Publications by authors named "Peter C Revenaugh"

40 Publications

Hypoglossal and Masseteric Nerve Transfer for Facial Reanimation: A Systematic Review and Meta-Analysis.

Facial Plast Surg Aesthet Med 2021 Feb 25. Epub 2021 Feb 25.

Section of Facial Plastic and Reconstructive Surgery, Department of Otorhinolaryngology-Head and Neck Surgery, Rush University Medical Center, Chicago, Illinois, USA.

Hypoglossal and masseteric nerve transfer are currently the most popular cranial nerve transfer techniques for patients with facial paralysis. The authors performed a systematic review and meta-analysis to compare functional outcomes and adverse effects of these procedures. A review of online databases was performed to include studies with four or more patients undergoing hypoglossal or masseter nerve transfer without muscle transfer or other cranial nerve transposition. Facial nerve outcomes, time to reinnervation, and adverse events were pooled and studied. A total of 71 studies were included: 15 studies included 220 masseteric-facial transfers, and 60 studies included 1312 hypoglossal-facial transfers. Oral commissure symmetry at rest was better for hypoglossal transfer (2.22 ± 1.6 mm vs. 3.62 ± 2.7 mm,  = 0.047). The composite Sunnybrook Facial Nerve Grading Scale was better for masseteric transfer (47.7 ± 7.4 vs. 33.0 ± 6.4,  < 0.001). Time to first movement (in months) was significantly faster in masseteric transfer (4.6 ± 2.6 vs. 6.3 ± 1.3,  < 0.001). Adverse effects were rare (<5%) for both procedures. Both nerve transfer techniques are effective for facial reanimation, and the surgeon should consider the nuanced differences in selecting the correct procedure for each patient.
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http://dx.doi.org/10.1089/fpsam.2020.0523DOI Listing
February 2021

Interest in Facial Cosmetic Surgery in the Time of COVID-19: A Google Trends Analysis.

Facial Plast Surg Aesthet Med 2021 Feb 24. Epub 2021 Feb 24.

Section of Facial Plastic and Reconstructive Surgery, Department of Otorhinolaryngology, Head and Neck Surgery, Rush University Medical Center, Chicago, Illinois, USA.

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http://dx.doi.org/10.1089/fpsam.2020.0605DOI Listing
February 2021

Cytopathologic assessment of gloves and instruments after major head and neck surgery.

Am J Otolaryngol 2021 Jan 6;42(3):102876. Epub 2021 Jan 6.

Department of Otorhinolaryngology - Head and Neck Surgery Rush University Medical Center, Chicago, IL, USA. Electronic address:

Purpose: To investigate the potential for cancer cells to be transferred between anatomic sites via instruments and other materials.

Materials And Methods: Pilot prospective study from April 2018-January 2019 at Rush University Medical Center. Glove and instrument washings were collected from 18 high-risk head and neck cancer resection cases (36 samples total). Each case maintained at least one of the following features in addition to a diagnosis of squamous cell carcinoma or sarcoma: palliative/salvage surgery, positive margins, extensive tumor burden, and/or extra capsular extension (ECE). Surgical gloves and four main instruments were placed through washings for blind cytological assessment (2 samples/case).

Results: 18 patients undergoing surgical tumor resection for biopsy-proven squamous cell carcinoma with at least one of the aforementioned characteristics were included. 26.7% of cases had ECE, 40.0% had positive final margins and 46.7% had close final margins. Tumor locations included: oral cavity (10), neck (4), parotid gland (2), and skin (2). Malignant cells were isolated on glove washings in 1 case (5.5%). No malignant cells were isolated from instrument washings. The single case of malignant cells on glove washings occurred in a recurrent, invasive squamous cell carcinoma of the scalp with intracranial extension. Anucleated squamous cells likely from surgeon skin were isolated from 94.4% of washings. Squamous cells were differentiated from mature cells by the absence of nuclei.

Conclusions: Malignant squamous cells can be isolated from surgical glove washings, supporting the practice of changing of gloves after gross tumor resection during major head and neck cancer resections.
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http://dx.doi.org/10.1016/j.amjoto.2020.102876DOI Listing
January 2021

Enhanced recovery after surgery for head and neck free flap reconstruction: A systematic review and meta-analysis.

Oral Oncol 2021 Feb 23;113:105117. Epub 2020 Dec 23.

Department of Otorhinolaryngology-Head and Neck Surgery, University of Pennsylvania, Philadelphia, PA, United States; Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, United States. Electronic address:

Introduction: Head and neck free flap reconstruction requires multidisciplinary and coordinated care in the perioperative setting to ensure safe recovery and success. Several institutions have introduced enhanced recovery after surgery (ERAS) protocols to attenuate the surgical stress response and improve postoperative recovery. With multiple studies demonstrating mixed results, the success of these interventions on clinical outcomes has yet to be determined.

Objective: To evaluate the impact of ERAS protocols and clinical care pathways for head and neck free flap reconstruction.

Methods: We searched PubMed, SCOPUS, EMBASE, and grey literature up to September 1st, 2020 to identify studies comparing patients enrolled in an ERAS protocol and control group. Our primary outcomes included hospital length of stay (LOS) and readmission. Mortality, reoperations, wound complication and ICU (intensive care unit) LOS comprised our secondary outcomes.

Results: 18 studies met inclusion criteria, representing a total of 2630 patients. The specific components of ERAS protocols used by institutions varied. Nevertheless, patients enrolled in ERAS protocols had reduced hospital LOS (MD -4.36 days [-7.54, -1.18]), readmission rates (OR 0.64 [0.45;0.92]), and wound complications (RR 0.41 [0.21, 0.83]), without an increase in reoperations (RR 0.65 [0.41, 1.02]), mortality (RR 0.38 [0.05, 2.88]), or ICU LOS (MD -2.55 days [-5.84, 0.74]).

Conclusion: There is growing body of evidence supporting the role of ERAS protocols for the perioperative management of head and neck free flap patients. Our findings reveal that structured clinical algorithms for perioperative interventions improve clinically-meaningful outcomes in patients undergoing complex ablation and microvascular reconstruction procedures.
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http://dx.doi.org/10.1016/j.oraloncology.2020.105117DOI Listing
February 2021

Enhanced recovery protocol for transoral robotic surgery demonstrates improved analgesia and narcotic use reduction.

Am J Otolaryngol 2020 Nov - Dec;41(6):102649. Epub 2020 Jul 15.

Department of Otorhinolaryngology-Head and Neck Surgery, Rush University Medical Center, Chicago, IL, United States of America. Electronic address:

Background: No study has evaluated the impact of the Enhanced Recovery After Surgery (ERAS) protocol on opioid usage among patients undergoing transoral robotic surgery (TORS).

Methods: In this retrospective study, patients undergoing TORS were enrolled in an ERAS protocol and compared to control patients. Primary outcome measures included postoperative mean morphine equivalent dose (MED), Defense and Veterans Pain Rating Scale (DVPRS) pain scores, and opioid prescriptions on discharge.

Results: The mean MED administered postoperatively was lower in the ERAS group (17.6 mg) than in the control group (65.0 mg) (p < .001). Average postoperative DVPRS scores were 2.9 in the ERAS group vs. 4.2 in the control group (p = .042). Fewer patients in the ERAS group received opioid prescriptions on discharge (31.6%) than controls (96.2%) (p < .001).

Conclusion: The TORS ERAS protocol is associated with reduced postoperative opioid usage, lower pain scores, and reduced opioid requirements on discharge.
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http://dx.doi.org/10.1016/j.amjoto.2020.102649DOI Listing
December 2020

Beauty is in the eye of the follower: Facial aesthetics in the age of social media.

Am J Otolaryngol 2020 Nov - Dec;41(6):102643. Epub 2020 Jul 15.

Section of Facial Plastic and Reconstructive Surgery, Department of Otorhinolaryngology - Head and Neck Surgery, Rush University Medical Center, Chicago, IL, United States of America.

Background: The advent of social media has influenced the relationship between aesthetic surgeons and their patients, as well as the motivations of such patients to seek cosmetic surgery.

Aims & Objectives: To determine how the cephalometric proportions of modern social media models fit with historical canons of beauty.

Materials & Methods: Frontal and lateral photographs of 20 high-influence female Instagram models were obtained and evaluated for cephalometric measures. The means of these measures were compared with previous reports in the literature.

Results: Cephalometric measurements of social media models were in agreement with historical ideals of beauty for Nostril axis (120.7°), Goode's ratio (0.6), Nasofacial angle (35.7°), Nasofrontal angle (130.9°), and the horizontal thirds. Results were discrepant from historical ideals for the Nasolabial angle (82.6°) and the vertical facial fifths.

Conclusion: Cephalometric measurements of social media models in the digital age closely resemble the ideal values proposed by previous authors. Due to a preference for larger or altered lip profiles, nostril axis is a more reliable measure of nasal tip rotation than nasolabial angle.
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http://dx.doi.org/10.1016/j.amjoto.2020.102643DOI Listing
December 2020

Disparate Nasopharyngeal and Tracheal COVID-19 Diagnostic Test Results in a Patient With a Total Laryngectomy.

Otolaryngol Head Neck Surg 2020 10 9;163(4):710-711. Epub 2020 Jun 9.

Department of Otolaryngology-Head and Neck Surgery, Rush University Medical Center, Chicago, Illinois, USA.

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http://dx.doi.org/10.1177/0194599820933605DOI Listing
October 2020

Rapid implementation of COVID-19 tracheostomy simulation training to increase surgeon safety and confidence.

Am J Otolaryngol 2020 Sep - Oct;41(5):102574. Epub 2020 Jun 1.

Department of Otorhinolaryngology - Head and Neck Surgery, Rush University Medical Center, Chicago, IL 60612, United States of America.

Objective: To determine if rapid implementation of simulation training for anticipated COVID-19 tracheostomy procedures can increase physician confidence regarding procedure competency and use of enhanced personal protective equipment (PPE).

Methods: A brief simulation training exercise was designed in conjunction with the development of a COVID-19 Tracheostomy Protocol. The simulation training focused primarily on provider safety, pre and post-surgical steps and the proper use of enhanced PPE. Simulation training was performed in the simulation lab at the institution over 2 days. Pre and post self-evaluations were measured using standardized clinical competency questionnaires on a 5-point Likert Scale ranging from "No knowledge, unable to perform" up to "Highly knowledgeable and confident, independent."

Results: Physicians self-reported a significant increase in knowledge and competency immediately after completing the training exercise. Resident physicians increased from a mean score of 3.00 to 4.67, p-value 0.0041, mean increase 1.67 (CI 95% 0.81 to 2.52). Attending physicians increased from a mean score of 2.89 to 4.67, p-value 0.0002, mean increase 1.78 (CI 95% 1.14 to 2.42). Overall, all participants increased from a mean score of 3.06 to 4.71, p-value 0.0001, mean increase 1.65 (CI 95% 1.24 to 2.05).

Discussion: Implementation of this simulation training at our institution resulted in a significant increase in physician confidence regarding the safe performance of tracheostomy surgery in COVID-19 patients.

Implications For Practice: Adoption of standardized COVID-19 tracheostomy simulation training at centers treating COVID-19 patients may result in improved physician safety and enhanced confidence in anticipation of performing these procedures in real-life scenarios.
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http://dx.doi.org/10.1016/j.amjoto.2020.102574DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7837027PMC
September 2020

Management of Upper Airway Bleeding in COVID-19 Patients on Extracorporeal Membrane Oxygenation.

Laryngoscope 2020 11 3;130(11):2558-2560. Epub 2020 Aug 3.

Department of Otorhinolaryngology-Head and Neck Surgery, Rush University Medical Center, Chicago, Illinois, U.S.A.

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http://dx.doi.org/10.1002/lary.28846DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7283688PMC
November 2020

Implementation of Preoperative Screening Protocols in Otolaryngology During the COVID-19 Pandemic.

Otolaryngol Head Neck Surg 2020 08 26;163(2):265-270. Epub 2020 May 26.

Department of Otorhinolaryngology-Head and Neck Surgery, Rush University Medical Center, Chicago, Illinois, USA.

Objective: To highlight emerging preoperative screening protocols and document workflow challenges and successes during the early weeks of the COVID-19 pandemic.

Methods: This retrospective cohort study was conducted at a large urban tertiary care medical center. Thirty-two patients undergoing operative procedures during the COVID-19 pandemic were placed into 2 preoperative screening protocols. Early in the pandemic a "high-risk case protocol" was utilized to maximize available resources. As information and technology evolved, a "universal point-of-care protocol" was implemented.

Results: Of 32 patients, 25 were screened prior to surgery. Three (12%) tested positive for COVID-19. In all 3 cases, the procedure was delayed, and patients were admitted for treatment or discharged under home quarantine. During this period, 86% of operative procedures were indicated for treatment of oncologic disease. There was no significant delay in arrival to the operating room for patients undergoing point-of-care screening immediately prior to their procedure ( = .92).

Discussion: Currently, few studies address preoperative screening for COVID-19. A substantial proportion of individuals in this cohort tested positive, and both protocols identified positive cases. The major strengths of the point-of-care protocol are ease of administration, avoiding subsequent exposures after testing, and relieving strain on "COVID-19 clinics" or other community testing facilities.

Implications For Practice: Preoperative screening is a critical aspect of safe surgical practice in the midst of the widespread pandemic. Rapid implementation of universal point-of-care screening is possible without major workflow adjustments or operative delays.
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http://dx.doi.org/10.1177/0194599820931041DOI Listing
August 2020

Sexual Dimorphism of the Nasal Skin and Soft Tissue Envelope.

Aesthetic Plast Surg 2020 10 18;44(5):1924-1925. Epub 2020 May 18.

Section of Facial Plastic and Reconstructive Surgery, Department of Otorhinolaryngology- Head and Neck Surgery, Rush University Medical Center, 1611 W. Harrison Street; Suite 550, Chicago, IL, 60612, USA.

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 .
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http://dx.doi.org/10.1007/s00266-020-01754-7DOI Listing
October 2020

Adverse Events Associated with Absorbable Implants for the Nasal Valve: A Review of the Manufacturer and User Facility Device Experience Database.

Facial Plast Surg Aesthet Med 2020 May 18. Epub 2020 May 18.

Department of Otorhinolaryngology-Head and Neck Surgery, Rush University Medical Center, Chicago, Illinois, USA.

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http://dx.doi.org/10.1089/fpsam.2020.0126DOI Listing
May 2020

Management of the Clinical and Academic Mission in an Urban Otolaryngology Department During the COVID-19 Global Crisis.

Otolaryngol Head Neck Surg 2020 07 19;163(1):162-169. Epub 2020 May 19.

Department of Otorhinolaryngology-Head and Neck Surgery, Rush University Medical Center, Chicago, Illinois, USA.

Objective: The objective of this study was to assess the strategic changes implemented in the departmental mission to continue safe delivery of otolaryngology care and to support the broader institutional mission during the COVID-19 pandemic response.

Study Design: Retrospective assessment was performed to the response and management strategy developed to transform the clinical and academic enterprise.

Setting: Large urban tertiary care referral center.

Results: The departmental structure was reorganized along new clinical teams to effectively meet the system directives for provision of otolaryngology care and support for inpatient cases of COVID-19. A surge deployment schedule was developed to assist frontline colleagues with clinical support as needed. Outpatient otolaryngology was consolidated across the system with conversion of the majority of visits to telehealth. Operative procedures were prioritized to ensure throughput for emergent and time-critical urgent procedures. A tracheostomy protocol was developed to guide management of emergent and elective airways. Educational and research efforts were redirected to focus on otolaryngology care in the clinical context of the COVID-19 crisis.

Conclusion: Emergence of the COVID-19 global health crisis has challenged delivery of otolaryngology care in an unparalleled manner. The concerns for preserving health of the workforce while ethically addressing patient career needs in a timely manner has created significant dilemmas. A proactive, thoughtful approach that reorganizes the overall departmental effort through provider and staff engagement can facilitate the ability to meet the needs of otolaryngology patients and to support the greater institutional mission to combat the pandemic.
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http://dx.doi.org/10.1177/0194599820929613DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7240314PMC
July 2020

Level of Evidence in Facial Plastic Surgery Research: A Procedure-Level Analysis.

Aesthetic Plast Surg 2020 10 23;44(5):1531-1536. Epub 2020 Apr 23.

Section of Facial Plastic and Reconstructive Surgery, Department of Otorhinolaryngology-Head and Neck Surgery, Rush University Medical Center, 1611 W. Harrison St., Suite 550, Chicago, IL, 60612, USA.

Background: As evidence-based medicine has taken hold across medical specialties, the level of evidence within the facial plastic surgery literature has risen, but remains weak in comparison. There has not yet been a systematic, critical appraisal of the relative strength of evidence among subsets of the practice of facial plastic surgery.

Methods: The current study is a systematic review, designed to evaluate the level of evidence observed in the facial plastic surgery literature. Five journals were queried using facial plastic surgery terms for four selected years over a 10-year period. Following screening, articles were assigned to a category regarding subject matter, assessed for the presence of various methodological traits, and evaluated for overall level of evidence. Comparisons were made in regard to level of evidence across the breadth of facial plastic surgery subject matter.

Results: A total of 826 articles were included for final review. Studies on operative facial rejuvenation and rhinoplasty had significantly fewer authors on average than studies on cancer reconstruction or craniofacial topics. Craniofacial studies demonstrated higher levels of evidence relative to all other categories, with the exception of facial paralysis and facial trauma studies, from which there was no significant difference. In general, reconstructive studies had significantly more authors and higher levels of evidence than did articles with an aesthetic focus.

Conclusion: Level of evidence in facial plastic surgery remains relatively weak overall. Reconstructive and particularly craniofacial studies demonstrate higher mean level of evidence, relative to other subsets of facial plastic surgery.

Level Of Evidence Iii: 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.
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http://dx.doi.org/10.1007/s00266-020-01720-3DOI Listing
October 2020

Nasal Skin and Soft Tissue Thickness Variation Among Differing Races and Ethnicities: An Objective Radiographic Analysis.

Facial Plast Surg Aesthet Med 2020 May/Jun;22(3):188-194. Epub 2020 Mar 26.

Section of Facial Plastic and Reconstructive Surgery, Department of Otorhinolaryngology-Head and Neck Surgery, Rush University Medical Center, Chicago, Illinois, USA.

Nasal skin and soft tissue envelope (SSTE) thickness has considerable effects on procedural planning and postoperative outcomes in rhinoplasty surgery. Objective understanding of relative SSTE thickness in patients is essential to optimal outcomes in rhinoplasty, and knowledge of its variation by demographic group is of aid to surgeons. To measure and compare nasal SSTE thickness across different races and nasal subsites and to determine whether objective variability exists for these parameters. Retrospective cross-sectional radiographic analysis was carried out on 200 adult patients, without nasal deformity, presenting to an academic otolaryngology clinic at a tertiary care academic referral center. Blinded evaluators measured nasal SSTE thickness at six sites on maxillofacial computed tomography (CT) scans and comparisons were made based on patient-reported race/ethnicity categories available in the electronic medical record. N/A Nasal SSTE thickness was measured at six predefined anatomic sites using high-resolution CT imaging. Statistical comparisons between races/ethnicities were made based on these measurements. Mean age of patients was 48.8 years, and 47% were male. Nasal SSTE showed thicker soft tissue at the sellion in Latin American (LA; mean (SD) 6.1 (1.8) mm) and white (5.8 (1.8) mm) patients vs. African American (AfA) and Asian American (AsA) patients. The supratip was thicker in AfA patients (5.2 (1.3) mm) vs. all other races. The tip SSTE was thinner in white patients (2.4 (0.7) mm) vs. all other races. Composite nasal SSTE thickness was thinner in AsA patients (3.22 (0.8) mm) relative to AfA and LA patients. SSTE thickness influences surgical planning and postoperative outcomes in rhinoplasty patients. This study supports varied thickness of the nasal SSTE among patients of different races. These data are foundational in providing a framework for developing treatment strategies specific to the SSTE properties of a multicultural patient population.
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http://dx.doi.org/10.1089/fpsam.2019.0008DOI Listing
November 2020

Setbacks in Forehead Feminization Cranioplasty: A Systematic Review of Complications and Patient-Reported Outcomes.

Aesthetic Plast Surg 2020 06 9;44(3):743-749. Epub 2020 Mar 9.

Section of Facial Plastic and Reconstructive Surgery, Department of Otorhinolaryngology-Head and Neck Surgery, Rush University Medical Center, 1611 W. Harrison Street; Suite 550, Chicago, IL, 60612, USA.

Importance: Forehead feminization cranioplasty (FFC) is an important component of gender-affirming surgery and has become increasingly popular in recent years. Little objective evidence exists for the procedure's safety and clinical impact via patient-reported outcome measures (PROMs).

Objective: To determine what complications are observed following FFC, the relative frequency of complications by surgical technique, and what impact the procedure has on patient's quality of life.

Data Sources: Database searches were performed in PubMed/MEDLINE, Scopus, CINAHL, Cochrane CENTRAL, Cochrane Database of Systematic Reviews, and PsycINFO. The search terms included variations of forehead setback/FFC. Both controlled vocabularies (i.e., MeSH and CINAHL's Suggested Subject Terms) and keywords in the title or abstract fields were searched.

Study Selection: Two independent reviewers screened the titles and abstracts of all articles. Two independent surgeon reviewers evaluated the full text of all included articles, and relevant data points were extracted.

Main Outcomes And Measures: Complications and complication rate observed following FFC. Additional outcome measures were the approach utilized, concurrent procedures performed, and the use and findings of a PROM.

Results: Ten articles describing FFC were included, encompassing 673 patients. The overall pooled complication rate was 1.3%. PROMs were used in half of studies, with no standardization among studies.

Conclusions And Relevance: Complications following FFC are rare and infrequently require reoperation. Further studies into standardized and validated PROMs in facial feminization patients are warranted.

Level Of Evidence Iii: 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.
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http://dx.doi.org/10.1007/s00266-020-01664-8DOI Listing
June 2020

An Update on Level of Evidence Trends in Facial Plastic Surgery Research.

Facial Plast Surg Aesthet Med 2020 Mar/Apr;22(2):105-109

Section of Facial Plastic and Reconstructive Surgery, Department of Otorhinolaryngology-Head and Neck Surgery, Rush University Medical Center, Chicago, Illinois.

Knowledge of the quality of evidence in facial plastic surgery research is essential for the implementation of evidence-based practices. The purpose of this study is to provide an update over the past decade as to whether the level of evidence in leading journals featuring topics in facial plastic surgery has changed in comparison with prior reports. This study is a systematic review, designed to evaluate the level of evidence observed in the facial plastic surgery literature over time. Five journals were queried using facial plastic surgery keywords for four selected years for a 10-year period. After screening, articles were assessed for the presence of various methodological traits and were evaluated for overall level of evidence. These variables were compared across the years studied to evaluate trends in level of evidence. A total of 826 articles were included for final review. For all selected years, level IV or level V evidence was the most prevalent level of evidence. Over time, significantly less level IV ( = 0.009) and significantly more level II ( = 0.007) evidence was published. The proportion of studies reporting confidence intervals ( < 0.001) and -values ( = 0.02) were significantly greater in later years. The level of evidence of facial plastic surgery literature has increased over time, as demonstrated by an increased proportion of level II evidence, decreased proportion of level IV evidence, and increased use of -values and confidence intervals. The absolute number of randomized controlled trials continues to remain low.
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http://dx.doi.org/10.1089/fpsam.2019.0003DOI Listing
August 2020

The Selfie View: Perioperative Photography in the Digital Age.

Aesthetic Plast Surg 2020 06 9;44(3):1066-1070. Epub 2020 Jan 9.

Section of Facial Plastic and Reconstructive Surgery, Department of Otorhinolaryngology-Head and Neck Surgery, Rush University Medical Center, 1611 W. Harrison Street; Suite 550, Chicago, IL, USA.

Background: The aesthetics of social media have become increasingly important to cosmetic surgery patients in recent years; however, aesthetic treatments have not kept pace with the desires of modern patients. The current study investigates the most common angles employed by various user cohorts when posting a selfie on social media platforms and proposes that aesthetic surgeons consider utilizing a selfie angle alongside standard pre- and postoperative photographic views.

Methods: Full face photographs published on the social media platform Instagram™ with the tag #selfie were divided into three cohorts: female models/influencers, amateur females, and amateur males. Each cohort contained 100 photographs. The photographs were analyzed using cloud-based facial analysis software for facial pan, roll, and tilt relative to the camera.

Results: One hundred photographs from each cohort were analyzed and demonstrated that amateur females (AF) take photographs from higher angles than amateur males (AM) or model females (MF). Roll-off-midline was significantly greater for AF and MF as compared to AM. The MF group had significantly a greater pan-off-midline as compared to AF and AM, while AF had significantly a greater pan-off-midline than AM.

Conclusions: Common photography practices employed within selfie photographs utilize angles not captured in standard perioperative photographs. This study supports the implementation of a selfie photograph into the standard set of pre- and postoperative photographs taken by aesthetic surgeons to evaluate the effects of interventions in the context of selfie photography. The angle employed can vary depending upon the demographic profile of the patient.

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.
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http://dx.doi.org/10.1007/s00266-019-01593-1DOI Listing
June 2020

Association of Perioperative Opioid-Sparing Multimodal Analgesia With Narcotic Use and Pain Control After Head and Neck Free Flap Reconstruction.

JAMA Facial Plast Surg 2019 Sep;21(5):446-451

Section of Facial Plastic and Reconstructive Surgery, Department of Otorhinolaryngology-Head and Neck Surgery, Rush University Medical Center, Chicago, Illinois.

Importance: An increase in narcotic prescription patterns has contributed to the current opioid epidemic in the United States. Opioid-sparing perioperative analgesia represents a means of mitigating the risk of opioid dependence while providing superior perioperative analgesia.

Objective: To assess whether multimodal analgesia (MMA) is associated with reduced narcotic use and improved pain control compared with traditional narcotic-based analgesics at discharge and in the immediate postoperative period after free flap reconstructive surgery.

Design, Setting, And Participants: This retrospective cohort study assessed a consecutive sample of 65 patients (28 MMA, 37 controls) undergoing free flap reconstruction of a through-and-through mucosal defect within the head and neck region at a tertiary academic referral center from June 1, 2017, to November 30, 2018. Patients and physicians were not blinded to the patients' analgesic regimen. Patients' clinical courses were followed up for 30 days postoperatively.

Interventions: Patients were administered a preoperative, intraoperative, and postoperative analgesia regimen consisting of scheduled and as-needed neuromodulating and anti-inflammatory medications, with narcotic medications reserved for refractory cases. Control patients were administered traditional narcotic-based analgesics as needed.

Main Outcomes And Measures: Narcotic doses administered during the perioperative period and at discharge were converted to morphine-equivalent doses (MEDs) for comparison. Postoperative Defense and Veterans Pain Rating Scale pain scores (ranging from 0 [no pain] to 10 [worst pain imaginable]) were collected for the first 72 hours postoperatively as a patient-reported means of analyzing effectiveness of analgesia.

Results: A total of 28 patients (mean [SD] age, 64.1 [12.3] years; 17 [61%] male) were included in the MMA group and 37 (mean [SD] age, 65.0 [11.0] years; 22 [59%] male) in the control group. The number of MEDs administered postoperatively was 10.0 (interquartile range [IQR], 2.7-23.1) in the MMA cohort and 89.6 (IQR, 60.0-104.5) in the control cohort (P < .001). Mean (SD) Defense and Veterans Pain Rating Scale pain scores postoperatively were 2.05 (1.41) in the MMA cohort and 3.66 (1.99) in the control cohort (P = .001). Median number of MEDs prescribed at discharge were 0 (IQR, 0-18.8) in the MMA cohort and 300.0 (IQR, 262.5-412.5) in the control cohort (P < .001).

Conclusions And Relevance: The findings suggest that after free flap reconstruction, MMA is associated with reduced narcotic use at discharge and in the immediate postoperative period and with superior analgesia as measured by patient-reported pain scores. Patients receiving MMA achieved improved pain control, and the number of narcotic prescriptions in circulation were reduced.

Level Of Evidence: 3.
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http://dx.doi.org/10.1001/jamafacial.2019.0612DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6692678PMC
September 2019

Enhanced recovery after surgery in head and neck surgery: Reduced opioid use and length of stay.

Laryngoscope 2020 05 17;130(5):1227-1232. Epub 2019 Jul 17.

Department of Otorhinolaryngology-Head and Neck Surgery, Rush University Medical Center, Chicago, Illinois, U.S.A.

Objectives: Enhanced recovery after surgery (ERAS) protocols were first developed in colorectal surgery and sought to standardize patient care. There have been several studies in the head and neck surgical literature looking at outcomes after ERAS protocol, but no studies focusing on narcotic use and length of stay. This study aimed to evaluate narcotic usage and length of stay, in addition to several other outcomes, following the implementation of an ERAS protocol.

Methods: A head and neck-specific ERAS protocol was implemented at this tertiary care center beginning July 2017. A retrospective cohort study was performed comparing this cohort to that of a retrospective control group. Outcomes included mean morphine equivalent dose, mean pain score, and percentage of patients prescribed narcotics on discharge. Secondary outcomes included ICU and total length of stay.

Results: The mean morphine equivalent dose (MED) administered within 72 hours postoperatively was significantly lower in the ERAS group (17.5 ± 46.0 mg vs. 82.7 ± 116.1 mg, P < .001). Average postoperative pain scores in the first 72 hours were lower in the ERAS group (2.6 ± 1.8 vs. 3.6 ± 1.9; P < .001). The average length of stay was shorter for ERAS patients (7.8 ± 4.8 vs. 9.7 ± 4.7 days, P = .008); however, there was no significant difference in ICU length of stay.

Conclusion: Following implementation of an ERAS protocol, patients undergoing head and neck surgery had decreased narcotic use in the immediate postoperative period and at discharge, while also demonstrating improved postoperative analgesia.

Level Of Evidence: Level 3 Laryngoscope, 130:1227-1232, 2020.
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http://dx.doi.org/10.1002/lary.28191DOI Listing
May 2020

Facial reanimation: an update on nerve transfers in facial paralysis.

Curr Opin Otolaryngol Head Neck Surg 2019 Aug;27(4):231-236

Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology - Head and Neck Surgery, Rush University Medical Center, Chicago, Illinois, USA.

Purpose Of Review: The aim of this article is to review the recent literature on nerve transfers in facial paralysis. The discussion focuses on direct nerve repair and three types of nerve transfers, cross facial nerve graft, hypoglossal, and masseter nerve transfers.

Recent Findings: Masseteric nerve transfers have a high probability of creating significant movement, although tone is poor. The hypoglossal to facial nerve transfer is reliable in affording facial tone and has been updated to involve a transposition technique that offers good results with minimal morbidity. Combination nerve transfer techniques using multiple cranial nerves or cross-face nerves are increasingly described.

Summary: Reinnervation of the facial nerve and neural regeneration in general are areas of intense research and novel surgical approaches continue to be explored. Although direct nerve repair is the most ideal, other nerve transfers can be performed with good results. More specifically, the masseteric nerve transfer can provide excellent movement and the hypoglossal transfer good tone. Combination transfers may afford the benefits of multiple nerves.
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http://dx.doi.org/10.1097/MOO.0000000000000543DOI Listing
August 2019

Slowly progressive facial paralysis: Intraneural squamous cell carcinoma of unknown primary.

Am J Otolaryngol 2019 Jan - Feb;40(1):129-131. Epub 2018 Oct 13.

Department of Otorhinolaryngology, Head and Neck Surgery, Rush University Medical Center, 1611 W. Harrison St., Suite 550, Chicago, IL 60612, United States of America. Electronic address:

Background: In this report, we present a unique case of intraneural squamous cell carcinoma of unknown primary found within the facial nerve and the proposed algorithms for diagnosis and management of progressive idiopathic facial paralysis.

Case Presentation: A 66-year-old female with a previous history of basal cell carcinoma presented with right-sided progressive facial paralysis. Repeated magnetic resonance imaging as well as targeted workup failed to reveal a diagnosis. 20 months following symptom onset, after the patient's facial function slowly progressed to a complete paralysis, repeat magnetic resonance imaging revealed enhancement at the stylomastoid foramen. The patient underwent superficial parotidectomy, transmastoid facial nerve decompression and resection of descending and proximal extratemporal facial nerve segments, as well as great auricular nerve interposition grafting. Intraoperatively, frozen sections from the surface of the facial nerve, and the proximal and distal segments of the facial nerve following resection, were negative for malignancy. The final pathology revealed infiltrating poorly differentiated squamous cell carcinoma of the facial nerve with negative margins.

Conclusion: In cases of slowly progressive facial paralysis the clinician needs to consider malignancy until proven otherwise. Without an identifiable primary malignancy, early algorithmic assessment of presenting characteristics may facilitate expedited clinical decision making and surgical management of malignancy involving the facial nerve. In cases of slowly progressive facial paralysis, when the time comes for surgical exploration and biopsy, head and neck surgeons must be aware that malignancy can exist entirely within the facial nerve, without pathologic changes on the surface of the nerve or in the surrounding tissue.
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http://dx.doi.org/10.1016/j.amjoto.2018.10.004DOI Listing
April 2019

Prognostic factors and survival outcomes for head and neck cutaneous adnexal cancers.

Am J Otolaryngol 2019 Jan - Feb;40(1):110-114. Epub 2018 Sep 22.

Department of Otorhinolaryngology - Head and Neck Surgery, Rush University Medical Center, Chicago, IL, United States of America.

Objectives: Malignant cutaneous adnexal tumors (MCAT) are rare and comprise a heterogeneous group of cancers. There have been several studies reviewing prognostic factors of these tumors, but no studies focusing on the head and neck. This study aimed to review a large population based database to evaluate prognostic factors that could impact survival.

Methods: The Surveillance, Epidemiology, and End Results (SEER) database was utilized to identify patients with MCAT of the head and neck. Both overall and disease specific survival were the main outcome measures for the study. Univariate and multivariate analyses were performed to evaluate the association of suspected prognostic factors with survival.

Results: The five-year OS and DSS were 72.6 and 95.5%, respectively. A favorable factor for OS was surgical resection ([HR] 0.324; P = 0.001), while unfavorable factors for OS include older age (1.051; P < 0.001), higher tumor grade (1.254; P = 0.049), larger tumor size (1.293; P = 0.003), and positive nodal involvement (3.323; P = 0.002). A favorable factor for DSS was surgical resection (0.026; P < 0.001). Unfavorable factors for DSS include older age (1.058; P = 0.046), larger tumor size (2.528; 1.565-4.085; P < 0.001), and positive nodal involvement (4.761; P = 0.022).

Conclusion: Review of the SEER database shows good 5-year OS and DSS rates, similar to those cited in other studies. We identified several prognostic factors associated with survival, while histologic sub-type does not seem to be associated with survival. Surgical resection is the mainstay of treatment.
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http://dx.doi.org/10.1016/j.amjoto.2018.09.011DOI Listing
April 2019

Use of Objective Metrics in Dynamic Facial Reanimation: A Systematic Review.

JAMA Facial Plast Surg 2018 Dec;20(6):501-508

Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland.

Importance: Facial nerve deficits cause significant functional and social consequences for those affected. Existing techniques for dynamic restoration of facial nerve function are imperfect and result in a wide variety of outcomes. Currently, there is no standard objective instrument for facial movement as it relates to restorative techniques.

Objective: To determine what objective instruments of midface movement are used in outcome measurements for patients treated with dynamic methods for facial paralysis.

Data Sources: Database searches from January 1970 to June 2017 were performed in PubMed, Embase, Cochrane Library, Web of Science, and Scopus. Only English-language articles on studies performed in humans were considered. The search terms used were ("Surgical Flaps"[Mesh] OR "Nerve Transfer"[Mesh] OR "nerve graft" OR "nerve grafts") AND (face [mh] OR facial paralysis [mh]) AND (innervation [sh]) OR ("Face"[Mesh] OR facial paralysis [mh]) AND (reanimation [tiab]).

Study Selection: Two independent reviewers evaluated the titles and abstracts of all articles and included those that reported objective outcomes of a surgical technique in at least 2 patients.

Main Outcomes And Measures: The presence or absence of an objective instrument for evaluating outcomes of midface reanimation. Additional outcome measures were reproducibility of the test, reporting of symmetry, measurement of multiple variables, and test validity.

Results: Of 241 articles describing dynamic facial reanimation techniques, 49 (20.3%) reported objective outcome measures for 1898 patients. Of those articles reporting objective measures, there were 29 different instruments, only 3 of which reported all outcome measures.

Conclusions And Relevance: Although instruments are available to objectively measure facial movement after reanimation techniques, most studies do not report objective outcomes. Of objective facial reanimation instruments, few are reproducible and able to measure symmetry and multiple data points. To accurately compare objective outcomes in facial reanimation, a reproducible, objective, and universally applied instrument is needed.
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http://dx.doi.org/10.1001/jamafacial.2018.0398DOI Listing
December 2018

Short-term donor site morbidity: A comparison of the anterolateral thigh and radial forearm fasciocutaneous free flaps.

Head Neck 2016 04 18;38 Suppl 1:E945-8. Epub 2015 Jul 18.

Cleveland Clinic Head and Neck Institute, Cleveland, Ohio.

Background: Donor site morbidity is an important consideration in the overall decision-making algorithm for fasciocutaneous free flap reconstruction of the head and neck.

Methods: A retrospective case series was conducted of donor site complications occurring within 30 days of surgery among 226 consecutive anterolateral thigh (ALT) or radial forearm free flap (RFFF) microvascular free tissue transfers performed by multiple reconstructive surgeons between 2005 and 2010.

Results: A greater number of donor site complications occurred among patients undergoing RFFF versus ALT free flaps (40; 35.4%; vs 14; 12.4%; p < .001). Wound dehiscence occurred significantly more frequently among patients undergoing RFFF versus ALT free flap reconstruction (34; 30%; vs 6; 5%; p < .001). Tendon exposure occurred in 16 of the 113 RFFFs (14.1%). Seromas occurred more commonly in the ALT group (6; 5%; vs 2; 1.7%; p = .280).

Conclusion: Although short-term donor site morbidity was low in both groups, the ALT was associated with a significantly lower incidence of wound dehiscence with or without tendon exposure. © 2015 Wiley Periodicals, Inc. Head Neck 38: E945-E948, 2016.
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http://dx.doi.org/10.1002/hed.24131DOI Listing
April 2016

Gracilis microneurovascular transfer for facial paralysis.

Facial Plast Surg 2015 Apr 8;31(2):134-9. Epub 2015 May 8.

Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland.

Facial nerve dysfunction occurs in varying degrees of severity due to several causes, and leads to asymmetric or absent facial movements. Regardless of the etiology, facial nerve dysfunction can be functionally and psychologically devastating. Many techniques to restore facial symmetry both at rest and with motion have been pursued throughout history. Within the past 30 years, free muscle microneurovascular transfer techniques have been developed to provide symmetric motion to the face. The aim of this article is to describe one of the most common and reliable techniques to restore midface mobility, namely, gracilis microneurovascular transfer.
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http://dx.doi.org/10.1055/s-0035-1549044DOI Listing
April 2015

Failed organ preservation strategy for adult laryngeal embryonal rhabdomyosarcoma.

Am J Otolaryngol 2015 Mar-Apr;36(2):277-9. Epub 2014 Oct 14.

Head and Neck Institute, The Cleveland Clinic Foundation, Cleveland, OH, USA. Electronic address:

Purpose: To present a case of embryonal rhabdomyosarcoma of the intrinsic laryngeal musculature and discuss the treatment of this rare tumor.

Methods And Materials: A 45year-old male presented with an eleven month history of hoarseness. A mass of the posterior glottis was noted on fiberoptic laryngoscopy. Computed tomography indicated a 1.5×2.5cm laryngeal mass without cartilage involvement. Direct laryngoscopy and biopsy were consistent with embryonal rhabdomyosarcoma involving the interarytenoid muscle. A multidisciplinary tumor board recommended multimodality therapy including total laryngectomy. His case was reviewed along with the available English language literature.

Results: The patient refused surgery, and he qualified for a pediatric rhabdomyosarcoma treatment protocol with induction chemotherapy followed by combined chemoradiation. There was no noted response and the patient was taken off protocol to increase the radiation dose without chemotherapy. Fifteen weeks following radiation, a repeat biopsy revealed viable tumor. The patient elected further experimental chemotherapy at an outside hospital. The patient currently is alive at 34months post-treatment with suspected persistent disease and continues to refuse surgery.

Conclusions: Embryonal rhabdomyosarcoma involving the larynx is an extremely rare tumor usually seen in children. There have been few previous adult cases reported and treatment options are not well described. We present a case of chemoradiation failure in an adult with embryonal rhabdomyosarcoma refusing surgical intervention. Although pediatric tumors can be effectively treated with organ preservation strategies, adult tumors may have a poorer response. Based upon our experience and existing literature regarding adult embryonal rhabdomyosarcoma of the larynx, multimodality therapy including surgical resection should be the treatment of choice.
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http://dx.doi.org/10.1016/j.amjoto.2014.10.011DOI Listing
November 2015

Minimizing morbidity in microvascular surgery: small-caliber anastomotic vessels and minimal access approaches.

JAMA Facial Plast Surg 2015 Jan-Feb;17(1):44-8

Department of Otolaryngology-Head and Neck Surgery, University of California-San Francisco, Medical Center, San Francisco.

Importance: Minimizing morbidity when performing free flap reconstruction of the head and neck is important in the overall reconstructive paradigm.

Objective: To examine the indications and success rates of free tissue transfer using small-caliber facial recipient vessels and minimal access incisions.

Design, Setting, And Participants: Retrospective medical record review of patients with head and neck defects undergoing free tissue transfer from May 2010 to June 2013 at 2 tertiary care academic medical centers.

Interventions: Free tissue transfer using small-caliber recipient vessels and minimal access approaches.

Main Outcomes And Measures: Postoperative complications, including flap failure, requirement for revision surgery, and nerve dysfunction.

Results: Eighty-nine flaps in 86 patients met inclusion criteria. Fifty flaps used the facial artery and vein distal to the facial notch, and 33 flaps used the superficial temporal vascular system. Six flaps used the angular artery and vein. A variety of flap donor sites were included. In most cases, free tissue transfer was indicated for the reconstruction of defects secondary to extirpation of malignant neoplasia. Overall success rate was 97.7% with 2 instances of total flap loss and 1 partial loss. One patient had transient nerve weakness (frontal branch), which resolved during a follow-up of 9 months.

Conclusions And Relevance: Free tissue reconstruction of head and neck defects can be safely and reliably accomplished using small-caliber recipient vessels, such as the superficial temporal, distal facial, and angular vessels. Minimal access approaches for microvascular anastomosis may be performed with excellent cosmesis and minimal morbidity.

Level Of Evidence: 4.
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http://dx.doi.org/10.1001/jamafacial.2014.875DOI Listing
October 2015

Anterolateral thigh adipofascial flap in mucosal reconstruction.

JAMA Facial Plast Surg 2014 Nov-Dec;16(6):395-9

Head and Neck Institute, Department of Otolaryngology-Head and Neck Surgery, Cleveland Clinic, Cleveland, Ohio.

Importance: This study describes a reliable technique for mucosal reconstruction of large defects using components of a common free flap technique.

Objective: To review the harvest technique and the varied scenarios in which the anterolateral thigh adipofascial flap (ALTAF) can be used for mucosal restoration in oral cavity and nasal reconstruction.

Design, Setting, And Participants: A retrospective review of the medical records of 51 consecutive patients was conducted. The patients had undergone ALTAF head and neck reconstruction between January 2009 and June 2013. Each case was reviewed, and flap survival and goal-oriented results were evaluated.

Results: Thirty patients met the inclusion criteria and were included in the analysis. The mean patient age was 60.6 years. Reconstruction sites included the tongue, palate, gingiva, floor of the mouth, and nasal mucosa. All mucosal reconstructions maintained function and form of replaced and preserved tissues. One patient (3%) experienced flap failure that was reconstructed with a contralateral adipofascial flap with excellent outcome. Three patients (10%) required minor flap revisions. There were no other complications.

Conclusions And Relevance: The ALTAF is a versatile flap easily harvested for use in several types of mucosal reconstructions.
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http://dx.doi.org/10.1001/jamafacial.2014.447DOI Listing
February 2016

Voice outcomes following reconstruction of laryngopharyngectomy defects using the radial forearm free flap and the anterolateral thigh free flap.

Laryngoscope 2014 Feb 15;124(2):397-400. Epub 2013 Oct 15.

Head and Neck Institute, Cleveland Clinic, Cleveland, Ohio.

Objectives/hypothesis: Patients undergoing laryngopharyngectomy with extensive pharyngeal mucosal resection or those failing chemoradiation protocols are commonly reconstructed using free tissue transfer. Radial forearm free flaps (RFFFs) and anterolateral thigh free flaps (ALTs) are two of the most commonly used free flaps for laryngopharyngectomy reconstruction. It has been suggested that alaryngeal tracheoesophageal prosthesis (TEP) speech outcomes in patients undergoing ALT reconstruction may be inferior due to the possibly bulkier neopharynx. We report the results of patients treated with ALT and RFFF with regard to postoperative TEP voice outcomes.

Study Design: Retrospective cohort study.

Methods: We identified 42 consecutive patients who were treated with total laryngopharyngectomy and free flap reconstruction utilizing either RFFFs (20 patients) or ALTs (22 patients) between April 2001 and August 2010. Evaluations with statistical analysis of standard TEP speech outcome measures (maximal sustained phonation, fluent count, syllable count) and qualitative variables were conducted.

Results: Patient demographics were similar between the RFFF and ALT groups, and 95% and 91% of RFFF and ALT patients received radiation therapy, respectively. Subjective voice quality did not significantly differ between the groups. Differences in outcomes of intelligibility, maximal sustained phonation time, maximum number of syllables, and fluent count, as evaluated by a single speech pathologist, were not statistically significant between RFFF and ALT patients. There was no difference in postoperative complications.

Conclusions: These data indicate that reconstruction of laryngopharyngectomy defects using either the ALT or RFFF technique can produce similarly acceptable TEP voice results.

Level Of Evidence: 2b.
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http://dx.doi.org/10.1002/lary.23785DOI Listing
February 2014