An Effective, Reproducible, and Cost-Effective Approach for Achieving Symmetry in Bicoronal Incisions in Pediatric Patients Undergoing Craniofacial Surgery.

SUMMARY: Bicoronal incisions are frequently used for exposure and access to the craniofacial skeleton. A zigzag design is often used to camouflage the resultant scar. Often, free-hand zigzag drawings require several correction attempts to ensure symmetry because of the need for replication of multiple limbs of the bicoronal incision that need to be similar lengths, distance, and angles from each other. The authors present a novel technique using a template that rapidly and consistently achieves symmetric zigzag bicoronal incisions. The device is a hairstyling device that is inherently geometric in its design. Retrospective results of pediatric craniofacial patients from 2010 to 2018 are presented. Patients undergoing endoscopic reconstructions and patients who had prior operations at other institutions were excluded from the study. Fifty-two patients met inclusion criteria, with age at surgery ranging from 3 to 207 months (mean, 17 months). Follow-up ranged from 1 to 66 months (mean, 26 months). Data collected included demographics, type of surgery, and operative outcomes, including incision-related complications. Using this dynamic hairstyling device in a novel application as a template results in a fast, effective, and easily reproducible symmetric bicoronal zigzag incision in all cases. This technique eliminates the need for adjusting the length and angles of bicoronal incisions, and it can be adapted across a variety of head sizes and shapes in both pediatric and adult populations.

Surgical Approach to Hemipalatal Discrepancy in Tessier 7 Reconstruction: Review of Literature and Case Series.

OBJECTIVE: The authors present findings and techniques to address hemipalatal discrepancy in patients with Tessier 7 cleft and associated cleft palate during cleft palatoplasty. DESIGN: The authors report 2 cases of pediatric patients with Tessier 7 facial clefts and associated cleft palate. One patient presents on the broader oculo-auriculo-vertebral spectrum and the other is has isolated Tessier cleft 7. Additionally, a PubMed search was performed using the MeSH terms "tessier 7," "cleft palate", "macrostomia," "tessier 7 AND cleft palate," "macrostomia AND cleft palate," AND "hemipalatal discrepancy." All relevant literature was identified and underwent full review for qualitative analysis. RESULTS: Two patients met criteria for inclusion in this article. The surgical techniques utilized to mitigate the hemipalatal length discrepancy are detailed, and intraoperative photographs are provided. The results of the literature review are also presented. Tessier 7 craniofacial cleft and palatal clefts, when occurring in combination, is noted to result in discrepant hemipalatal length with short maxillary palate length on the affected side as well hypoplasia of the associated speech musculature. The postoperative palatal length after palatoplasty in both patients was longer than the preoperative hypoplastic palatal length. CONCLUSIONS: When occurring in combination, Tessier 7 craniofacial cleft and concomitant palatal cleft results in discrepant hemipalatal length, and deficiency of the bony maxillary palatal shelves, and associated speech musculature and soft tissues. The techniques described in this article may assist in maximizing postoperative palatal length.

Efficacy of Staged Oronasal Fistula Reconstruction and Improved Bone Graft Survival in Cleft Patients Undergoing Secondary Reconstruction.

OBJECTIVE: To evaluate the efficacy of the senior author's technique of staged reconstruction in patients with recalcitrant oronasal fistulas. DESIGN: A retrospective review of the Pediatric Plastic Surgery Cleft & Craniofacial Surgery Database of cases from September 2013 to December 2018 was conducted. PATIENTS: A total of 31 patients who had previously undergone >1 surgical attempt to repair a fistula or patients who have failed >1 attempt at bone graft were included in this study. All patients were referrals from outside facilities. MAIN OUTCOME MEASURES: Primary outcomes examined included fistula recurrence, infection rates, ability to proceed with second stage bone grafting after first stage fistula takedown and reconstruction, and bone graft loss. RESULTS: Charts of 1053 patients were reviewed and 31 (2.94%) cases met inclusion criteria for this study. Nineteen (61.3%) of these patients proceeded with the second stage of reconstruction and 100% did not experience any graft loss. Seven patients who completed the first stage are undergoing orthodontic optimization prior to bone grafting. The remaining 5 are adult patients not interested in pursuing bone grafting. All 31 patients with recurrent and recalcitrant fistulas had successful fistula reconstruction with our approach, despite multiple previous failed reconstructions. CONCLUSIONS: The 2-staged reconstructive approach described herein effectively resulted in resolution of prior recurrent recalcitrant fistulas and resulted in eventual bone grafting. By employing this technique, we report successful fistula repair and bone grafting in patients who had previously undergone multiple surgical reconstructions.

Hyperbaric Oxygen Therapy for Large Composite Grafts: An Alternative in Pediatric Facial Reconstruction.

BACKGROUND: Management of pediatric facial defects can be challenging, as reattachment of large composite grafts is usually unsuccessful. Hyperbaric oxygen therapy (HBO) has been researched to augment composite graft survival, but clinical use for this application remains anecdotal. The authors present their successful experience managing select cases with large composite grafts and HBO as an adjunct. METHODS: A retrospective chart review identified children presenting with facial defects and managed operatively with large composite grafts (≥1.5 × 1.5 cm) and HBO therapy. Records were reviewed for defect characteristics, management details, and outcomes at last follow-up. RESULTS: Nine children (avg. 8.4 years, range 1.6-15.1) presented with ear or nose defects secondary to dog bites (n=7), falls (n=1), or congenital causes (n=1). Three experienced ear amputations, and six suffered nasal avulsions of varying degrees. All avulsed ears were reattached. Three cases of nose avulsions were reattached; the other three underwent secondary reconstruction with composite ear grafts. HBO was initiated immediately and continued for 8-10 days. All grafts survived at least 80% with no postoperative complications. At last follow-up (avg. 30.1 months; 0.8-63.9), all patients demonstrated good cosmetic results with minimal residual deformity. CONCLUSION: When reconstruction of pediatric facial defects warrants a large chondrocutaneous graft, immediate postoperative HBO therapy can increase survival. Particularly when reattaching amputated segments, if successful, this approach offers an anatomically ideal result without donor site morbidity. If unsuccessful, it does not "burn bridges" and decreases the extent of secondary reconstruction. The authors present their HBO protocol along with a review of available literature.

Primary Cutaneous Peripheral T-Cell Lymphoma of the Hand: Case Report of a Rare Diagnosis and Review of the Literature.

Purpose Primary cutaneous T-cell lymphoma (CTCL) is a rare diagnosis, and the subset primary cutaneous peripheral T-cell lymphoma (pcPTL) is even more uncommon. Both CTCLs and pcPTLs typically occur in the head and neck. The authors aim to evaluate the literature for reports of presentation in the hand. Materials and Methods A case report of a 77-year-old man with pcPTL of the hand is presented. Oncologic workup revealed an independent diagnosis of medullary thyroid carcinoma. A review of the literature was performed using the following search terms in the PubMed database: primary, cutaneous, T-cell lymphoma, peripheral presentation, and hand. One case of pcPTL in the hand was identified and included in this study. Results One case report in the literature was identified describing a 78-year-old man with a 1-year history of a progressive hand lesion. Biopsy revealed pcPTL. Conclusion This report presents a rare presentation of pcPTL in the hand, reviews the current literature, and provides insight into management. Prompt biopsy of any unresolving lesion of the hand is crucial to expedite diagnosis and treatment of otherwise difficult to diagnose pathologies. Increased awareness of rare malignancies is important to avoid delay in patient care and to improve outcomes.

Diagnosis and Treatment of Scalp Arteriovenous Malformations With Intracranial Extension.

Scalp arteriovenous malformations (AVMs) are rare entities that may present as large, tortuous vascular lesions with resultant craniofacial deformity. Radiologic findings include feeding arteries and veins associated with dilated tortuous vessels. Intracranial extension is rare. A 5-year-old African American male presented with an occipital mass presumed to be a dermoid cyst on referral. Further workup revealed the presence of a scalp AVM that demonstrated extension into the left sigmoid sinus. Radiologic and intraoperative images are presented. Literature search revealed only 4 patients with scalp AVM extending intracranially into the sagittal sinus, 2 of which were managed with coagulation and division of the feeding vessels and the other 2 underwent preoperative embolization. Our patient is the 1st to be reported to have sigmoid sinus extension. Scalp AVMs with intracranial extension are rare, and require further preoperative workup. Following ultrasound evaluation, computed tomography angiography, magnetic resonance angiography, magnetic resonance imaging, or cerebral angiography can be considered. Treatment entails resection, but preoperative embolization is increasingly used, mirroring patients without intracranial extension. Further studies are needed to evaluate the efficacy and risk profile of these treatments.

Cranial Erosion Associated With Non-Midline Dermoid Cysts in the Pediatric Population.

BACKGROUND: While the risk for intracranial extension of midline nasoglabellar dermoid cysts is well-described, the risk in non-midline dermoid cysts and role of preoperative imaging in these lesions is less understood. This study aims to address this gap and provide preoperative recommendations. MATERIALS AND METHODS: A retrospective review was performed evaluating patients who underwent excision of craniofacial dermoid cysts by a single surgeon. Findings on preoperative physical examination and imaging modalities were compared to intraoperative findings to assess effectiveness of each in predicting bony erosion. A treatment algorithm is proposed. RESULTS: Twenty-eight patients were included and 50% had intraoperatively confirmed bony erosion. Bony erosion was identified in 100% of lesions immobile on examination, compared to 30% of mobile lesions (P = 0.001). Bony erosion was identified in 40.9% of lateral brow cysts compared to 83.3% of lesions located elsewhere (P = 0.03), in 60% of patients with periorbital sequelae compared to 47.8% without periorbital sequelae, and in 66.7% of patients with reported change in cyst size with Valsalva compared to 48.0% without change with Valsalva. Sensitivities for preoperative identification of bony erosion were as follows: physical examination 57.1%, US 11.1%, MRI 66.7%, and CT 100%. CONCLUSIONS: A management algorithm for non-midline dermoid cysts is presented. CT or MRI is recommended for lesions that are immobile, in atypical locations, or have associated periorbital sequelae or change with Valsalva. The authors feel there is no role for ultrasound and don't recommend routine imaging in patients with non-midline dermoid cysts without features suggestive of bony erosion.

Cultural Competence and Ethnic Diversity in Healthcare.

Today's model of healthcare has persistent challenges with cultural competency, and racial, gender, and ethnic disparities. Health is determined by many factors outside the traditional healthcare setting. These social determinants of health (SDH) include, but are not limited to, education, housing quality, and access to healthy foods. It has been proposed that racial and ethnic minorities have unfavorable SDH that contributes to their lack of access to healthcare. Additionally, African American, Hispanic, and Asian women have been shown to be less likely to proceed with breast reconstructive surgery post-mastectomy compared to Caucasian women. At the healthcare level, there is underrepresentation of cultural, gender, and ethnic diversity during training and in leadership. To serve the needs of a diverse population, it is imperative that the healthcare system take measures to improve cultural competence, as well as racial and ethnic diversity. Cultural competence is the ability to collaborate effectively with individuals from different cultures; and such competence improves health care experiences and outcomes. Measures to improve cultural competence and ethnic diversity will help alleviate healthcare disparities and improve health care outcomes in these patient populations. Efforts must begin early in the pipeline to attract qualified minorities and women to the field. The authors are not advocating for diversity for its own sake at the cost of merit or qualification, but rather, these efforts must evolve not only to attract, but also to retain and promote highly motivated and skilled women and minorities. At the trainee level, measures to educate residents and students through national conferences and their own institutions will help promote culturally appropriate health education to improve cultural competency. Various opportunities exist to improve cultural competency and healthcare diversity at the medical student, resident, attending, management, and leadership levels. In this article, the authors explore and discuss various measures to improve cultural competency as well as ethnic, racial, and gender diversity in healthcare.

Cranial Suture Anchor Temporalis Resuspension: A New Technique to Reconstruct Temporal Hollowing After Craniotomy.

INTRODUCTION: Proper temporalis resuspension following craniotomy or craniectomy is necessary to prevent significant temporofacial deformity. Several methods of temporalis reconstruction have been described with varying success; currently there are no reports of suture anchor utilization. METHODS: A patient is presented displaying successful temporalis resuspension using suture anchor fixation. An incision was made in the temporal hair-bearing scalp to access and lengthen the retracted temporalis under direct visualization. Stab incisions were then made in the scalp to expose the superior temporal line, where suture anchors were placed for muscle fixation. After confirming appropriate vectors for muscle resuspension, 1 suture arm was passed through a subgaleal tunnel to capture the temporalis and the other was fixated to the temporoparietal skull. The suture anchors were secured and the incisions were closed in layers. RESULTS: A 36-year-old female with history of decompressive craniectomy for hemorrhagic stroke presented with significant temporal hollowing. Her temporalis was retracted with a noticeable defect on frontal view and bulging over the zygomatic arch. The patient underwent temporalis resuspension as described with durable correction resembling her premorbid state. The buried suture anchors were nonpalpable. CONCLUSION: Temporal hollowing after craniotomy is a difficult contour deformity to correct. In the presented patient, reconstruction with temporalis elevation and suture anchor resuspension was found to be an effective technique with excellent cosmetic outcome. The efficiency of suture anchor placement, postoperative maintenance of muscle tension, and nonpalpable profile of the buried suture anchors suggest comparable efficacy to plate fixation and suture-only techniques.

Endoscopic Brow Lift Fixation With Mitek Suture Anchors: A 9-Year Experience of a New "Ideal" Technique.

PURPOSE: In recent years, the endoscopic technique has emerged as a minimally invasive approach to forehead rejuvenation, although the specific need for and mode of brow fixation for endoscopic brow lifts remain under considerable debate. An ideal fixation device should provide non-palpable long-lasting fixation and allow retention of the device post-operatively without the need for removal. It should also allow precise intraoperative adjustment for symmetry and correction of brow ptosis. METHODS: The authors describe an endoscopic brow lift technique using an absorbable bone anchor, Mitek Microfix. A retrospective chart review was conducted in patients who underwent endoscopic brow lift procedures utilizing this fixation method at an academic practice. Outcomes evaluated included operative times, reoperation rates, palpability, fixation device permanence, incremental costs comparisons to conventional methods, efficacy, and technical learning curve. Complication rates were evaluated and the economic, incremental cost analysis of current fixation methods was reviewed. RESULTS: Eighty-two patients underwent single-procedure endoscopic brow fixation using the Mitek anchor over a 9-year period (2005-2014). The mean operative time was 100 minutes. There were no cases of implant palpability, alopecia, or other postoperative complications. Two patients underwent revision secondary lifts after an average of 5.5 months for temporal ptosis. CONCLUSION: The Mitek Microfix QuickAnchor provides durable, long-lasting fixation without device palpability. Its technical ease of use is demonstrated by the reasonable mean operative time achieved with the active involvement of resident surgeons. This device is operator-friendly, easy to use, fully indwelling, and provides lasting fixation without the development of palpability or alopecia.

OBJECTIFS: Ces dernières années, la technique endoscopique est devenue une approche peu invasive du rajeunissement du front, mais la nécessité et le moyen de fixer les sourcils font l'objet de vifs débats. Le dispositif de fixation idéal doit être non palpable, durable et demeurer en place sans devoir être retiré. Il doit également assurer le rajustement intraopératoire précis de la symétrie et de la correction de la ptose des sourcils. MÉTHODOLOGIE: Les auteurs décrivent une technique de redrapage endoscopique des sourcils à l'aide de l'ancre osseuse absorbable Mitek Microfix. Ils ont procédé à une analyse rétrospective des dossiers des patients qui avaient subi un redrapage endoscopique des sourcils à l'aide de cette méthode de fixation dans un cabinet universitaire. Ils ont évalué la durée de l'opération, le taux de réopérations, la palpabilité, la permanence du dispositif de fixation, les comparaisons des coûts différentiels par rapport aux méthodes traditionnelles, l'efficacité et la courbe d'apprentissage technique. Ils ont également évalué le taux de complications et examiné l'analyse des coûts différentiels des méthodes de fixation. RÉSULTATS: Sur une période de neuf ans (de 2005 à 2014), 82 patients ont subi une seule intervention de fixation endoscopique des sourcils à l'aide de l'ancre Mitek. L'opération durait 100 minutes en moyenne. Il n'y a eu aucun cas de palpabilité de l'implant, d'alopécie ou d'autres complications postopératoires. Deux patients ont subi un redrapage secondaire après une ptose temporale au bout d'une période moyenne de 5,5 mois. CONCLUSION: L'ancre Mitek Microfix QuickAnchor procure une fixation durable sans palpabilité du dispositif. La simplicité de la technique est démontrée par le temps moyen raisonnable de l'opération obtenu avec la participation active de résidents en chirurgie. Ce dispositif à demeure est facile à utiliser pour l'opérateur et procure une fixation durable sans apparition de palpabilité ou d'alopécie.

Surgical Management of Pediatric Lymphedema: A Systematic Review.

BACKGROUND: Lymphedema is a rare, progressive, and debilitating condition caused by failure of the lymphatic system to adequately drain the protein-rich fluid exiting the capillaries. Conservative management is often emphasized in pediatric patients, resulting in a paucity of literature describing surgical treatment in this population. METHODS: A systematic review was performed using PubMed, ScienceDirect, and Google Scholar to identify all studies describing surgical management of lymphedema in the pediatric population. RESULTS: Of the 343 relevant articles identified, 14 met the criteria for full review. Articles were divided into the following treatment categories: genital lymphedema, excisional procedures for extremity lymphedema, and physiologic procedures for extremity lymphedema. Outcomes for genital lymphedema were overall positive. For extremity lymphedema, excisional procedures yielded good results overall and included the majority of patients in this study. Physiologic procedures had mixed outcomes in the small population included in this study, but definitive conclusions cannot be drawn due to the paucity of existing data. CONCLUSION: While conservative management of pediatric lymphedema is well described, the literature remains sparse regarding surgical treatment. Further studies are needed to evaluate efficacy and outcomes in all three categories in this population.

The Oxymoron of Financial Illiteracy in a Highly Educated Population: Are We Appropriately Equipping Trainees?

Medical professionals often incur a significant financial burden in pursuit of a medical education. Despite rigorous medical education, financial education appears to be lacking during training. This study intended to explore the financial preparedness and education of 2 cohorts of medical professionals-alumni graduates of a single institution and current plastic surgery residency trainees. METHODS: An electronic survey of the residency alumni at a single institution across all specialties over a 50-year period was conducted. This was conducted concurrent with a survey to current plastic surgery residency trainees across the country. The survey explored several core financially relevant areas, including financial education at various levels of training, fiscal goals, debt profile, spending and saving habits, investment management, financial and family obligations, estate planning, and retirement preparedness. RESULTS: A total of 521 alumni and 84 residents completed the survey from the residency alumni cohort and plastic surgery training programs cohort, respectively. Results from both groups demonstrated that although the large majority considered financial education a priority, this was not prioritized in medical or residency training. Most were introduced to financial education either by a family member or by self-directed learning. Data on investments, savings, finances, and retirement planning are also presented. CONCLUSIONS: As a very literate group, there is an unacceptably high level of "illiteracy" concerning financial education at an early stage. Practicing physicians and current trainees believe that a more directed approach to financial education should be adopted, rather than the current laissez-faire climate during medical education and residency training.

A Critique of the Impact Factor and Ramifications of Its Misuse in Plastic and Reconstructive Surgery: The Real Impact of the Impact Factor.

The impact factor is used to compare the number of citations of a journal with its number of publications. Although first used to assess the significance of various journals, its very creator has stated that it is an imperfect system. Presently, the impact factor overvalues the importance of large-readership journals and undervalues that of smaller more specialized journals. Although no metric can serve as a perfect assessment of a journal's worth, it is vital when selecting journals for publication, resource allocation, funding, or citation to weigh not only the impact factor of a large-volume journal, but also the added value of lower impact factor but also effective specialized subspecialty journals.

An Algorithmic Approach to the Management of Infantile Digital Fibromatosis: Review of Literature and a Case Report.

Objective: Infantile digital fibromatosis is a rare benign childhood tumor, infrequently cited in the literature. Hallmarks include nodular growths exclusive to fingers and toes and the presence of eosinophilic cytoplasmic inclusions on histology. This article aims to exemplify diagnoses of infantile digital fibromatosis and possible treatment options. Methods: A computerized English literature search was performed in the PubMed/MEDLINE database using MeSH headings "infantile," "juvenile," "digital," and "fibromatosis." Twenty electronic publications were selected and their clinical and histological data recorded and used to compile a treatment algorithm. Results: A 9-month-old male child was referred for a persistent, symptomatic nodule on the third left toe. A direct excision with Brunner-type incisions was performed under general anesthesia. The procedure was successful without complications. The patient has no recurrence at 2 years postsurgery and continues to be followed. Histological examination revealed a proliferation of bland, uniformly plump spindle cells with elongated nuclei and small central nucleoli without paranuclear inclusions consistent with fibromatosis. Conclusions: Asymptomatic nodules should be observed for spontaneous regression or treated with nonsurgical techniques such as chemotherapeutic or steroid injection. Surgical removal should be reserved for cases with structural or functional compromise.

Craniosynostosis and Guanine Nucleotide-binding Protein Alpha Stimulating Mutation: Risk of Bleeding Diathesis and Circulatory Collapse in Patients Undergoing Cranial Vault Reconstruction.

Reconstruction of the craniosynostosis deformity is a relatively safe operation with low overall complication risks. Despite expected risk of significant blood loss, life-threatening bleeding is relatively rare, and there is a low incidence of reported deaths in the literature. Several modalities have been described for perioperative mitigation of blood loss and transfusion requirements. Due to the low overall risk of life-threatening bleeding and circulatory collapse, it is judicious that any potential causes of such unusual but potentially significant fatal bleeding complication be evaluated and reported to increase awareness for craniofacial surgeons treating these conditions. In this report and literature review, the authors present a highly unusual patient with significant bone bleeding and circulatory collapse in a metopic craniosynostosis patient with guanine nucleotide-binding protein alpha stimulating (GNAS) mutation; perform a literature review regarding bleeding diathesis in craniosynostosis patients with GNAS mutations; and suggest guidelines to potentially prevent mortality in such patients.