dorsal height, mid-dorsal width, alar width, nasal tip width, and tip projection. Patients were surveyed preoperatively and postoperatively using the FACE-Q Nose module. Paired t -tests were utilized to assess changes in postoperative measurements and FACE-Q Nose satisfaction scores., Results: Twenty patients underwent FGAS during the study period. The average time between surgery and postoperative 3-dimensional images was 13.6 ± 6.8 months. The nasofrontal angle increased by 8.2° (148.0 ± 7.4° to 156.1 ± 6.7°, P < .001) and tip projection increased by 0.017 (0.58 ± 0.03 to 0.60 ± 0.04, P < .01). Dorsal height, mid-dorsal width, and tip width all decreased significantly ( P < .05). There were significant improvements in patients' "Satisfaction with Nose," "Satisfaction with Facial Appearance Overall," "Psychological Function," and "Social Function" on FACE-Q. One revision rhinoplasty was performed, and no documented surgical complications were reported., Conclusions: There were statistically significant changes in the nasofrontal angle, tip projection, dorsal height, mid-dorsal width, and tip width in patients receiving feminization rhinoplasty. These data may help surgeons with preoperative planning and intraoperative decision making., (© The Author(s) 2023. Published by Oxford University Press on behalf of The Aesthetic Society.)

Purpose: We examine prevalence, characteristics, quality of life (QOL) assessments, and long-term effects of interventions for laryngeal dysfunction after recovery from COVID-19 infection., Materials and Methods: 653 patients presenting to Yale's COVID clinic from April 2020 to August 2021 were identified retrospectively. Patients with PCR-positive COVID-19 who underwent evaluation by fellowship-trained laryngologists were included. Patient demographics, comorbidities, intubation/tracheostomy, strobolaryngoscopy, voice metrics, and management data were collected. Patient-reported QOL indices were Dyspnea Index (DI), Cough Severity Index (CSI), Voice Handicap Index-10 (VHI-10), Eating Assessment Tool-10 (EAT-10), and Reflux Symptom Index (RSI)., Results: 57 patients met inclusion criteria: 37 (64.9 %) were hospitalized for COVID-19 infection and 24 (42.1 %) required intubation. Mean duration between COVID-19 diagnosis and presentation to laryngology was significantly shorter for patients who were intubated compared to non-intubated (175 ± 98 days versus 256 ± 150 days, respectively, p = 0.025). Dysphonia was diagnosed in 40 (70.2 %) patients, dysphagia in 14 (25.0 %) patients, COVID-related laryngeal hypersensitivity in 13 (22.8 %), and laryngotracheal stenosis (LTS) in 10 (17.5 %) patients. Of the 17 patients who underwent voice therapy, 11 (64.7 %) reported improvement in their symptoms and 2 (11.8 %) patients reported resolution. VHI scores decreased for patients who reported symptom improvement. 7 (70 %) patients with LTS required >1 procedural intervention before symptom improvement. Improvement across QOL indices was seen in patients with LTS., Conclusions: Laryngeal dysfunction commonly presents and is persistent for months after recovery from COVID-19 in non-hospitalized and non-intubated patients. Voice therapy and procedural interventions have the potential to address post-COVID laryngeal dysfunction., Competing Interests: Declaration of competing interest None., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Objective: To perform a literature review on burnout prevalence, factors that affect burnout and well-being, and solutions to address burnout in otolaryngology-head and neck surgery (OTO-HNS) residents and residents in other surgical specialties., Data Sources: Ovid Medline, Embase, and article reference lists., Review Methods: A literature search was performed to identify articles on resident burnout, distress, wellness, well-being, and quality of life. Articles deemed outside the scope of the current work were excluded. Search was limited to the past 5 years., Conclusions: Moderate to high burnout has been reported in 35% to 86% of OTO-HNS residents. Among other surgical specialties, resident burnout ranges between 58% and 66% in plastics, 11% and 67% in neurosurgery, 38% and 68% in urology, and 31% and 56% in orthopedics. Highest burnout rates were seen in postgraduate year 2 residents. Factors significantly associated with burnout included hours worked (>80 h/wk), level of autonomy, exercise, and program support. Reported resident work hours have steadily increased: 8% of OTO-HNS residents in 2005 vs 26% in 2019 reported averaging >80 h/wk. Practical implications of resident burnout include decreased empathy, moral distress and injury, poor health, decreased quality of life, increased attrition, decreased desire to pursue fellowship, and increased likelihood of medical errors. Structured mentorship programs, wellness initiatives, and increased ancillary support have been associated with lower burnout rates and improvements in resident well-being across specialties., Implications for Practice: Addressing burnout, which is prevalent in OTO-HNS residents, is critical to improving patient care and physician well-being. Surgical specialties can share strategies to effectively address resident burnout through institutional interventions, which can be essential quality improvement initiatives, to promote well-being., (© 2023 American Academy of Otolaryngology-Head and Neck Surgery Foundation.)

Deformational plagiocephaly and brachycephaly, or abnormal flattening of the infant skull due to external forces, are often managed with orthotic helmet therapy. Although helmet therapy is widely used, the factors that predict poor outcomes are not well characterized. In this study of over 140,000 patients who received helmet therapy, older age and greater severity at presentation, and noncompliance with treatment were each independently associated with worse craniometric and provider-reported outcomes. Each additional point of cranial vault asymmetry index or cephalic index at a presentation is associated with an increased likelihood of residual brachycephaly at completion [odds ratio (OR): 1.067; 95% Cl: 1.058-1.075; P <0.0001 and OR: 2.043; 95% CI: 2.021-2.065; P <0.0001, respectively], whereas each additional point of cranial vault asymmetry index at a presentation associated with increased likelihood of residual asymmetry at completion (OR: 2.148; 95% Cl: 2.118-2.179; P <0.0001). Patients were more likely to have residual brachycephaly or asymmetry with increasing age at treatment initiation (OR: 1.562; 95% CI: 1.524-1.600; P <0.0001 and OR: 1.673; 95% Cl: 1.634-1.713; P <0.0001, respectively, for each additional month of age at initiation). These results highlight a need for prompt referral for helmeting, especially in cases with severe features or when patients present late to care. Potentially modifiable factors are age at helmeting and compliance with treatment protocols, and consideration of these factors may be important for achieving success in some cases., Competing Interests: T.R.L. is the Chief Science and Technology Officer at Cranial Technologies Inc., and he has a financial interest in Cranial Technologies Inc. The remaining authors report no conflicts of interest., (Copyright © 2022 by Mutaz B. Habal, MD.)

The conversion of proliferating skeletal muscle precursors (myoblasts) to terminally-differentiated myocytes is a critical step in skeletal muscle development and repair. We show that EphA7, a juxtacrine signaling receptor, is expressed on myocytes during embryonic and fetal myogenesis and on nascent myofibers during muscle regeneration in vivo. In EphA7 -/- mice, hindlimb muscles possess fewer myofibers at birth, and those myofibers are reduced in size and have fewer myonuclei and reduced overall numbers of precursor cells throughout postnatal life. Adult EphA7 -/- mice have reduced numbers of satellite cells and exhibit delayed and protracted muscle regeneration, and satellite cell-derived myogenic cells from EphA7 -/- mice are delayed in their expression of differentiation markers in vitro. Exogenous EphA7 extracellular domain will rescue the null phenotype in vitro, and will also enhance commitment to differentiation in WT cells. We propose a model in which EphA7 expression on differentiated myocytes promotes commitment of adjacent myoblasts to terminal differentiation., Competing Interests: LA, AC, DS, JI, RC, AC, SZ, DC No competing interests declared, (© 2020, Arnold et al.)

Background: A movement is emerging to encourage health providers and health organizations to take action on the social determinants of health. However, few evidence-based interventions exist. Digital tools have not been examined in depth., Objective: To assess the acceptability and feasibility of integrating, within routine primary care, screening for poverty and an online tool that helps identify financial benefits., Methods: The setting was a Community Health Centre serving a large number of low-income individuals in Toronto, Canada. Physicians were encouraged to use the tool at every possible encounter during a 1-month period. A link to the tool was easily accessible, and reminder emails were circulated regularly. This mixed-methods study used a combination of pre-intervention and post-intervention surveys, focus groups and interviews., Results: Thirteen physicians participated (81.25% of all) and represented a range of genders and years in practice. Physicians reported a strong awareness of the importance of identifying poverty as a health concern, but low confidence in their ability to address poverty. The tool was used with 63 patients over a 1-month period. Although screening and intervening on poverty is logistically challenging in regular workflows, online tools could assist patients and health providers identify financial benefits quickly. Future interventions should include more robust follow-up., Conclusions: Our study contributes to the evidence based on addressing the social determinants of health in clinical settings. Future approaches could involve routine screening, engaging other members of the team in intervening and following up, and better integration with the electronic health record., (© The Author(s) 2019. Published by Oxford University Press. All rights reserved.For permissions, please e-mail: journals.permissions@oup.com.)