Publications by authors named "Tom Shokri"

65 Publications

Postoperative outcomes of autologous rib graft for microtia repair in children: A NSQIP study.

Int J Pediatr Otorhinolaryngol 2021 Jul 27;146:110733. Epub 2021 Apr 27.

Department of Otolaryngology - Head and Neck Surgery, Pennsylvania State University, College of Medicine, Hershey, PA, USA.

Objective: To compare the effect of surgical specialty and patient factors on 30-day postoperative outcomes and complications for children undergoing autologous costochondral grafting for microtia reconstruction.

Methods: The American College of Surgeons National Surgical Quality Improvement Program Pediatric (NSQIP-P) database was searched from 2012 through 2017 for patients who underwent autologous rib grafting (CPT 21230). The group was further filtered for coexisting ICD 9 or 10 code for microtia (744.23, Q17.2) as an indication for surgery. Outcomes analyzed included patient demographics, medical comorbidities, admission type (inpatient vs. outpatient), operative time, surgeon specialty, length of hospital stay (LOS), complications, and readmission.

Results: A total of 375 pediatric patients were identified of which 157 were female and 218 were male. Mean age at time of surgery was 9.6 years. Postoperative complications and readmission occurred in 5.6% and 3.5% of patients, respectively. Surgical site infection was the most common complication. Average operative time was 246.9 min. When comparing Otolaryngology to Plastic Surgery with multivariate analysis, there was no difference in admission type (OR 1.00, p = 0.993), complication rate (OR 0.91, p = 0.744), readmission (OR 0.68, p = 0.576), operative time (p = 0.471) or total LOS (p = 0.266).

Conclusion: The present study demonstrated postoperative complications and readmission rates following microtia repair as reported by the NSQIP-P database. Overall complication and readmission rates were low. No significant risk factors were identified on multivariate analysis. There were no differences between surgical specialty for complication rate, operative time, hospital stay or readmission when accounting for demographic data and comorbidities.
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http://dx.doi.org/10.1016/j.ijporl.2021.110733DOI Listing
July 2021

Facial Protection to Prevent Facial Trauma and Allow for Optimal Protection after Facial Fracture Repair.

Facial Plast Surg 2021 Feb 1. Epub 2021 Feb 1.

Department of Facial Plastics, Otolaryngology and Facial Plastic Surgery Associates, Fort Worth, Texas.

Facial skeletal fractures continue to affect humankind, and many methods to alleviate and prevent the injuries outright have been sought after. Prevention is desired, but the implementation and general compliance may contribute to missed opportunities to decrease the burden of facial skeletal trauma. In this article, we explore the preventative as well as postoperative options for the protection of the facial skeleton.
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http://dx.doi.org/10.1055/s-0041-1723006DOI Listing
February 2021

Perfusion dynamics in pedicled and free tissue reconstruction: Infrared thermography and laser fluorescence video angiography.

Am J Otolaryngol 2021 Mar-Apr;42(2):102751. Epub 2020 Oct 17.

Pennsylvania State Health Milton S Hershey Medical Center, Dept Otolaryngology, Director, Facial Plastic & Reconstructive Surgery, United States of America.

Objective: Preoperative planning, design, and perioperative monitoring of microsurgical free flaps is of paramount importance to successful reconstruction. Infrared Thermography provides an indirect method by which vascular perfusion may be monitored and has previously shown efficacy in detection of cutaneous perforators. In a proof-of-concept study, we assessed the utility of infrared thermography in delineating angiosomes and monitoring for adequate tissue perfusion in the preoperative, intraoperative, and postoperative setting. This technology was compared to conventional indocyanine green fluorescence angiography (ICG-FA).

Method: Four patients undergoing locoregional pedicled or free flap reconstruction were assessed using ICG-FA and Forward-looking infrared (FLIR) thermography in standardized conditions. Monitoring of flap angiosomes and tissue perfusion using both fluorescent pixel intensity and thermography was then performed implementing proprietary software.

Conclusion: Our study is unique in that tissue perfusion intraoperatively was assessed with both thermography and indocyanine green fluorescence angiography (ICG-FA), which represents a previously established system. We demonstrate that smartphone compatible thermal cameras may be used as an adjunct to clinical exam, as well as other monitoring technologies, providing further information in not only selection of perforators, in the operative setting, but also in the early detection of poor flap viability secondary to microvascular compromise allowing for timely salvage.
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http://dx.doi.org/10.1016/j.amjoto.2020.102751DOI Listing
October 2020

Erratum: Surgical Techniques to Improve the Soft Tissue Triangle in Rhinoplasty: A Systematic Review.

Facial Plast Surg 2021 Jan 11. Epub 2021 Jan 11.

Otolaryngology and Facial Plastic Surgery Associates, Fort Worth, Texas.

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http://dx.doi.org/10.1055/s-0040-1718516DOI Listing
January 2021

Rugby-related adult maxillofacial trauma injuries: a NEISS database study.

Oral Maxillofac Surg 2021 Jan 7. Epub 2021 Jan 7.

Department of Otolaryngology-Head and Neck Surgery, University of Arizona College of Medicine, 1501 N. Campbell Avenue, Tucson, AZ, 85724, USA.

Purpose: The primary objective of this study is to delineate the data on maxillofacial trauma in rugby utilizing the National Electronic Injury Surveillance System (NEISS) database. Specifically, we want to establish the prevalence of facial rugby injuries in terms of age, mechanism of injury, and degree of injury in order to develop ways to limit facial trauma in the future.

Methods: The NEISS database was accessed in February 2020 in order to identify adult patients (> 19 years of age) presenting to the emergence department (ED) for rugby-related head and facial injuries from the previous 10 years (2009-2018). Descriptive statistics were organized and presented. Chi-squared testing (χ) was performed to compare categorical variables, and ANOVA was performed to compare continuous variables.

Results: A total of 507 patients (national estimate = 18,952) from 2009 to 2018 were identified as appropriate for study inclusion. The most common injuries were those to the facial region including the eyelid, eye area, and nose (59.4%). The most frequently encountered facial fracture while playing rugby was the nasal bone (58.6%). Overall, 98.4% of patients who presented to the ED with rugby injuries were treated and released, 1.2% were admitted or observed, and 0.4% left against medical advice.

Conclusions: When evaluating a patient with a rugby-related injury, one should expect injuries to the eyelid, eye area, or nose. The most common fracture pattern will most likely be nasal bone. Despite these injuries, the vast majority of patients will be treated and released.
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http://dx.doi.org/10.1007/s10006-020-00925-9DOI Listing
January 2021

Flap Failure and Salvage in Head and Neck Reconstruction.

Semin Plast Surg 2020 Nov 24;34(4):314-320. Epub 2020 Dec 24.

Otolaryngology and Facial Plastic Surgery Associates, Fort Worth, Texas.

With advanced head and neck ablative surgery comes the challenge to find an ideal reconstructive option that will optimize functional and aesthetic outcomes. Contemporary microvascular reconstructive surgery with free tissue transfer has become the standard for complex head and neck reconstruction. With continued refinements in surgical techniques, larger surgical volumes, and technological advancements, free flap success rates have exceeded 95%. Despite these high success rates, postoperative flap loss is a feared complication requiring the surgeon to be aware of potential options for successful salvage. The purpose of this article is to review free flap failure and ways to optimize surgical salvage in the scenario of flap compromise.
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http://dx.doi.org/10.1055/s-0040-1721766DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7759432PMC
November 2020

Paradigms in Complex Facial Scar Management.

Semin Plast Surg 2020 Nov 24;34(4):305-313. Epub 2020 Dec 24.

Otolaryngology and Facial Plastic Surgery Associates, Fort Worth, Texas.

The process of scar formation is a sequela of the healing following soft tissue injury extending to, or through, the reticular dermis. Scars, within the head and neck in particular, may be physically disfiguring with resultant psychosocial implications. Mitigation of excessive scar formation during the healing process following surgery, or in the setting of trauma, begins with meticulous soft tissue handling and reconstructive technique. The reconstructive surgeon's armamentarium must therefore include techniques that minimize initial scar formation and revision techniques that address unfavorable outcomes. With this in mind, this article reviews both conservative nonsurgical and surgical treatment modalities that mitigate scar formation or address mature scar formation.
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http://dx.doi.org/10.1055/s-0040-1721768DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7759425PMC
November 2020

Complications in Skull Base Surgery and Subsequent Repair.

Semin Plast Surg 2020 Nov 24;34(4):286-292. Epub 2020 Dec 24.

Otolaryngology and Facial Plastic Surgery Associates, Fort Worth, Texas.

Over the past several decades, endoscopic sinus surgery has revolutionized the approach to skull base surgery. Open skull base approaches remain a viable option for advanced skull base tumors. Complications have gone down with increased reliability of vascularized tissue transfer. In this article, the authors explore the various complications that can present following skull base surgery and review the approaches for repair when such issues are encountered.
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http://dx.doi.org/10.1055/s-0040-1721765DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7759428PMC
November 2020

Modern Management of Facial Nerve Disorders.

Semin Plast Surg 2020 Nov 24;34(4):277-285. Epub 2020 Dec 24.

Otolaryngology and Facial Plastic Surgery Associates, Fort Worth, Texas.

Facial paralysis is a devastating condition, encompassing a spectrum of disorders, with resultant psychosocial, functional, and aesthetic sequelae. With this in mind, an individualized treatment approach based on the cause, pattern, and duration of palsy is necessary. Treatment options include pharmacologic agents, corneal protective interventions, physical therapy, and surgical procedures. The use of steroids and antivirals in the setting of idiopathic facial paralysis or virus-associated facial paralysis is well supported. Despite the diversity of surgical interventions described, there is a lack of consensus regarding optimal treatment. This article provides an overview of the current management of facial paralysis. Medical, surgical, and physical treatment options are discussed with a review of the relevant literature.
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http://dx.doi.org/10.1055/s-0040-1721824DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7759435PMC
November 2020

Complications in Facial Esthetic Surgery.

Semin Plast Surg 2020 Nov 24;34(4):272-276. Epub 2020 Dec 24.

Otolaryngology and Facial Plastic Surgery Associates, Fort Worth, Texas.

Esthetic surgery continues to become increasingly popular both in the United States and globally. Facial esthetic procedures in particular account for a large proportion of procedures performed. This increase in popularity will inevitably result in the number of potential complications associated with these procedures. In this review, the authors describe common complications encountered with frequently performed cosmetic facial procedures and their associated management. This article is meant as a general overview and introduction to potential complications surgeons may encounter, interested readers are encouraged to further review comprehensive subspecialty literature for more detailed discussion.
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http://dx.doi.org/10.1055/s-0040-1721764DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7759431PMC
November 2020

Facial Transplantation: Complications, Outcomes, and Long-Term Management Strategies.

Semin Plast Surg 2020 Nov 24;34(4):245-253. Epub 2020 Dec 24.

Otolaryngology and Facial Plastic Surgery Associates, Fort Worth, Texas.

Within the past two decades, vascularized facial composite allotransplantation has evolved into a viable option in the reconstructive surgeons' armamentarium for patients with extensive facial disfigurements. As it has expanded the frontiers of microsurgical reconstructive techniques, facial transplantation has come to garner widespread interest within both the medical community and the general public. The procedure has established itself as an amalgamation of the forefronts of reconstructive microsurgery, immunology, and transplantation science. Therein too lies its complexity as multifaceted scientific developments are met with ethical and social issues. Both patients and physicians are faced with the everlasting challenges of immunosuppression regimens and their inherent complications, long-term aesthetic and functional considerations, the role of revision procedures, and the inevitable psychosocial implications. This article reflects on the medical and surgical advancements in facial transplantation surgery and highlights anticipated future challenges. It aims to encourage discussion regarding anticipated barriers to current practice and suggest future directions as we transition into the next phase of facial allograft transplantation.
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http://dx.doi.org/10.1055/s-0040-1721760DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7759434PMC
November 2020

Osteoradionecrosis of the Midface and Mandible: Pathogenesis and Management.

Semin Plast Surg 2020 Nov 24;34(4):232-244. Epub 2020 Dec 24.

Otolaryngology and Facial Plastic Surgery Associates, Facial Plastics, Fort Worth, Texas.

Radiation therapy is an important and commonly used treatment modality for head and neck cancers. Osteoradionecrosis (ORN) is a potential debilitating complication of treatment, which most commonly affects the mandible. Management strategies are tailored to the severity of disease. Medical management including oral rinses, irrigations, antibiotics, and pharmacological treatments is viable for mild-to-moderate ORN. More severe disease is best addressed with a combination of medical management and surgical intervention aimed at aggressively removing devitalized tissue until bleeding bone is encountered and reconstructing the soft tissue and bone defect. Reconstruction with either regional vascularized flaps or vascularized osteocutaneous free flaps in case of larger full-thickness bone defects (greater than 6 cm) or anterior mandible (medial to mental foramen) is most appropriate. Maxillary ORN complications can present with a wide range of functional problems and facial disfigurement. Life-threatening and time-sensitive problems should be treated first, such as skull base bone coverage or correction of severe ectropion, to avoid blindness from exposure keratopathy. Then, less time-sensitive issues can be addressed next, such as nasal obstruction, velopharyngeal insufficiency, and chronic tearing. It may require a combination of specialists from different disciplines to address various issues that can arise from maxillary ORN.
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http://dx.doi.org/10.1055/s-0040-1721759DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7759426PMC
November 2020

Septal Perforation Repair Using Bilateral Rotational Flaps With Interposed Mastoid Periosteal Graft.

Laryngoscope 2021 07 28;131(7):1497-1500. Epub 2020 Dec 28.

Otolaryngology and Facial Plastic Surgery Associates, Fort Worth, Texas, U.S.A.

Objectives/hypothesis: To evaluate the outcomes of endonasal repair of septal perforations utilizing opposing bilateral rotational flaps and a periosteum interposition graft.

Methods: Retrospective review of a single surgeon, tertiary referral center experience of patients who underwent septal perforation repair. Patient demographics, etiology of perforation, closure rate, and complication data were obtained. Patients screening positively for cocaine use or anti-neutrophil cytoplasmic antibodies (ANCA) were not offered repair.

Results: A total of 104 patients were included, 65 male and 39 female with mean age of 45.4 years. Etiology of perforations included prior surgery in 45, trauma in 15, and unknown in 44, and the average perforation size in each etiologic group were 1.35 cm, 1.25 cm, and 1.30 cm, respectively. The greatest dimension of perforations repaired ranged from 0.5 cm to 1.5 cm. The overall success rate was 87.5% at 6 month follow-up. Successful closure was achieved in 95.6%, 86.7%, and 79.5%, respectively (χ  = 5.264, P = .0218).

Conclusion: Our described technique is a reliable endonasal approach with predictable outcomes in septal perforations up to 1.5 cm in size. Having an unknown etiology of septal perforation may be a risk factor for failure.

Level Of Evidence: 4 Laryngoscope, 131:1497-1500, 2021.
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http://dx.doi.org/10.1002/lary.29347DOI Listing
July 2021

Palatomaxillary Obturation and Facial Prosthetics in Head and Neck Reconstruction.

Facial Plast Surg 2020 Dec 24;36(6):715-721. Epub 2020 Dec 24.

Otolaryngology and Facial Plastic Surgery Associates, Fort Worth, Texas.

Rehabilitation of head and neck defects following trauma, oncologic resection, or congenital malformation is a challenging task. Not only is the restoration of three-dimensional form necessary for acceptable cosmesis, but simultaneous restoration of functional speech and swallow is also essential for optimal reconstruction outcomes. While advances in free tissue transfer have allowed surgical reconstruction of head and neck defects once considered inoperable and associated with poor quality of life, not all patients are ideal surgical candidates. As such, nonsurgical solutions to both functional and cosmetic restoration remain a necessary alternative option. Facial prostheses and palatomaxillary obturators have evolved with increasingly biocompatible materials as well as retention systems to address significant defects that challenge the limits of surgical reconstruction.
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http://dx.doi.org/10.1055/s-0040-1721114DOI Listing
December 2020

Customized Orbit and Frontal Bone Implants.

Facial Plast Surg 2020 Dec 24;36(6):711-714. Epub 2020 Dec 24.

Otolaryngology and Facial Plastic Surgery Associates, Fort Worth, Texas.

Orbitocranial reconstruction objectives include creation of a solid barrier between intracranial contents and the environment allowing restoration of physiologic homeostasis and restoration of aesthetic craniofacial contours. Historically, bone grafts have been used for reconstruction but were fraught with unpredictable resorption and imperfect contouring given the complex anatomy of the orbitofrontal bones. With advances in three-dimensional modeling technology, alloplastic custom implants in orbital and frontal bone reconstruction have allowed for rapid fixation reducing surgical times and improved cosmesis.
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http://dx.doi.org/10.1055/s-0040-1721109DOI Listing
December 2020

A Century in Review: Medicolegal Implications of Facial Nerve Paralysis.

Facial Plast Surg Aesthet Med 2020 Dec 21. Epub 2020 Dec 21.

Department of Otolaryngology-Head and Neck Surgery, The Pennsylvania State University, College of Medicine, Hershey, Pennsylvania, USA.

It is important to recognize factors that may mitigate the risk of a potential lawsuit and increase knowledge and awareness of physicians. To evaluate and characterize facial nerve paralysis litigation claims and related potential causes. These data were extracted from the two main computerized legal databases: WestLaw and LexisNexis. The data were queried on April 2, 2020. The records from 1919 to 2020 were obtained from a population-based setting. A total of 186 cases were included. Data were gathered for all alleged cases of facial nerve paralysis. There was a continuous rise in the amount of malpractice payments with the highest mean amount being in the past decade. From 1919 to 2020, a total of 186 malpractice cases for facial nerve damage were identified. A total amount of $89,178,857.99 was rewarded to plaintiffs in 66 cases. The mean amount of paid malpractice claim was $1,351,194.80. Improper performance/treatment was the most common reason for alleged litigation ( = 97). This was followed by misdiagnosis/delayed diagnosis ( = 47), and failure of informed consent ( = 34). The highest number of malpractice claims with a total of 53 cases was from 1991 to 2000. The highest mean amount per payment was in the past decade (2011-2020) with a mean of $3,841,052.68. Over the past century, improper performance/procedure, delayed/misdiagnosis, and failure of informed consent were the most common reasons for litigations related to facial nerve paralysis.
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http://dx.doi.org/10.1089/fpsam.2020.0390DOI Listing
December 2020

Treatment of Oligometastatic Disease in Squamous Cell Carcinoma of the Head and Neck.

Laryngoscope 2021 05 12;131(5):E1476-E1480. Epub 2020 Oct 12.

Facial Plastic Surgery Associates, Fort Worth, Texas, U.S.A.

Objective: No surgical or radiotherapeutic treatment guidelines exist for oligometastatic head and neck squamous cell carcinoma (oHNSCC), and only recently have interventions with curative intent been studied. Herein, we sought to elucidate survival rates among patients with oHNSCC to determine if treatment with curative intent is warranted in this population.

Study Design: Retrospective chart review.

Methods: We retrospectively reviewed cases of oHNSCC treated between March 1998 and March 2018. Fisher's exact test was used to compare patients treated with radiotherapy (RT) to those who underwent surgical excision and to compare outcomes of patients with oligometastases at the time of initial presentation to those that developed oligometastatic disease after primary treatment.

Results: Eighty one patients with metastases to the lungs, ribs, pelvis, vertebral column, liver, clavicle, and sternum were included. Overall, 32 patients (40%) were alive 5 years post-treatment. The site of metastasis, the modality of treatment, and the time of development of oligometastatic disease did not significantly affect 5-year survival.

Conclusion: Herein, we demonstrate that multi-modality treatment of oHNSCC is warranted for some patients with an estimated 40% 5-year survival. Aggressive treatment of the primary and regional sites is necessary in addition to treatment of the metastatic site and incurs a survival benefit compared to patients with metastatic HNSCC treated with systemic therapy alone. oHNSCC should be approached separately from polymetastatic disease. Patients should be counseled about the possibility for long-term survival, and aggressive initial treatment with the intention for cure should be considered in this population.

Level Of Evidence: 4 Laryngoscope, 131:E1476-E1480, 2021.
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http://dx.doi.org/10.1002/lary.29115DOI Listing
May 2021

Reconstructive Options During Nonfunctional Laryngectomy.

Laryngoscope 2021 05 10;131(5):E1510-E1513. Epub 2020 Oct 10.

Facial Plastic Surgery Associates, Fort Worth, Texas, U.S.A.

Objective: A paucity of data exists regarding surgical outcomes for patients undergoing total laryngectomy for a dysfunctional larynx. Herein, we present the largest study evaluating the method of closure on postoperative fistula rate and swallowing ability.

Method: We performed a retrospective review of patients undergoing total laryngectomy for a dysfunctional larynx after primary radiation or chemoradiation therapy for laryngeal carcinoma from 1998 to 2020. Demographic information, operative details, length of hospitalization, fistula formation, method of fistula treatment, and need for enteral feeding 6 months after surgery were analyzed.

Results: A total of 268 patients were included. Flaps were performed in 140 (52.2%) patients, including radial forearm free flaps (RFFF), pectoralis flaps, and supraclavicular flaps. Sixty-four (23.9%) patients developed postoperative fistulas. There was no significant difference in the fistula rate between flap and primary closure methods (P = .06). However, among patients who had a flap, RFFF had a significantly lower fistula rate (P = .02). Significantly more patients who had initial closure with a pectoralis flap required an additional flap for fistula repair than those who underwent RFFF or primary closure (P < .05). Last, whereas 87 patients (32.5%) required an enteral feeding tube 6 months after surgery, significantly fewer patients who underwent RFFF were feeding tube-dependent (P = < .0001).

Conclusion: Herein, we present the largest study of outcomes after total laryngectomy for dysfunctional larynx. Postoperative fistula rates are high, 23%; however, the majority of patients, 67%, will not require long-term enteral support. The RFFF is an excellent option demonstrating the lowest rates of postoperative fistula and enteral feeding tube dependence.

Level Of Evidence: 4 Laryngoscope, 131:E1510-E1513, 2021.
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http://dx.doi.org/10.1002/lary.29154DOI Listing
May 2021

Volleyball-related Adult Maxillofacial Trauma Injuries: A NEISS Database Study.

J Craniofac Surg 2021 Jun;32(4):1564-1567

Department of Otolaryngology-Head and Neck Surgery, University of Arizona College of Medicine, Tucson, AZ.

Introduction: Craniofacial trauma among athletes of various sports has been well detailed and described. Despite this research, there is a dearth of literature describing the nature of facial trauma secondary to volleyball, despite its global popularity.

Methods: A cross-sectional analysis of volleyball-related facial trauma was conducted using the National Electronic Injury Surveillance System (NEISS) database from 2009 to 2018. Patient demographics (age, sex, and race), medical injury information (injury type and location), and disposition (observed and discharged, admitted, deceased) were collected and analyzed. χ2 testing was performed to compare categorical variables.

Results: A total of 235 volleyball-related facial traumas were recorded with an estimated 10,424 visits occurring nationally. The majority of injuries were among young adults aged 20 to 29 years (52.3%) and was evenly distributed for men and women. Lacerations were the most frequent injury type (37.9%), whereas the face was the most common site of injury (41.7%). The majority of fractures involved the nose (71.4%) and among individuals aged 20 through 49 (90.5%). Males had significantly more lacerations than females (75.3% vs 24.7%), whereas females had significantly more contusions/abrasions (64.5% vs 35.5%) and concussions (72.9% vs 27.1%).

Conclusions: Volleyball-related craniofacial injuries can vary depending on patient demographics. This information can help with the development of safety and preventative measures for individuals participating in the sport.
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http://dx.doi.org/10.1097/SCS.0000000000006984DOI Listing
June 2021

Reply to: Comment on "Investigation of topical intranasal cocaine for sinonasal procedures: a randomized, phase III clinical trial".

Int Forum Allergy Rhinol 2021 Jan 18;11(1):85-86. Epub 2020 Aug 18.

Department of Otolaryngology-Head and Neck Surgery, Division of Facial Plastic Reconstructive Surgery, Ochsner LSU Health, Shreveport, LA.

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http://dx.doi.org/10.1002/alr.22675DOI Listing
January 2021

Trends in the Treatment of Bell's Palsy.

Facial Plast Surg 2020 Oct 13;36(5):628-634. Epub 2020 Aug 13.

Section of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology, Penn State Health Milton S Hershey Medical Center, Hershey, Pennsylvania.

The aim of the study is to: (1) evaluate national trends in care of facial paralysis, namely Bell's palsy, patients to identify the types of treatments patients are receiving and treatment gaps and (2) identify if newer, more complex surgical therapies published in the literature are being employed. Data were collected from the MarketScan Commercial Claims and Encounters Database by Truven Health. From the database, all inpatient and outpatient claims with International Classification of Diseases, 9th Revision, Clinical Modification diagnosis codes for facial paralysis/dysfunction between 2005 and 2013 were extracted. Trends in medical and surgical management were evaluated specifically cataloging the use of steroids, antivirals, botulinum toxin, surgical and rehabilitation service current procedural terminology codes. A total of 42,866 of patients with a formal diagnosis of Bell's palsy were identified with 39,292 (92%) adults and 3,754 (8%) children (< 18 years old), respectively. Steroids were provided to 50.1% of children and 59.8% of adults and antivirals were prescribed to 26.2 and 39.4% of the children and adults, respectively. Within the first 2 years after diagnosis, 0.5% of children and 0.9% of adults received surgery, 0.1% of children and 0.8% of adults received botulinum toxin treatments, and 10.9% of children and 21.5% of adults received rehabilitation services. Despite the limitations of a claims database study, results showing trends in care of facial paralysis are still nonsurgical with many patients receiving no treatment at all. Although limited literature has shown an increase in the use of pharmacotherapy as well as techniques including physiotherapy, chemodenervation, and various surgical therapies, these interventions may be underutilized.
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http://dx.doi.org/10.1055/s-0040-1713808DOI Listing
October 2020

Comparison of Maxillofacial Trauma Patterns in the Urban Versus Suburban Environment: A Pilot Study.

Craniomaxillofac Trauma Reconstr 2020 Jun 25;13(2):115-121. Epub 2020 Mar 25.

Department of Otolaryngology-Head and Neck Surgery, Einstein Medical Center, Philadelphia, PA, USA.

Introduction: Assault appears to be the most frequent cause of facial fractures in certain urban trauma centers, possibly due to the ease of acquiring weapons and increasingly aggressive behavior. The objectives of this study were to identify specific demographic, socioeconomic, maxillofacial fracture, and assault patterns in urban versus suburban communities.

Methods: A retrospective chart review of patients who sustained maxillofacial fractures from August 2014 through August 2016 at one urban campus, Einstein Medical Center, Philadelphia, and two suburban campuses, Einstein Medical Center Montgomery and Elkins Park. The χ testing was used to compare the categorical variables between the 2 groups.

Results: A total of 259 maxillofacial trauma patients were identified, with 204 (79%) in the urban and 55 (21%) in the suburban environment. Patients in the urban population were more likely to be African American (70% vs 33%) and Hispanic (15% vs 6%) but less likely to be Caucasian (12% vs 55%, < .0001). Urban patients were more likely to be single (70% vs 47%, < .01), unemployed (64% vs 44%, < .001), and receive Medicaid coverage (58% vs 26%, < .001). Urban patients were more likely to be victims of assault (63% vs 44%), whereas suburban patients were more likely to sustain accidental injuries (16% vs 2%, < .0001). Urban victims were more likely to be assaulted with an object (30% vs 12%) or gun (7% vs 0%, = .05).

Conclusion: Maxillofacial trauma patterns were shown to be significantly different in the urban versus suburban environment.
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http://dx.doi.org/10.1177/1943387520910338DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7311833PMC
June 2020

Management of Isolated Zygomatic Arch Fractures and a Review of External Fixation Techniques.

Craniomaxillofac Trauma Reconstr 2020 Mar 17;13(1):38-44. Epub 2020 Mar 17.

Department of Otolaryngology-Head and Neck Surgery, Einstein Medical Center, Philadelphia, PA, USA.

Introduction: Fractures of the zygomatic bone can present with complicated aesthetic and neurological pathology. Specifically, management of isolated zygomatic fracture has been sparsely discussed in the literature, and most studies are based upon older techniques. Here, we compare the results of 2 critical operative techniques as well as review the available literature in the setting of isolated zygomatic fractures.

Methods: A retrospective chart review was performed at our institution from 2010 to 2018 examining for patients who had sustained an isolated zygomatic fracture confirmed by computed tomography scan. Patients were excluded if they sustained additional maxillofacial fractures. Demographical information, symptoms on presentation, fracture management modality, and postoperative course were all collected and examined.

Results: A total of 218 patients were identified for inclusion. The average age of this cohort was 45.5 ± 18 years, with 77.5% being male. Assault (55%) was most the frequent cause of injury with accidents being the least common (17.9%). Most patients (78.8%) underwent nonoperative management. Patients who underwent operation more often presented with zygomatic deformity (97.7% vs 18.4%), paresthesia (29.5% vs 2.9%), and trismus (29.5% vs 6.9%) when compared to their nonoperatively managed counterparts. In all, 44 operatively managed patients underwent open reduction with or without eternal fixation (Gillies Approach vs Keen Approach). There were no significant differences in the presence of zygomatic deformity, paresthesia, and trismus between the 2 operative techniques.

Conclusions: Isolated zygomatic arch fractures can present with discerning symptoms. Unfortunately, the literature on appropriate management is not well described. We find external fixation to provide reestablishment of both form and function with minimal required exposure, although the outcomes may be similar without the use of external fixation.
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http://dx.doi.org/10.1177/1943387520905164DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7311848PMC
March 2020

Dangers beyond drowning: craniomaxillofacial trauma in adult water activities.

Oral Maxillofac Surg 2020 Dec 29;24(4):441-446. Epub 2020 Jun 29.

Otolaryngology and Facial Plastic Surgery Associates, 923 Pennsylvania Ave, Fort Worth, TX, 76104, USA.

Purpose: Water recreation is one of the most popular activities for both fitness and leisure. The dangers of water activities have mostly been examined in the context of drowning and general bodily injuries. Despite the existing research, little is known about adult maxillofacial injuries in these settings.

Methods: We accessed the National Electronic Injury Surveillance System in order to identify adult patients presenting to emergency departments with traumatic maxillofacial injuries secondary to a water-based sport or activity over the most recent 10-year period (2009-2018). Data collected included demographical information, anatomical location, mechanism of injury, and visit circumstances, as well as visit disposition.

Results: A total of 1350 total patients were identified as appropriate for study inclusion. Young, Caucasian male adults were the most common age group to present with maxillofacial injuries secondary to water sport activities. Surfing and water skiing were associated with lacerations, while diving board incidents posed a higher fracture risk. Patients participating in all water activities were more likely to be treated and released rather than admitted.

Conclusion: There appears to be a distinct pattern profile for individuals who sustain maxillofacial trauma while participating in water sports: young, Caucasian males in particular. Additionally, specific activities may be associated with varying injury types. The results of this study may increase interest in legislature and patient counseling when seeking such activities.
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http://dx.doi.org/10.1007/s10006-020-00869-0DOI Listing
December 2020

Facial Plastic and Reconstructive Surgery During the COVID-19 Pandemic: Implications in Craniomaxillofacial Trauma and Head and Neck Reconstruction.

Ann Plast Surg 2020 08;85(2S Suppl 2):S166-S170

From the Department of Otolaryngology-Head and Neck Surgery, College of Medicine, The Pennsylvania State University, Hershey, PA.

Background: The global COVID-19 pandemic has had a profound impact on facial plastic and reconstructive surgery. Our review serves as a safety resource based on the current literature and is aimed at providing best-practice recommendations. Specifically, this article is focused on considerations in the management of craniomaxillofacial trauma as well as reconstructive procedures after head and neck oncologic resection.

Methods: Relevant clinical data were obtained from peer-reviewed journal articles, task force recommendations, and published guidelines from multiple medical organizations utilizing data sources including PubMed, Google Scholar, MEDLINE, and Google search queries. Relevant publications were utilized to develop practice guidelines and recommendations.

Conclusions: The global COVID-19 pandemic has placed a significant strain on health care resources with resultant impacts on patient care. Surgeons operating in the head and neck are particularly at risk of occupational COVID-19 exposure during diagnostic and therapeutic procedures and must therefore be cognizant of protocols in place to mitigate exposure risk and optimize patient care.
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http://dx.doi.org/10.1097/SAP.0000000000002492DOI Listing
August 2020

Nasal Bone Fractures: Differences Amongst Sub-Specialty Consultants.

Ann Otol Rhinol Laryngol 2020 Nov 6;129(11):1120-1128. Epub 2020 Jun 6.

Department of Otolaryngology-Head and Neck Surgery, Einstein Medical Center, Philadelphia, PA, USA.

Background: Nasal fractures constitute the largest proportion of facial trauma each year, however, there is no consensus management. In this study, we investingated the role of the consultant and the functional and aesthetic outcomes of procedures performed to address nasal bone fractures.

Methods: A retrospective chart review of patients who sustained nasal bone fractures was conducted from 8/1/14 through 1/23/18. Categorical variables were analyzed using chi-squared testing and Fisher's exact test, where appropriate, while continuous variables were compared using Mann-Whitney U testing.

Results: During the study period, 136 patients met inclusion criteria for full analysis. The mean age of this cohort was 47.6 ± 20.2 years with the majority identifying as African-American (53.7%) and male (67.2%). Otolaryngologists were significantly more likely to assess pre-operative nasal obstruction (100%) compared to plastic surgeons (24.1%) ( < .001). Otolaryngology elected operative management (53.3%) at a significantly higher rate than plastic surgery (24.1%) ( = .005). Additionally, otolaryngology was significantly more likely to manage patients in an outpatient setting (91.2%), whereas plastic surgery more commonly performed inpatient management (57.1%) ( = .006). Plastic surgery averaged a significantly shorter amount of time from presentation to operative management (7.3 ± 10.7 days) compared to otolaryngology (20 ± 27.7) ( = .019). Consulting service was not associated with a need for revision surgery.

Conclusions: Consultants across subspecialties differ in the management of nasal bone trauma. A more standardized approach is warranted by all individuals involved in the care of maxillofacial trauma patients.
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http://dx.doi.org/10.1177/0003489420931562DOI Listing
November 2020

Tennis-related adult maxillofacial trauma injuries.

Phys Sportsmed 2021 02 18;49(1):64-67. Epub 2020 May 18.

Department of Otolaryngology-Head and Neck Surgery, University of Arizona College of Medicine , Tucson, AZ, USA.

Tennis participation continues to increase amongst adults across the United States. The purpose of this study was to analyze trends in adult tennis-related facial injury epidemiology, demographics, diagnoses, and locations of injury. : The National Electronic Injury Surveillance System was evaluated for tennis-related facial injuries in adults from 2009 through 2018. Number of injuries were extrapolated, and data were analyzed for age, sex, specific injury diagnoses, locations, and discharge disposition. Descriptive statistics were used to present and describe variables of interest. Chi-squared testing (χ2) was performed to compare categorical variables. : During the study period, 342 tennis-related facial trauma ED visits were analyzed. Lacerations were the most common injury (45%), followed by contusions or abrasions (33.3%), concussions (11.7%), and fractures (8.5%). The most common sites of injury were the face (47.4%) and head (27.2%) regions. Males accounted for 62.0% of injuries, while females accounted for the remaining 38.0%. Patients between 34-65 years-old accounted for 47.7% of all injuries, and athletes over 65 years-old had the highest rate of fractures (10.1%). : Facial trauma incurred secondary to tennis may follow patient-specific patterns. The incidence of tennis-related facial trauma is smaller compared to other sports, but the severity of such injuries remain a danger. Facial protection and enforcement in tennis is virtually absent, and these findings strengthen the need to educate athletes, families, and physicians on injury awareness and prevention.
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http://dx.doi.org/10.1080/00913847.2020.1768451DOI Listing
February 2021

Prosthetic Reconstruction of the Maxilla and Palate.

Semin Plast Surg 2020 May 6;34(2):114-119. Epub 2020 May 6.

Otolaryngology and Facial Plastic Surgery Associates, Fort Worth, Texas.

Maxillary defects commonly present following surgical resection of oncologic processes. The use of rotational and free flaps has largely replaced the use of prosthetic options for hard palate and maxillary reconstruction, but prostheses remain a useful tool. Prosthetic devices may be invaluable in patients considered poor candidates for surgical reconstruction secondary to poor vascularity, need for postoperative radiation, or medical comorbidities that place them at high risk for healing following reconstruction. Obturators may also be considered over soft tissue options if oncologic surveillance via direct visualization of the surgical site is warranted.
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http://dx.doi.org/10.1055/s-0040-1709143DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7202916PMC
May 2020

Osteoradionecrosis of the Maxilla: Conservative Management and Reconstructive Considerations.

Semin Plast Surg 2020 May 6;34(2):106-113. Epub 2020 May 6.

Otolaryngology and Facial Plastic Surgery Associates, Fort Worth, Texas.

The implementation of radiotherapy in the multimodal treatment of advanced head and neck cancer has greatly improved survival rates. In some patients, however, this benefit comes at the potential expense of the tissue surrounding the primary site of malignancy. Osteoradionecrosis (ORN) of the facial bones, in particular the maxilla, is a debilitating complication of radiation therapy. Exposure to ionizing radiation results in devitalization of underlying bone with necrosis of adjacent soft tissue. Controversy surrounding appropriate early intervention in ORN persists and no consensus for clinical treatment has been established. In the present article, we review the pathophysiology of maxillary ORN and discuss the role of both conservative medical therapy and reconstruction.
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http://dx.doi.org/10.1055/s-0040-1709144DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7202910PMC
May 2020

Premaxillary Deficiency: Techniques in Augmentation and Reconstruction.

Semin Plast Surg 2020 May 6;34(2):92-98. Epub 2020 May 6.

Otolaryngology and Facial Plastic Surgery Associates, Fort Worth, Texas.

Progressive premaxillary retrusion is a common sequela of the facial aging process. In most cases, this manifests with central maxillary recession. Central maxillary insufficiency is also commonly encountered within certain ethnic communities, or in cleft lip nasal deformity, and may represent a challenge for the plastic and reconstructive surgeon attempting correction in the setting of facial contouring, rhinoplasty, or reconstruction following oncologic resection or trauma. Aesthetically, premaxillary retrusion may be coincident with an acute nasolabial angle and ptotic nasal tip. Minor deformities may be addressed with use of either alloplastic implants, autogenous tissue, lipotransfer, or injectable filler. Larger composite defects may require reconstruction with implementation of free tissue transfer. Herein, we describe techniques that aim to augment, or reconstruct, the premaxillary region in the context of nasal deformity, osseous resorption, or composite maxillofacial defects.
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http://dx.doi.org/10.1055/s-0040-1709175DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7202913PMC
May 2020