10 Health Moonshots: How a Global Army of Health Transformers Is Accomplishing One Impossible Dream

Learning Objectives: Describe moonshot thinking and how it’s being used to help improve health care. Identify and recognize what the 10 Health Moonshots are to improve the health and wellbeing of everyone in the world. Describe how technology has an imperative role in improving the health and significance in moonshot thinking. Presentation: 49:5

Use of the Anterolateral Thigh in Cranio-Orbitofacial Reconstruction

Objective. To detail the clinical outcomes of a series of patients having undergone free flap reconstruction of the orbit and periorbita and highlight the anterolateral thigh (ALT) as a workhorse for addressing defects in this region. Methods. A review of 47 patients who underwent free flap reconstruction for orbital or periorbital defects between September 2006 and May 2011 was performed. Data reviewed included demographics, defect characteristics, free flap used, additional reconstructive techniques employed, length of stay, complications, and follow-up. The ALT subset of the case series was the focus of the data reviewed for this paper. Selected cases were described to highlight some of the advantages of employing the ALT for cranio-orbitofacial reconstruction. Results. 51 free flaps in 47 patients were reviewed. 38 cases required orbital exenteration. The ALT was used in 33 patients. Complications included 1 hematoma, 2 wound infections, 3 CSF leaks, and 3 flap failures. Conclusions. Free tissue transfer allows for the safe and effective reconstruction of complex defects of the orbit and periorbital structures. Reconstructive choice is dependent upon the extent of soft tissue loss, midfacial bone loss, and skullbase involvement. The ALT provides a versatile option to reconstruct the many cranio-orbitofacial defects encountered

Economic Impact of Facial Plastic and Reconstructive Surgery: The Case Mix Index

Background: The case mix index (CMI) represents the average medicare severity-diagnosis related group relative weight over a period of time. The higher the CMI, the more the hospital gets reimbursed, on average. Little has been published in regards to CMI within Otolaryngology particularly in Facial Plastic and Reconstructive Surgery. Aim: This study was performed to determine the economic impact of Facial Plastic and Reconstructive Surgery has on hospital medicare reimbursements. Methods: In a retrospective review we analyzed the admissions of facial plastic and reconstructive surgeons as well as general otolaryngologists at a tertiary medical center from October 2015 through May 2018. General otolaryngology excluded pediatrics, otology, and admissions under fellows. The admissions analyzed were limited to patients that required observation or intervention from a plastics perspective. Of the FPRS admissions, there were no patients included that were admitted for oncologic resection or surgeries that would have fallen within other specialties of otolaryngology. The case mix index was then calculated for each admission. Results: There were two facial plastic and reconstructive surgeons and thirteen general otolaryngology surgeons who admitted patients from October 2015 through May 2018. A total of 103 admissions were found to have plastics-only observation or intervention. The average CMI for these patients was 2.92. Of the 1,918 general otolaryngology admissions, the average CMI was 2.62. There were 14 FPRS admissions that had a CMI of less than 1.00, and five of those did not have a procedure completed during the admission. Conclusion: At the studied tertiary care center, case mix index values greater than a value of 2.2 indicated that the average medicare reimbursements per admission surpassed the costs of the admission. The result is a profit for the hospital. As demonstrated in our study, FPRS admissions consistently produced a profit for this tertiary medical center. Furthermore, FPRS admissions resulted in a greater average CMI as compared to admissions under general otolaryngologists

Reconstructive trends and complications following parotidectomy: incidence and predictors in 11,057 cases.

BACKGROUND: Parotidectomy is a common treatment option for parotid neoplasms and the complications associated with this procedure can cause significant morbidity. Reconstruction following parotidectomy is utilized to address contour deformity and facial nerve paralysis. This study aims to demonstrate national trends in parotidectomy patients and identify factors associated with adverse postoperative outcomes. This study includes the largest patient database to date in determining epidemiologic trends, reconstructive trends, and prevalence of adverse events following parotidectomy. METHODS: A retrospective review was performed for parotidectomies included in the ACS-NSQIP database between January 2012 and December 2017. CPT codes were used to identify the primary and secondary procedures performed. Univariate and multivariate analysis was utilized to determine associations between pre- and perioperative variables with patient outcomes. Preoperative demographics, surgical indications, and common medical comorbidities were collected. CPT codes were used to identify patients who underwent parotidectomy with or without reconstruction. These pre- and perioperative characteristics were compared with 30-day surgical complications, medical complications, reoperation, and readmission using uni- and multivariate analyses to determine predictors of adverse events. RESULTS: There were 11,057 patients who underwent parotidectomy. Postoperative complications within 30 days were uncommon (1.7% medical, 3.8% surgical), with the majority of these being surgical site infection (2.7%). Free flap reconstruction, COPD, bleeding disorders, smoking, and presence of malignant tumor were the strongest independent predictors of surgical site infection. Readmission and reoperation were uncommon at an incidence of 2.1% each. The strongest factors predictive of readmission were malignant tumor and corticosteroid usage. The strongest factors predictive of reoperation were free flap reconstruction, malignant tumor, bleeding disorder, and disseminated cancer. Surgical volume/contour reconstruction was relatively uncommon (18%). Facial nerve sacrifice was uncommon (3.7%) and, of these cases, only 25.5% underwent facial nerve reinnervation and 24.0% underwent facial reanimation. CONCLUSIONS: There are overall low rates of complications, readmissions, and reoperations following parotidectomy. However, certain factors are predictive of adverse postoperative events and this data may serve to guide management and counseling of patients undergoing parotidectomy. Concurrent reconstructive procedures are not commonly reported which may be due to underutilization or underreporting

Fat Graft for Parotidectomy Defect Reconstruction in the Setting of Malignant Disease

Objectives: Currently, limited data examines the safety of utilizing fat transfers in the setting of malignant parotid disease. Here we evaluate the safety of fat graft reconstruction of parotidectomy defects in the setting of malignant disease. Study Design: Retrospective cohort study Methods: Electronic chart review of patients who underwent parotidectomy from 2012-2020 were reviewed. Results: Three hundred and sixty-one patients were identified at a single institution who underwent parotidectomy, and 113 (31.3%) were for malignancy. One hundred and thirty-two patients underwent fat graft reconstruction (49.2%, n=65 for umbilical, 50.8%, n=67 for dermal). One-third of patients had malignant pathology (34.8%, n=46). The most common malignant tumors were squamous cell carcinoma (n=15), acinic cell carcinoma (n=9), and mucoepidermoid carcinoma (n=6). Twenty patients (45.5%) received postoperative radiation therapy. Complications included: surgical site necrosis (13%), hematoma (4.3%), and infection (2.2%). Overall incidence of malignant recurrence was 4.4% with a mean time of follow-up of 10.3 (range 0 – 77.3) months. Incidence of malignant recurrence in the fat graft reconstruction subset was 0% with a mean follow-up of 9.8 (range 0.2 – 49.3) months. There was no association with use of fat graft and recurrence (p\u3e0.05). Conclusion: Parotidectomy defects for malignant neoplasms can be reconstructed with fat graft transfers with no impact on surveillance for disease recurrence.https://jdc.jefferson.edu/otoposters/1010/thumbnail.jp

A Preliminary Report of Percutaneous Craniofacial Osteoplasty in a Rat Calvarium

Objective: To evaluate the potential for injectable, permanent bone augmentation by assessing the biocompatibility and bioactivity of subperiosteal hydroxylapatite (Radiesse) deposition in a rat model. Methods: Fourteen adult Sprague Dawley rats were injected in the parietal skull with hydroxylapatite (n=10) or a carrier gel control (n=4), using a subperiosteal injection technique on the right and a subcutaneous injection technique on the left. At 1, 3, and 6 months, 3 rats (1 negative control, 2 variables) were sacrificed. At 12 months, the remaining 5 rats were sacrificed. After each harvest, the calvaria were examined under both light and polarized microscopy. Results: The inflammatory response was limited in all specimens. Injectables were still present 12 months after the injection. New bone formation was only seen when the injection was located deep to a disrupted periosteum The odd of new bone formation was 48.949 times higher (95% CI (2.637, 3759.961), p = 0.002) with subperiosteal hydroxylapatite injections compared to all other combinations of injection plane and injectable. Conclusion: This preliminary report of subperiosteal hydroxylapatite (Radiesse) injection in a rat model has verified the biocompatibility of injectable hydroxylapatite at the bony interface and suggests the potential for new bone formation

Intraoperative Evaluation of Nasal Valve Repair Interventions: A Prospective Analysis

Objectives: To allow for early identification and treatment of inadequate nasal valve repair interventions in the intraoperative setting, based on degree of nasal valve collapse quantified by suction-assisted pressure readings. Patient outcomes were measured by comparison of pre- and post-operative Nasal Obstruction Symptom Evaluation (NOSE) surveys. Study Design: Prospective study. Methods: All enrolled patients undergo suction-assisted evaluation of nasal valve collapse before surgical intervention. Patients randomized into the experimental group underwent repeat assessment after various nasal valve interventions, compared to a control group where adequacy of interventions was assessed by palpation of the nasal ala. Results: 20 patients who underwent nasal valve repair were first randomized into control (10) or experimental (10) groups. Two patients in the control group did not receive nasal valve work due to pre-operative readings and were excluded from further analysis. Nasal valve interventions included alar rim grafts (5), spreader grafts (10), batten grafts (2), and nasal valve suture suspension (8). After nasal valve interventions, average suction reading at first sign of collapse increased by 92% (p \u3c 0.0001) and average suction reading at maximal collapse increased by 16% (p \u3c 0.0001). Pre-operative NOSE scores decreased by 55% (p \u3c 0.0001) at the first follow-up visit at 9.3±3.5 days. No patients in the experimental group required additional nasal valve interventions after repeat suction-assisted evaluations intraoperatively. Conclusion: Intraoperative suction-assisted evaluation of nasal valve collapse can help assess adequacy of nasal valve interventions and determine whether additional interventions are necessary to improve nasal valve integrity.https://jdc.jefferson.edu/otoposters/1011/thumbnail.jp

Postoperative Opioid-Prescribing Practices in Nasal Surgery: A Prospective Study

Introduction: Within facial plastic and reconstructive surgery (FPRS), prescription practices have trended toward prescribing larger amounts of perioperative opioids. However, there is limited literature regarding the postoperative pain experience and opioid consumption for FPRS. The purpose of our study was to investigate opioid prescription and consumption following procedures of the nose, with the aim of developing evidence-based guidelines for postoperative pain management. Methods: In this prospective single center study, morphine milligram equivalents (MME) consumption and pain scores were collected in 72 patients who underwent nasal surgery. Patient demographics, MME use, and pain scores were examined. MME use was compared to patient demographics, surgical procedure type, and postoperative pain scores. Results: In total, 3427 MME were prescribed: 2082 MME (60.8%) were used, leaving 1345 MME (39.2%). Patients were prescribed a total average of 47.6 ± 23.6 MME. Four (5.6%) patients required a second prescription. Average pain peaked on postoperative day 0 (POD0) and trended downwards. Visual analog scale (VAS) score dropped from 5.5 ± 2.8 on POD0 to 1.7 ± 1.9 at POD office visit. Mean POD follow-up visit was 7.0. Obesity, smoking (current and former), and history of opioid use were negative predictors of opioid consumption in postoperative patients (P\u3c0.05). Discussion: A significant portion of opioid prescriptions are not consumed by patients after nasal surgery, and several factors may explain why some patients use fewer opioids. Assessing opioid consumption for nasal procedures will guide prescribing practices. Our results indicate that prescription practices can likely be down titrated in select patients

Design and Printing of a Low-Cost 3D-Printed Nasal Osteotomy Training Model: Development and Feasibility Study.

BACKGROUND: Nasal osteotomy is a commonly performed procedure during rhinoplasty for both functional and cosmetic reasons. Teaching and learning this procedure proves difficult due to the reliance on nuanced tactile feedback. For surgical simulation, trainees are traditionally limited to cadaveric bones, which can be costly and difficult to obtain. OBJECTIVE: This study aimed to design and print a low-cost midface model for nasal osteotomy simulation. METHODS: A 3D reconstruction of the midface was modified using the free open-source design software Meshmixer (Autodesk Inc). The pyriform aperture was smoothed, and support rods were added to hold the fragments generated from the simulation in place. Several models with various infill densities were printed using a desktop 3D printer to determine which model best mimicked human facial bone. RESULTS: A midface simulation set was designed using a desktop 3D printer, polylactic acid filament, and easily accessible tools. A nasal osteotomy procedure was successfully simulated using the model. CONCLUSIONS: 3D printing is a low-cost, accessible technology that can be used to create simulation models. With growing restrictions on trainee duty hours, the simulation set can be used by programs to augment surgical training

The Current State of Performance Appraisal Research and Practice: Concerns, Directions, and Implications

On the surface, it is not readily apparent how some performance appraisal research issues inform performance appraisal practice. Because performance appraisal is an applied topic, it is useful to periodically consider the current state of performance research and its relation to performance appraisal practice. This review examines the performance appraisal literature published in both academic and practitioner outlets between 1985 and 1990, briefly discusses the current state of performance appraisal practice, highlights the juxtaposition of research and practice, and suggests directions for further research