OBJECTIVES:To evaluate the surgical outcomes and perioperative complications in patients with systemic sclerosis (SSc) undergoing surgical resection with free flap reconstruction for advanced oral cavity squamous cell carcinoma (OCSCC). METHODS:Retrospective review of SSc patients who underwent surgical resection with free flap reconstruction for oral cavity SCC from 2008 to 2023. Data extracted included demographics, SSc subtype, cancer characteristics, surgical details, postoperative complications, and long-term outcomes. RESULTS:Four female patients over age 50 were identified; 2 had diffuse SSc and 2 had limited SSc. All presented with pathologic stage IV OCSCC. Free flap reconstruction included scapular (n = 2), radial forearm (n = 1), and fibular (n = 1) flaps. No patients experienced flap failure. All patients experienced at least 1 postoperative complication. Major morbidity, defined as prolonged ICU admission (>7 days), prolonged tracheostomy dependence (>30 days), cardiopulmonary arrest, or death within 1 year, occurred exclusively in patients with diffuse SSc (50%). Both diffuse SSc patients required hospitalization exceeding 35 days and died within 1 year of surgery. Patients with limited SSc had shorter stays and more favorable outcomes. CONCLUSIONS:Microvascular free flap reconstruction is feasible in SSc patients with OCSCC; however, those with diffuse SSc may experience higher morbidity and mortality. SSc subtype should be considered in preoperative planning. Further multicenter studies are needed to guide management in this high-risk population.

Blepharoplasty is among the fastest-growing aesthetic procedures in male patients, reflecting shifting cultural norms and increasing demand for facial rejuvenation that preserves masculine features. This review outlines the anatomical and aging patterns specific to the male periorbital region and discusses contemporary surgical techniques tailored to this population.The gender-specific anatomical differences in the periorbital region influence both surgical planning and outcomes are highlighted.Aging in men involves distinct patterns that must be addressed to preserve masculine facial identity.Surgical strategies emphasize conservative tissue excision, preservation of eyelid fullness, and avoidance of feminizing features.Men are predisposed to complications like lower lid malposition, visible scarring, and wound dehiscence due to anatomical factors and skin characteristics. Overcorrection may lead to feminization, necessitating a conservative surgical philosophy and meticulous technique.A deep understanding of sex-specific anatomy and aging, coupled with meticulous surgical technique, is essential for achieving natural, harmonious outcomes that align with the male aesthetic ideal.

BACKGROUND The increased demand for minimally invasive facial cosmetic procedures in tandem with the ease of acquiring injectable cosmetics through direct-to-consumer retailers has led to a rise in self-injecting cosmetics among untrained individuals. OBJECTIVE To analyze complications, treatments, and outcomes associated with self-injecting fillers into the face. METHODS A systematic review of the literature from PubMed and Embase databases was performed from inception to September 10, 2022, to identify studies pertaining to self-injection of facial fillers. RESULTS A total of 15 articles describing 38 complications among 18 patients were included in the data collection. The most commonly injected substance was hyaluronic acid (76.4%). The lips were the most common site of injection (33%). The most reported complication was edema (61%). Severe complications included acute vascular compromise (11%) and acute hearing loss (5%). The most common intervention was use of hyaluronidase and/or antibiotics (87.5%). Patients generally healed after treatment although residual localized hyperpigmentation was noted among 11% of patients. CONCLUSION Injecting commercially available substances into the face is associated with potentially irreversible aesthetic, infectious, and vascular complications, especially in the hands of untrained consumers. Patients and providers should be aware of this dangerous trend.

AbstractObjectivesInvestigate opioid usage and postoperative pain in patients undergoing head and neck free flap surgery.MethodsA retrospective review of 100 consecutive patients undergoing head and neck free flap reconstruction at two academic centers was performed. Data captured included demographics, postoperative inpatient pain, pain at postoperative visits, morphine equivalent doses (MEDs) administration, medication history, and comorbidities. Data were analyzed using regression models, χ2 tests, and student's t‐tests.ResultsSeventy‐three percent of patients were discharged with opioid medication, with over half (53.4%) continuing to take opioids at their second postoperative visit, and over one‐third (34.2%) continuing to take them around 4‐month postoperatively. One out of every five (20.3%) opioid‐naïve patients chronically took opioids postoperatively. There was a poor association between inpatient postoperative pain scores and daily MEDs administered (R2 = 0.13, 0.17, and 0.22 in postoperative Days 3, 5, and 7, respectively). Neither preoperative radiotherapy nor postoperative complications were associated with an increase in opioid usage.ConclusionsFor patients undergoing head and neck free flap operations, opioid medications are commonly used for postoperative analgesia. This practice may increase the chance an opioid‐naïve patient uses opioids chronically. We found a poor association between MEDs administered and patient‐reported pain scores, which suggests that standardized protocols aimed at optimizing analgesia while reducing opioid administration may be warranted.Level of Evidence: 3 (Retrospective cohort study).

Background: Absence of published literature on facial plastic and reconstructive surgery (FPRS) fellows' pursuit of academic careers hampers informed decision making for those interested in the specialty, fellowship program directors, and leaders in the American Academy of Facial Plastic and Reconstructive Surgery. Objective: To examine career choices among FPRS fellows from 2000 to 2019 and identify factors linked to academic or private practice employment after fellowship. Methods: Data from 796 fellows were analyzed, including gender, medical school, residency program, fellowship program, fellowship year, and degrees, to categorize them based on academic or nonacademic career placement. Logistic regression analyses were conducted to explore the association between demographic factors and academic career placement. Results: Forty-three percent (n = 345) obtained academic positions, with significant associations found between academic placement and additional advanced degrees, completion of fellowship training in the northeast, and residency training at an institution offering FPRS fellowship. Conclusion: Although fellows in FPRS predominantly pursue private practice, the decision to pursue academia is influenced by complex and multifactorial factors among graduates in the field.

Background: Advances in machine learning age progression technology offer the unique opportunity to better understand the public's perception on the aging face.Objective: To compare how observers perceive attractiveness and traditional gender traits in faces created with a machine learning model.Methods: Eight surveys were developed, each with 10 sets of photographs that were progressively aged with a machine learning model. Respondents rated attractiveness and masculinity or femininity of each photograph using a sliding scale (range: 0-100). Mean attractiveness scores were calculated and compared between men and women as well as between age groups.Results: A total of 315 respondents (51% men, 49% women) completed the survey. Accuracy of the facial age progression model was 85%. Females were considered significantly less attractive (-10.43, p < 0.01) and less feminine (-7.59, p < 0.01) per decade with the greatest drop over age 40 years. Male attractiveness and masculinity were relatively preserved until age 50 years where attractiveness scores were significantly lower (-5.45, p = 0.39).Conclusions: In this study, observers were found to perceive attractiveness at older ages differently between men and women.

Objective: To compare quantitative Nasal Obstruction Symptom Evaluation (NOSE) scores for ACG and Latera implants for nasal valve repair. Methods: Retrospective chart review of patients who underwent ACG or Latera placement between January 2016 through May 2019 by a single surgeon. Patients who had completed NOSE surveys pre- and post-operatively were identified and eligible for inclusion. Data regarding baseline demographic characteristics, adjunctive surgical procedures, NOSE scores at 1, 3, and 6-month post-operative visits, complications, and total operative time were collected. Unpaired t-tests and linear mixed models were performed to analyze differences between study groups. Results: There were 24 and 39 patients who underwent ACG and Latera, respectively, who met eligibility criteria. There were no differences in demographic characteristics or pre-operative baseline NOSE scores (ACG: 65.1 and Latera: 64.4; P = .92) between groups. Mean operative times were not significantly different between groups (ACG: 113 minutes and Latera: 102 minutes; P = .76). Within each group, NOSE scores were significantly improved at each post-operative visit compared to pre-operative baselines. Between groups, mean NOSE scores were lower at each post-operative visit for ACG compared to Latera (1-month ACG: 21.7 and Latera: 45.9, P = .002 ; 3-month ACG: 14.5 and Latera: 39.9, P = .034; 6-month ACG: 8.4 and Latera: 44.2, P = .003). Conclusions: Both ACG and Latera offer significant improvements in patient-reported nasal obstruction severity; however, ACG may yield more favorable subjective symptom scores.

The use of appearance manipulating applications on our smartphones has increased in popularity. As the aim of this study is to determine the impact of self-directed appearance manipulation on perceptions of personality and examine the influence of respondent age and gender on the various personality domains. This cross-sectional cohort study included 20 subjects between the ages of 18 to 34 who had headshots taken and were provided an introduction on the use of the Facetune2 app. After 1 week of engaging in digital appearance manipulation, subjects submitted their self-determined most attractive edited photograph. Four surveys were constructed with 10 sets of photographs each. Each of these surveys were then sent to lay people via a web-based survey tool. Anonymous blinded respondents used a 7-point Likert scale to rate their perception of each patient's aggressiveness, likeability, sociability, trustworthiness, attractiveness, authenticity, and masculinity or femininity. A multivariate linear mixed effect model was applied to analyze the overall patient trait data as well as to assess the impact of rater age and gender. A total of 288 respondents (mean age range, 25-34 years [43%]; 202 [70%] female) completed a survey. Overall, digitally enhanced photographs were perceived as more attractive (0.22; 95% CI, 0.06-0.38). Analysis based on gender of the study subjects revealed increased attractiveness scores for men (0.19; 95% CI, 0.07-0.33). Females were also perceived as being more attractive (0.16; 95% CI, 0.03-0.40), but less authentic (-0.24; 95% CI, -0.36 to -0.12). Females rated enhanced photographs of men as less masculine (-0.23; 95% CI, -0.46 to -0.04). Raters aged 35 to 64 rated altered photos as less attractive (0.31; 95% CI, 0.09-0.52), authentic (0.20; 95% CI, 0.01-0.38), and gender enhancing (0.42; 95% CI, 0.24-0.61) compared with individuals aged 18 to 34. Patients and surgeons should be aware of the ways in which self-enhanced photographs may affect social perception.

The use of filters and editing tools for perfecting selfies is increasing. While some aesthetic experts have touted the ability of this technology to help patients convey their aesthetic goals, others have expressed concerns about the unrealistic expectations that may come from the ability for individuals to digitally alter their own photos in these so-called "super-selfies." The aim of the study is to determine the changes that individuals seek when enhancing selfies. Twenty subjects participated in this study between July 25 and September 24, 2019. Subjects had two sets of headshots taken (neutral and smile) and were provided an introduction on the use of the Facetune2 app. Subjects received a digital copy of their photographs and were asked to download the free mobile app. After 1 week of trialing the different tools for enhancing their appearance, subjects submitted their self-determined most attractive edited photographs. Changes in marginal reflex distance (MRD) 1 and 2, nose height and width, eyebrow height, facial width, skin smoothness, skin hue, and saturation as well as overall image brightness were recorded. Paired two-tailed t -test was used to evaluate pre- and post-facial measurements. There were no statistically significant changes identified in the analysis of the altered photos in neutral expression. Analysis of all smiling photographs revealed that subjects increased their smile angle (right: +2.92mm, p =0.04; left: +3.58mm, p <0.001). When smiling photographs were assessed by gender, females were found to significantly increase their MRD2 (right: +0.64mm, p =0.04; left: +0.74mm, p =0.05) and their smile angle (right: +1.90mm, p =0.03; left: +2.31mm, p =0.005) while also decreasing their nose height (-2.8mm, p =0.04). Males did not significantly alter any of the facial measurements assessed. This study identifies the types of changes that individuals seek when enhancing selfies and specifies the different aspects of image adjustment that may be sought based on a patient's gender.

Background Limited data exist on safe discontinuation of antiprogrammed cell death protein 1 (PD-1) therapy in responding patients with advanced melanoma. The use of 18fluorodeoxyglucose ((18)FDG)-PET/CT scan and tumor biopsy for assessment of active disease may be an effective predictive biomarker to guide such treatment decisions. Methods A retrospective study of 122 patients with advanced melanoma treated with anti-PD-1 monotherapy or anti-PD-1/anticytotoxic T-lymphocyte-associated protein 4 combination therapy at Georgetown Lombardi Comprehensive Cancer Center was conducted. Uveal melanoma patients and those receiving concurrent experimental therapy were excluded. Baseline characteristics, treatment outcomes, and survival were analyzed. Patients who decided to come off treatment typically after 12 months using CT scan radiographic complete response (CR), (18)FDG-PET/CT scan complete metabolic response (CMR) or tumor biopsy of a non-CR/CMR tumor site negative for active disease (possible pathological CR) were identified and compared with patients who discontinued treatment due to toxicity while their disease was in control. Event-free survival (EFS) was assessed from the last dose of anti-PD-1 therapy to progression requiring subsequent treatment (surgery, radiation, and/or systemic therapy) or referral to hospice/death due to melanoma. Results 24 (20%) patients discontinued treatment by choice with no active disease and 28 (23%) patients discontinued treatment due to toxicity with disease control after 12-month and 4-month median treatment durations, respectively. Similar baseline characteristics were observed between cohorts except higher prior receipt of ipilimumab (29% vs 7%; p=0.036) and fewer BRAF mutant positive disease (17% vs 41%; p=0.064) in patients off treatment by choice. Three-year EFS rates were 95% and 71%, respectively. No significant associations between EFS and sex, disease stage, lactate dehydrogenase elevation, BRAF status, prior systemic therapy, ECOG performance status, presence of brain metastases, or combination versus monotherapy were observed. Tumor biopsies led to alternative management in 3/10 patients due to active metastatic melanoma or second malignancy. Conclusions Anti-PD-1 therapy discontinuation after 12 months when no active disease is observed on CT scan, PET/CT scan or tumor biopsy may have low rates of disease relapse in patients with advanced melanoma. Biopsy of residual disease may frequently lead to a change in management. These findings are undergoing validation in the EA6192 trial.

PURPOSE:Determine the impact of upper eyelid weight placement at 3 months post onset of idiopathic facial paralysis (IFP) on the recovery of facial function in patients with lagophthalmos.METHODS:This is a retrospective review of patients with incomplete recovery of IFP-defined as a Sunnybrook Facial Grading Scale (FGS) score of less than 100, 3 months after onset. Only patients with FGS and Facial Clinimetric Evaluation (FaCE) scores recorded at 3 and 12 months were included. Patients were categorized into 3 groups: Group A, lagophthalmos with eyelid weight placement; Group B, lagophthalmos without eyelid weight placement; Group C, complete eye closure (CEC) without eyelid weight placement. The eye comfort domain and composite score of the FaCE questionnaire were analyzed. Voluntary eye closure, synkinesis with eye closure, overall synkinesis and the composite score of the FGS were also analyzed. Paired two-tailed t-test was used to evaluate the data comparing the 3 and 12 month FaCE and FGS scores within and between the 3 groups.RESULTS:The change in composite FGS score significantly increased from month 3 to month 12 in Group A as compared to Group B (37 vs 4.25, P = 0.01). While Group A had significantly lower eye comfort (-12.5, P = 0.01), voluntary eye closure (-1.75, P = 0.05) and overall FGS scores (-28.75, P = 0.04) at 3 months compared to those in Group C, there were no differences between these two groups at 12 month follow-up.CONCLUSIONS:For patients with lagophthalmos at 3 months, early eyelid weight placement may lead to improved facial function at 12 months.

Background: Social media has gained significant popularity over the last decade. We now have the opportunity to digitally enhance our physical appearance using a variety of applications in the palm of our hands. One app, in particular, Facetune2, allows one to smooth skin, alter the size and shape of our nose, and even enhance our jaw line. Objectives: (1) To assess whether using a digital appearance manipulation (DAM) application directly causes increased acceptance of cosmetic surgery and (2) to measure the impact photograph editing has on an individual's self-esteem, self-rated attractiveness, and self-rated personality traits. Design Type: Prospective cohort study. Methods: A total of 20 subjects were recruited to participate in this study between July 25 and September 24, 2019, using University e-mail list invitations. Subjects first completed a basic intake questionnaire that included demographic information as well as baseline acceptance of cosmetic surgery, Rosenberg self-esteem, and self-perception scores. Subjects then had two sets of headshots taken (neutral and smile) and provided an introduction on the use of the Facetune2 app. Subjects received a digital copy of their photographs and were asked to download the free mobile app. After 1 week of appearance manipulation, subjects submitted their best edited photographs and completed the same three questionnaires. Wilcoxon signed rank test analysis was then used to assess for changes before and after DAM. Results: Overall, study participants indicated increased consideration of cosmetic surgery on the acceptance of cosmetic surgery scale after DAM (+3.45, p = 0.04). When divided by gender, females further signified increased consideration of cosmetic surgery to keep looking young (+1.4, p = 0.04). Males indicated increased social motivation for cosmetic surgery after DAM (+1.5, p = 0.04). Both males (+1.0, p = 0.04) and females (+0.8, p = 0.03) indicated that they "could end up having some kind of cosmetic surgery" in the future. Comparison of the personality perception and Rosenberg self-esteem scores for all study participants before and after DAM showed no significant changes. Conclusions: The results of this study suggest that DAM can directly lead to increased consideration of cosmetic surgery for both males and females without affecting self-esteem.

OBJECTIVETo determine the utility of treating facial palsy with mirror book therapy in conjunction with facial physical rehabilitation.METHODSWe randomly selected and reviewed the charts of 25 patients with idiopathic facial palsy. 10 of these patients received facial physical rehabilitation including manual therapy and postural exercises. 15 of these patients received mirror book therapy in conjunction with standard facial rehabilitation. Before and after treatment, patients in both groups were rated using the Facial Grading System (FGS) score, the Facial Disability Index--Physical (FDIP) score, and the Facial Disability Index--Social (FDIS) score. Differences in response to therapy were analyzed.RESULTSPatients in the facial physical rehabilitation group without mirror book therapy group showed on average a 20.8% increase in the FGS score, a 19% increase in the FDIP score, and a 14.6% increase in the FDIS score. Patients in the mirror book therapy group showed an average of 24.9% increase in the Facial Grading System (FGS) score, a 21.6% increase in the Facial Disability Index--Physical (FDIP) score, and a 24.5% increase in the Facial Disability Index--Social (FDIS) score.CONCLUSIONThe addition of mirror book therapy to standard facial rehabilitation treatments does significantly improve outcomes in the treatment of idiopathic facial palsy.

Importance Facial paralysis has a significant effect on affect display, with the most notable deficit being patients' the inability to smile in the same way as those without paralysis. These impairments may result in undesirable judgements of personal qualities, thus leading to a significant social penalty in those who have the condition. Objective To quantify the association of facial paralysis with the way smiling patients are perceived by others with respect to personality traits, attractiveness, and femininity or masculinity and to evaluate the potential association of facial palsy-related patient-reported outcome measures with how patients are perceived by others. Design, Setting, and Participants This retrospective cross-sectional study used 20 images of smiling patients with facial paralysis evaluated between January 1, 2014, and December 31, 2016. Using photograph editing software, the photographs were edited to create a simulated nonparalysis smiling facial appearance. A total of 40 photographs were split into 4 groups of 10 photographs, each with 5 altered and 5 unaltered photographs. The surveys were designed such that altered and unaltered photographs of the same patient were not placed in the same survey to avoid recall bias. Anonymous raters used a 7-point Likert scale to rate their perception of each patient's personality traits (ie, aggressiveness, likeability, and trustworthiness), attractiveness, and femininity or masculinity based on photographs in their assigned survey. Raters were blinded to study intent. Scores from the Facial Clinimetric Evaluation questionnaire were included to assess self-perception. Data were analyzed from November 11, 2019, to February 20, 2020. Main Outcomes and Measures Ratings of personality traits, attractiveness, and femininity or masculinity. Social function domain scores and overall scores were analyzed from the Facial Clinimetric Evaluation questionnaire. Results This study included photographs of 20 patients with facial paralysis (mean [range] age, 54 [28-69] years; 15 [75%] women). A total of 122 respondents completed the survey (71 [61%] women). Most respondents were between the ages of 25 and 34 years (79 participants [65%]). Overall, smiling photos of patients with facial paralysis were perceived as significantly less likeable (difference, -0.29; 95% CI, -0.43 to -0.14), trustworthy (difference, -0.25; 95% CI, -0.39 to -0.11), attractive (difference, -0.47; 95% CI, -0.62 to -0.32), and feminine or masculine (difference, -0.21; 95% CI, -0.38 to -0.03) compared with their simulated preparalysis photographs. When analyzed by sex, smiling women with facial paralysis experienced lower ratings for likeability (difference, -0.34; 95% CI, -0.53 to -0.16), trustworthiness (difference, -0.24; 95% CI, -0.43 to -0.06), attractiveness (difference, -0.74; 95% CI, -0.94 to -0.55), and femininity (difference, -0.35; 95% CI, -0.58 to -0.13). However, smiling men with facial paralysis only received significantly lower ratings for likeability (difference, -0.24; 95% CI, -0.47 to -0.01) and trustworthiness (difference, -0.30; 95% CI, -0.53 to -0.07). As patients' self-reported social function and total Facial Clinimetric Evaluation scores increased, there was an increase in perceived trustworthiness (rs[480] = 0.11; P = .02) and attractiveness (rs[478] = 0.10; P = .04) scores by raters. Conclusions and Relevance In this study, photographs of patients with facial paralysis received lower ratings for several personality and physical traits compared with digitally edited images with no facial paralysis. These findings suggest a social penalty associated with facial paralysis. This cross-sectional study examines how facial paralysis is associated with perception of attractiveness, femininity or masculinity, and personality. Question How is facial paralysis associated with the perception of attractiveness, femininity or masculinity, and personality, and do patient-reported outcome measures correlate with how patients are perceived by others? Findings In this cross-sectional study including 20 patients with facial paralysis and 122 survey respondents, respondents rated photographs of patients with facial paralysis significantly lower in likeability, trustworthiness, attractiveness, and femininity or masculinity compared with the digitally edited images of patients without facial paralysis. Higher social function and total Facial Clinimetric Evaluation scores were associated with increased trustworthiness and attractiveness scores. Meaning These results broaden understanding of how facial paralysis is associated with societal perceptions of persona.

Rhinoplasty is known to increase attractiveness; however, the influence of observer age and gender are largely undetermined. This retrospective cross-sectional study included 20 women who underwent cosmetic rhinoplasty between January 1st, 2012, and December 31st, 2019. A total of 4 surveys were constructed with 10 sets of photographs each (5 preoperative and 5 postoperative). Surveys were designed such that photographs of the same patient were not placed in the same survey to avoid recall bias. Each of these surveys were then sent to at least 30 lay people via a web-based survey tool. Anonymous blinded respondents used a 7-point Likert scale to rate their perception of each patient’s aggressiveness, likeability, sociability, trustworthiness, attractiveness, femininity, intelligence and confidence. A multivariate linear mixed effect model was applied to analyze the overall patient trait data as well as to assess age and gender differences. This survey study included photographs of 20 women (mean age, 28.2 years) before and after cosmetic rhinoplasty. A total of 174 respondents (mean age range, 25–34 years [41%]; 108 [62%] were female) completed the survey. Overall, postoperative photographs were perceived as significantly more sociable (0.13; 95% CI, 0.01–0.25), attractive (0.21; 95% CI, 0.09–0.34), feminine (0.18; 95% CI, 0.05–0.30), and confident (0.15; 95% CI, 0.02–0.27). When analyzed by sex, men rated women as less aggressive (−0.42, 95% CI, −0.65,−0.17) and more likeable (+0.45, 95% CI, 0.21–0.69), sociable (+0.38, 95% CI, 0.14–0.62), trustworthy (+0.37, 95% CI, 0.13–0.61), attractive (+0.60, 95% CI, 0.35–0.84), feminine (+0.23, 95% CI, 0.07–0.41) and intelligent (+0.29, 95% CI, 0.04–0.53). In contrast, female respondents indicated an increase in perceived attractiveness (+0.16, 95% CI, 0.06–0.22) and femininity (+0.18, 95% CI, 0.03–0.32) for women after rhinoplasty. Raters aged 25–34 indicated improvements across all traits analyzed. Almost all age ranges rated post-operative photographs as more attractive (18–24: +0.32, 95% CI, 0.19–0.46; 25–34: +0.52, 95% CI, 0.33–0.72; 35–44: +0.29, 95% CI, 0.12–0.51; 45–54: +0.50, 95% CI, 0.11–0.89) while individuals over age 55 only indicated increased trustworthiness (+0.51, 95% CI, 0.03–0.99). These findings suggest that cosmetic rhinoplasty improves perceptions of personality and physical traits of women with males and individuals aged 25–34 indicating the greatest benefit. Level IV.