Background: Enhanced recovery after surgery (ERAS) protocols reduce opioid exposure in many surgical fields, but their impact on rhinoplasty has not been studied.Objective: To compare postoperative pain control and opioid use during the first week after open septorhinoplasty among patients treated with a traditional hydrocodone/oxycodone and patients treated in an ERAS pathway, as measured by patient-reported pain score and opioid use.Methods: Retrospective cohort study of open septorhinoplasty patients before and after ERAS implementation. Cohort I received hydrocodone/oxycodone with nonstandardized perioperative management. Cohort II followed a standardized ERAS pathway with tramadol, Celebrex, prednisone, and acetaminophen. Pain scores and opioid consumption were compared.Results: Fifty-one patients were studied (n = 24 and n = 27, respectively). The average age was 37.6 (SD 14) and 35.4 (SD 10.7), respectively. In cohort I, 54% were female and 46% male, and in cohort II, 67% were female and 33% were male. Mean pain scores were lower in cohort II (3.8 vs. 5.9, p = 0.0007). Total morphine milligram equivalent use was lower in cohort II (37.8 vs. 46.3, p = 0.51).Conclusion: A multi-modality ERAS protocol after open septorhinoplasty reduced postoperative pain during the first week after surgery, without increasing opioid usage, compared to traditional pain management with opioids.

Objectives:There are currently no validated patient-reported outcome measures (PROMs) to specifically evaluate quality-of-life outcomes for patients who have suffered bony facial trauma. Our goals are the following: (1) Investigate functional and psychosocial concerns that are self-identified as important among patients following bony facial trauma. (2) Formalize these factors into an appropriate patient-reported outcome measurement tool that can be utilized clinically. Methods:We performed semi-structured interviews with 10 providers at the University of Virginia and other academic institutions who are experts in the field of facial trauma. Providers were asked about functional and psychosocial concerns that patients with bony facial trauma may experience. Responses were then used to create a preliminary PROM instrument, which was programmed for self-administration through the Qualtrics online survey platform. Subsequent semi-structured interviews with 15 patients affected by bony facial trauma were conducted during the cognitive debriefing portion. Patients completed the questionnaire and their responses provided focus to the finalized PROM survey. Results:The final PROM instrument included functional concerns such as nasal obstruction, persistent facial numbness, vision issues, and limited jaw mobility. Psychosocial concerns included difficulty completing personal tasks, feeling depressed or anxious, and not wanting to spend time with family or friends. Conclusion:Using a standardized approach, we developed a patient-reported outcome measure specific to bony facial trauma patients by performing semi-structured interviews with content experts as well as cognitive debriefing interviews with patients. The final PROM included functional and psychosocial concerns relevant to the bony facial trauma population, such as vision issues and difficulty completing personal tasks. Future directions of the study will include a multi-institution validation phase with a larger volume of patients. Level of Evidence:4.

Failure to recognize concomitant ocular injury in orbital fracture patients is a feared consequence of evaluation in the acute setting. These injuries and their accompanying functional sequelae range in severity, and reconstructive surgeons need to be sensitive to the possibility of major ocular injuries that could potentially have serious outcomes. Indications for specialty-trained ophthalmology evaluation in patients with orbital fractures remain controversial, with some advocating for an immediate and comprehensive evaluation of every patient with an orbital fracture. In many institutions, however, this may be difficult to achieve. Additionally, a reflexive emergent ophthalmologic consultation on every orbital fracture yields many normal examinations and therefore potentially places a great burden on the healthcare system. Current literature was reviewed to guide management of these injuries.

Objective Giant basal cell carcinoma (GBCC) of the face is a rare, disfiguring entity with poorly understood psychological challenges and factors contributing to social isolation. This study evaluates the reasons for delays in care in this patient population. Methods A retrospective review of patients with GBCC of the face (>5 cm) treated at a tertiary care academic center from January 2003 to May 2024 was conducted. The clinical course, time to presentation, insurance type, and geographic factors were analyzed to identify causes for delay. Telephone interviews assessed reasons for delays in care. The Hospital Anxiety and Depression Scale (HADS) was administered and compared with a control group. Results A total of 39 patients with GBCC were identified; 16 patients consented to interviews. The average lesion length was 64.5 mm. Patients presented on average 6 years (range: 0.5–18 years) after noticing the lesion, citing denial or financial concerns as reasons for delay. HADS results showed increased anxiety ( p = 0.01) compared with controls. Additionally, 33.3% of patients reported habitual alcohol use, and 43.8% lived alone. Geographical analysis showed lower high school graduation rates ( p < 0.001). No significant socioeconomic predictors for insurance type or treatment delays were found. Conclusion This study reveals the substantial psychosocial challenges experienced by patients with GBCC of the face. Increased anxiety, social isolation, and lower education levels contribute to delays in care. This subpopulation would benefit from targeted social support and health literacy interventions as they may be crucial to their final treatment recommendations and outcomes. Level of Evidence 4 Laryngoscope , 2025

This article provides an updated, comprehensive overview of grafting principles and techniques in reconstructive rhinoplasty. It reviews current options for grafting material and recent literature regarding the advantages and disadvantages of different graft sources. Various grafts, their indications, and recommended surgical techniques are also described in detail. Finally, the use of three-dimensional imaging and printing technology in reconstructive rhinoplasty is discussed.

The auricle is susceptible to various injuries due to its location and projection from the scalp. The unique contours of the external ear makes reconstruction a challenging endeavor. This chapter provides a comprehensive overview of auricular reconstruction, based on the depth, location, and size of injury. Strategies for reconstructing superficial, composite, and full-thickness injuries are discussed in relation to the location of the defect. Targeted reconstructive options for injuries of the upper, middle, and lower thirds of the auricle are outlined. Methods for total auricular reconstruction and auricular prosthesis are discussed. Options for managing traumatic injuries are reviewed, including avulsion/amputation injuries, burns, electrical injuries, frostbite, and human/animal bites. This chapter provides a practical framework for surgeons faced with complex auricular defects, offering insights to recreate a discreet, harmonious ear.

Introduction:Rhinoplasty is one of the most common cosmetic surgical procedures performed globally. Twitter, also known as "X," is used by both patients and physicians and has been studied as a useful tool for analyzing trends in healthcare. The public social media discourse of rhinoplasty has not been previously reported in the field of otolaryngology. The goal of this study was to characterize the most common user type, sentiment, and temporal trends in the discussion of rhinoplasty on Twitter to guide facial plastic surgeons in their clinical and social media practices. Methods:A total of 1,427,015 tweets published from 2015 to 2020 containing the keywords "rhinoplasty" or "nose job" were extracted using Twitter Academic API. Tweets were standardized and filtered for spam and duplication. Natural language processing (NLP) algorithms and data visualization techniques were applied to characterize tweets. Results:Significantly more "nose job" tweets (80.8%) were published compared with "rhinoplasty" (19.2%). Annual tweet frequency increased over the 5 years, with "rhinoplasty" tweets peaking in January and "nose job" tweets peaking in the summer and winter months. Most "rhinoplasty" tweets were linked to a surgeon or medical practice source, while most "nose job" tweets were from isolated laypersons. While discussion was positive in sentiment overall (M = +0.08), "nose job" tweets had lower average sentiment scores (P < .001) and over twice the proportion of negative tweets. The top 20 most prolific accounts contributed to 14,758 (10.6%) of total "rhinoplasty" tweets. Exactly 90% (18/20) of those accounts linked to non-academic surgeons compared with 10% (2/20) linked to academic surgeons. Conclusions:Rhinoplasty-related posts on Twitter were cumulatively positive in sentiment and tweet volume is steadily increasing over time, especially during popular holiday months. The search term "nose job" yields significantly more results than "rhinoplasty," and is the preferred term of non-healthcare users. We found a large digital contribution from surgeons and medical practices, particularly in the non-academic and private practice sector, utilizing Twitter for promotional purposes.

Background: In 2017, the Bony Facial Trauma Score (BFTS) was developed to quantify and describe bony trauma of the face.Objective: To compare BFTSs for the need of hospital admission, intensive care unit (ICU) admission, surgery, tracheostomy tube placement, cervical spine (c-spine) injury, and mortality.Methods: A retrospective review of patients sustaining bony facial trauma from January 1, 2017 to November 30, 2019 was done. Logistic regression modeling measured the association between BFTS and admission status, need for operative repair, tracheostomy, mortality, ICU admission, and c-spine injury.Results: Three hundred six patients were included for this analysis. Median BFTS was 3.5 (interquartile range, 5), while the average age was 45.0 years (standard deviation, 22.3). The most common mechanisms of injury were motor vehicle accident (44.8%) and ground-level fall (32.5%). BFTS was found to correlate with the following (p < 0.05): admission (odds ratio [OR] 1.06, 95% confidence interval [CI] 1.01-1.13), mortality (OR 1.05, 1.00-1.10), tracheostomy (OR 1.11, 1.07-1.17), operative management (OR 1.16, 1.11-1.22), ICU (OR 1.07, 1.03-1.11), and c-spine injury (OR 1.05, 95% CI 1.03-1.11).Conclusion: A significant correlation was found between BFTS and all the outcomes investigated.

The forehead flap is a time-tested and robust resurfacing flap used for nasal reconstruction. Owing to its excellent color and texture match, acceptable donor site morbidity, and robust and independent blood supply that can support both structural and internal lining grafts, this flap remains the workhorse flap for resurfacing large nasal defects. Various nuances of this technique relating to defect and template preparation, flap design, flap elevation, flap inset, donor site closure, and pedicle division are discussed in this article. These nuances are the guiding principles for improved outcomes using a forehead flap for the reconstruction of large nasal defects.

Facial fractures are frequently assessed by the practicing otolaryngologist. All injuries with signs of active infection warrant antimicrobial therapy. However, there is a significant variability regarding the use of prophylactic antibiotics in cases of mid-facial and upper facial third fractures. The current literature on this topic was, therefore, reviewed to better guide management of these injuries. A literature search was conducted via PubMed and Cochrane Library using keywords including "mid-face," "trauma," "fracture," "zygoma," "orbit," "frontal sinus," "antibiotic," and "prophylactic." Five studies with the highest level of evidence were selected. These studies provided detail on the timing and duration of antibiotics in the setting of mid-facial and frontal sinus trauma. The studies were consistent in their definitions of antibiotic timing, with details outlined in Table I. In 2015, a systematic review was performed by Mundinger et al. evaluating pre-, peri-, and post-operative prophylactic antibiotics in the setting of traumatic fractures of all facial thirds.1 The outcome assessed was surgical site infection. Specifically, 20 studies were included reviewing fractures to the mid-face and seven of the frontal sinus. Of the articles including mid-face trauma, one study was a randomized control trial and one was a systematic review. All articles regarding the upper facial third were observational and retrospective. The authors identified benefit of prophylactic antibiotics in the peri-operative setting for mid and upper third fractures, but recommended against their routine use in the pre-operative and post-operative setting with a grade C recommendation due to the low level of evidence. Peri-operative antibiotics were defined as those received immediately prior to and during the procedure but not administered >24 h after surgery. The authors found inconsistent evidence supporting a potential benefit in reduction of orbital cellulitis through the use of prophylactic antibiotics in mid-facial fractures of patients with underlying acute or chronic sinusitis. However, the evidence is too weak to support routine use in this scenario. Generally, the authors found that results were reported inconsistently across studies regarding all mid- and upper third facial fractures and, therefore, deriving clinical utility was difficult. Forrester et al. published a systematic review in 2020 incorporating data from 10 studies to provide specific recommendations for three clinical questions regarding the use of prophylactic antibiotics for mid- and upper third facial trauma.2 Again, the outcome assessed was surgical site infection. The first question assessed the use of prophylactic antibiotics in non-operative trauma. The authors recommended against prophylactic use in this setting but acknowledged that the evidence is moderate to low quality with a low incidence of infections across all groups. They also recommended against pre- and post-operative prophylactic antibiotics in non-mandibular facial trauma, with the strongest evidence against post-operative use which included one randomized control trial and several meta-analyses. The utility of post-operative antibiotics in facial trauma was assessed by Habib et al. in a meta-analysis published in 2018.3 The primary outcome of this study was surgical site infection and included mandibular and non-mandibular trauma. Of the 13 studies reviewed, 6 of these included middle and upper third facial fractures. Cases of mandibular and non-mandibular trauma were analyzed together in a pooled analysis. This showed no change in infection rate between post-operative, peri-operative alone, nor peri + post-operative antibiotic prophylaxis (RR = 1.11 [95% CI: 0.86–1.44], p > 0.1). While the overall sample size in the non-mandibular fracture group was too small to perform pooled analysis, the authors did not find significant differences in infection rates to suggest a benefit of post-operative antibiotics in their review. The variability in fracture type and inconsistent reporting of outcomes limits the clinical utility of the studies included. Delaplain et al. further attempted to address the question of post-operative prophylactic antibiotic use in facial trauma and their effect on surgical site infection rate in their systematic review and meta-analysis from 2020.4 Four studies assessing mid-face fractures were determined to meet inclusion for the review, with two having sufficient data to be included in a Mantel-Hanszel pooled analysis. This analysis showed no difference in the odds of developing post-operative surgical site infection (OR 1.05 [95% CI, 0.20–5.63]). Only seven of the 439 patients in the pooled group (1.6%) developed an infection. Six studies regarding orbital fractures were included in this review. While the available data were too limited to perform pooled analysis for this subgroup, the authors did note a low incidence of post-operative surgical site infections of 1.77%. Soong et al. evaluated the benefit of prophylactic post-operative antibiotics to prevent surgical site infections for Le Fort and zygomatic fractures in a randomized control trial from 2014.5 Patients with one of these fracture patterns who underwent open reduction and internal fixation (ORIF) were randomized in double-blinded fashion into a control group with 24 h of post-operative amoxicillin-clavulanic acid versus a therapeutic group who received 5 days of the same regimen. Patients with evidence of an acute infection at presentation were excluded. Ninety four of the 98 randomized patients completed the study, 35 of which with LeFort I or II fractures and 59 with zygomatic or LeFort III fractures. Two patients in each group (4%) developed a post-operative surgical site infection demonstrating no significant difference between the 24 h antibiotic and 5-day-extended antibiotic groups, nor a difference in the incidence of side effects from antibiotic use. The current literature—encompassing one randomized control trial and four systematic reviews including data from 37 individual studies—remains weak on the topic of prophylactic antibiotic use in the setting of mid-facial trauma and particularly limited regarding fractures of the frontal sinus. This literature is heterogeneous and includes a wide variety of fractures with sparse information regarding criteria for excluding pre-existing infection. Antibiotic regimens were varied and inconsistently reported and, therefore, an optimal regimen could not be determined. There is adequate evidence to recommend prophylactic peri-operative antibiotics for all cases undergoing ORIF defined as antibiotics provided <2 h prior to surgery start but not to exceed 24 h post-surgery. The current evidence does not support use of antibiotics beyond 24 h post-operatively in this setting. Routine pre-operative antibiotics do not appear to be beneficial; however, the available evidence on this topic is weakest and the clinical context and ultimate decision is perhaps best assessed on an individual basis. The available literature on this topic contains studies ranging from 1a,1, 3 1b,2, 5 2a,1, 3, 4 to 2c2, according to the Oxford classification of levels of evidence. There were few randomized control trials included in the systematic reviews and as such the level of evidence is best classified as 2a.

Throughout the evolution of functional rhinoplasty, numerous techniques have been described and shown to be successful. Controversy exists regarding which techniques are most effective to address various deformities. The goal of this article is to review the available literature to examine the question, which surgical techniques within functional rhinoplasty are most successful in treating nasal airway obstruction. Based on the available data, it is not currently possible to draw conclusions about the superiority of a single graft or technique in functional rhinoplasty.

Introduction Bone morphogenetic proteins (BMPs) are used as key therapeutic agents for the treatment of difficult fractures. While their effects on osteoprogenitors are known, little is known about their effects on the immune system. Methods We used permutations of BMP-6 (B), vascular endothelial growth factor (V), and Hedgehog signaling pathway activator smoothened agonist (S), to treat a rat mandibular defect and investigated healing outcomes at week 8, in correlation with the cellular landscape of the immune cells in the fracture callus at week 2. Results Maximum recruitment of immune cells to the fracture callus is known to occur at week 2. While the control, S, V, and VS groups remained as nonunions at week 8; all BMP-6 containing groups - B, BV, BS and BVS, showed near-complete to complete healing. This healing pattern was strongly associated with significantly higher ratios of CD4 T (CD45 + CD3 + CD4 + ) to putative CD8 T cells (CD45 + CD3 + CD4 - ), in groups treated with any permutation of BMP-6. Although, the numbers of putative M1 macrophages (CD45 + CD3 - CD11b/c + CD38 high ) were significantly lower in BMP-6 containing groups in comparison with S and VS groups, percentages of putative - Th1 cells or M1 macrophages (CD45 + CD4 + IFN-γ + ) and putative – NK, NKT or cytotoxic CD8T cells (CD45 + CD4 - IFN-γ + ) were similar in control and all treatment groups. Further interrogation revealed that the BMP-6 treatment promoted type 2 immune response by significantly increasing the numbers of CD45 + CD3 - CD11b/c + CD38 low putative M2 macrophages, putative - Th2 cells or M2 macrophages (CD45 + CD4 + IL-4 + ) cells and putative – mast cells, eosinophils or basophils (CD45 + CD4 - IL-4 + cells). CD45 - non-haematopoietic fractions of cells which encompass all known osteoprogenitor stem cells populations, were similar in control and treatment groups. Discussion This study uncovers previously unidentified regulatory functions of BMP-6 and shows that BMP-6 enhances fracture healing by not only acting on osteoprogenitor stem cells but also by promoting type 2 immune response.

Objectives/HypothesisThe prescribing of postoperative antibiotics for patients undergoing Mohs reconstructive surgery has increased in the last decade, while antibiotic resistance has been increasing. We hypothesized that routine prescribing of postoperative antibiotics after Mohs reconstruction does not decrease the risk of surgical site infection.Study DesignRetrospective, single‐institution cohort study.MethodsThis study assessed patients who underwent Mohs reconstructive surgery from January 1, 2012, to January 29, 2019. The main outcomes assessed included postoperative surgical site infections, partial or full flap/graft necrosis, hematoma, and dehiscence.ResultsA total of 900 defects in 800 patients (mean age [range] = 65.3 [21–96], 54.60% female) were identified over the 7‐year period. Patient‐specific variables reviewed included comorbidities, age, and smoking status. Surgery‐specific variables analyzed included defect characteristics, time interval between Mohs micrographic surgery and reconstruction, reconstructive modalities, and use of postoperative antibiotics. All patients received peri‐incisional antibiotics. On regression analysis, use of cartilage grafts (odds ratio [OR]: 6.53; 95% CI: 2.1‐20.6; P = .001), current smoking status (OR: 6.67; 95% CI: 2.09‐21.30; P = .001), full‐thickness defects (OR: 1.2; 95% CI: 1.0‐3.4; P = .045), and interpolated flap reconstruction (OR: 3.4; 95% CI: 1.0‐11.5; P = .049) were associated with an increased risk of postoperative infections. Smoking and cartilage grafting remained significant on bivariable regression modeling. Use of perioperative antibiotics was not associated with a decreased risk of infection (OR: 1.82; 95% CI: 0.23‐14.21; P = .568).ConclusionsWe found no association between postoperative infections after Mohs reconstructive surgery and the use of postoperative antibiotics. These data support a more targeted approach to antibiotic prescribing in Mohs reconstructive surgery.Level of Evidence4 Laryngoscope, 131:E434–E439, 2021

The principles of facial reconstruction are well established and some unique modifications apply to the non-White population. Anatomic and physiologic distinctions to this group give rise to alterations in design and surgical planning. Different ethnic groups have different skin anatomy and physiology and that should be taken into consideration. Healing differs among the different ethnic groups, affecting the final result regardless of method chosen. Variations in aesthetic units can lead to different flap selection and design. These should be considered for this population to maximize aesthetic outcomes and patient satisfaction.

BACKGROUND Over 1 million rhinoplasties are performed worldwide each year. While autologous cartilage remains the gold standard for implantable material, controversy exists regarding the role of alloplastic implants and alleged risks of infection and extrusion. Some experts avoid alloplastic implants altogether due to feared complications in unforgiving anatomy. In other areas of the world, however, they are used widely and successfully. The aim of this study is to summarize the evidence about the safety of alloplastic materials in rhinoplasty.

The nose plays a crucial role in the human experience, both aesthetically and functionally. The biomechanics of covering flaps, the importance of a firm framework, and the anatomical basis for aesthetic subunits are imperative concepts as one proceeds through the algorithm of reparative options. The subunits consist of three paired units-the ala, soft tissue facets (also known as soft tissue triangles), and sidewall, as well as three unpaired units-the dorsum, tip, and columella. Because many defects cross aesthetic subunits, it is critical to understand when to adapt the subunit principle and how or when to use a combination of techniques. It can be more challenging to apply the subunit principle to small grafts and local flaps of the nose. Convex subunits, such as the nasal tip and alar lobule, more frequently follow the subunit principle. In our practice, we adhere to a teaching of producing "straight lines and sharp corners." This applies to local flaps and grafts and focuses on keeping scar lines inconspicuous. In this article, we discuss approaches we follow for various defects along with technical pearls for performing these reconstructions. The subunit principle is more of a practice of thinking of resultant scars within a background of existing lines, reflections, and contour inflections.

Importance Reconstructing Mohs defects often requires grafting in the form of full-thickness skin grafts (FTSGs) and composite grafts. These grafts can be complicated by a variable and often indeterminable survival rate. Other researchers have found that delaying FTSG reconstruction improves graft outcomes, but the optimal interval between excision and reconstruction remains unclear, and no study has examined the association between delaying composite graft reconstruction and graft survival. Objective To review the outcomes of Mohs micrographic surgery defect reconstruction using FTSG and composite grafts with respect to patient- and surgery-specific variables, particularly early vs delayed reconstruction. Design, Setting, and Participants This retrospective, single-institution cohort study assessed patients who underwent Mohs reconstructive surgery from January 1, 2012, to January 1, 2018. No patients had to be excluded for inadequate follow-up or incomplete medical records. Delayed reconstruction was defined as greater than 6 days after Mohs excision, the third quartile of the interval to reconstruction among our cohort. Main Outcomes and Measures Primary outcome was postoperative complications, including hematoma, infection, dehiscence, epidermolysis, and partial or full graft loss. Results A total of 320 defects were reconstructed with FTSG or composite grafts in 310 patients (median [range] age, 68 [21-96] years; 167 female [53.9%]) during the 6-year study period. The mean interval between the ablative and reconstructive operations was 4.73 days (range, 0-35 days). Univariate logistic regression was used to determine the significant indicators among patient and defect characteristics analyzed. A multivariate logistic regression model found delayed reconstruction to have a protective association (odds ratio, 0.52; 95% CI, 0.27-0.97; P = .046) and male sex to have a harmful association (odds ratio, 2.51; 95% CI, 1.52-4.20; P < .001) with postoperative complications. Conclusions and Relevance This study found that delaying reconstruction in FTSGs and composite grafts was associated with decreased rates of postoperative complications, and male sex was associated with an increased risk of postoperative complications. The findings suggest that this strategy can be considered in patients at increased risk for developing postoperative complications, such as current smokers, patients with large defects, and patients who require use of composite grafts. Level of Evidence 3.

Reconstruction of cutaneous defects is a key component following completion of extirpative surgery, with a primary aim of restoring form and function to sensitive regions of the face and scalp. We review flap physiology, defect analysis, and reconstructive options in the reconstructive ladder, and describe key principles in unit reconstruction.