The Paisley Pattern Breast Reduction.

BACKGROUND: Skin resection patterns inform the shape and scars after breast reduction. The 2 most commonly performed skin resection patterns, the Wise pattern and vertical pattern, each have limitations. The most common challenge is addressing excess lateral skin while avoiding medial scars. The Paisley Pattern breast reduction addresses this by incorporating lateral dogear excision in the skin resection design. METHODS: Thirty consecutive patients received a Paisley Pattern breast reduction. After institutional review board approval, a chart review was performed to evaluate resection weight, operative time, American Society of Anesthesiologists class, flap necrosis, and seroma. RESULTS: Operative times were comparable to published times for the Wise and vertical pattern techniques. No patients had lateral flap necrosis, and no patients required a return to the operating room during the follow-up period. One patient developed a unilateral seroma that was drained by interventional radiology. CONCLUSIONS: This report of a novel skin resection design demonstrates a proof of concept that the skin resection pattern can be performed safely in a wide variety of patients. Although there is a learning curve to the technique to prevent over-resection laterally, it provides efficient and aesthetically acceptable alternative to the Wise and vertical skin resection patterns for both large and small reductions.

HISTORIQUE: Les profils de résection cutanée présagent de la forme et des cicatrices après la réduction mammaire. Les deux principaux patrons de résection cutanée, le patron de Wise et le patron vertical, ont leurs limites. Le problème le plus courant consiste à corriger l'excès de peau latérale tout en évitant les cicatrices médiales. La réduction mammaire par patron de Paisley règle ce problème en intégrant l'excision latérale « en oreilles de chien ¼ à la conception de la résection. MÉTHODOLOGIE: Trente patientes consécutives ont subi une réduction mammaire par patron de Paisley. Après l'approbation du comité d'éthique indépendant, les chercheurs ont procédé à une analyse des dossiers pour évaluer le poids de la résection, la durée de l'opération, la classification ASA, la nécrose du lambeau et le sérome. RÉSULTATS: La durée des opérations était comparable à celle publiée pour les techniques par patron de Wise et patron vertical. Aucune patiente n'a souffert de nécrose du lambeau latéral, et aucune n'a dû retourner en salle d'opération pendant la période de suivi. Une patiente a présenté un sérome unilatéral qui a été drainé par radiologie interventionnelle. CONCLUSIONS: Ce rapport d'une nouvelle conception de la résection cutanée valide la possibilité d'utiliser le nouveau patron de résection en toute sécurité chez toute une variété de patientes. Une courbe d'apprentissage s'impose avant de maîtriser la technique, afin d'éviter les surrésections latérales, mais cette méthode remplace de manière efficace et esthétique le patron de Wise et le patron vertical, tant pour les réductions importantes que mineures.

Innovative Surgical Treatment of Severe Cherubism.

BACKGROUND: Cherubism is an autosomal dominant syndrome characterized by excessive bilateral maxillomandibular bony degeneration and fibrous tissue hyperplasia. Conservative management is the preferred treatment as cherubism has a self-limiting course. Functional or emotional disturbances may, however, demand surgical intervention. We report a patient who underwent surgical intervention. METHOD/DESCRIPTION: He had significant enlargement of lower cheeks and bilateral lower lid scleral show. On computed tomography of the face, the patient had significant fibrous tissue involving bilateral maxilla and mandible. The mandibular tumor was excised. Given normal inferior border, bilateral sagittal split osteotomy was performed to infracture and inset the outer cortex. During the procedure, patient required blood transfusion intraoperatively, so the maxillary portion of the procedure was delayed until 6 months later. For the maxilla, bilateral transconjunctival approach was used to resect parts of the orbital floors that were concave, resulting in 1 × 2 cm defects bilaterally which were reconstructed using resorbable plates. Then the anterior maxillary tumor was excised. RESULTS: The patient and his parents were satisfied with his appearance after surgery. The patient was noted to have improvement in contour and decreased scleral show. He has most recently followed up 15 months after the initial surgery. There were no long-term complications. CONCLUSIONS: Severity of cherubism influences the type of surgical intervention. The present case is innovative because this is the first reported case of recontouring orbital floors with resorbable plates and infracturing of the mandible using sagittal split osteotomies for surgical treatment of cherubism.

Impact of interdisciplinary rounds in the spinal cord injury unit on relational coordination for patients with pressure injury: A pilot study.

CONTEXT/OBJECTIVE: Multiple medical specialties are often involved in the management of patients with both spinal cord injuries (SCI) and pressure injuries (PIs), sometimes leading to inadequate communication. Our Veterans Affairs (VA) hospital has an interdisciplinary team for PI patients in the SCI unit. This team conducts monthly bedside rounds and journal clubs; there is no similar team for patients with PIs outside the SCI unit. This pilot study aims to determine whether such an interdisciplinary team improves care coordination among practitioners. DESIGN: Survey-based study. SETTING: VA hospital. PARTICIPANTS: Healthcare providers who participate in interdisciplinary SCI rounds and who also care for patients with PIs outside the SCI unit. INTERVENTIONS: Interdisciplinary rounds, including monthly bedside rounds and journal clubs with variety of specialists take place within the SCI unit. There are no similar interdisciplinary rounds for patients with PIs outside of the SCI unit. OUTCOME MEASURES: The Relational Coordination (RC) survey is a validated tool for gauging team performance. Survey results quantified relational dynamics inside and outside the SCI unit across four communication domains (frequent communication, timely communication, accurate communication, and problem-solving communication) and three relationship domains (shared knowledge, mutual respect, and shared goals). RESULTS: Interdisciplinary rounds in the SCI unit was associated with significantly better RC with hospitalists, surgical specialists, infectious diseases, nursing, and pharmacy. This effect was primarily due to improvements in communication domains, without significant difference in relationship domains. CONCLUSIONS: Interdisciplinary rounds in the SCI unit significantly improves RC in the care of PI patients.

Do Academic Health Care Systems Really Value Education? A Survey of Academic Plastic Surgeons.

BACKGROUND: Although education is critical to the mission of academic medical centers in the United States, it is often not quantified and monetized as are their research and clinical missions. We undertook this survey to assess the perceived valuation of educational endeavors of plastic surgeon faculty at the U.S. academic medical centers. METHODS: A survey using Qualtrics software (Qualtrics, Provo, UT) was distributed to faculty members of the American Council of Academic Plastic Surgeons by electronic mail in February 2015. A total of 16 questions included both demographic information and Likert-item questions of perception of valuation of educational activities. For analysis, responses were grouped according to an adapted Net Promoter Score including "unsupportive" (0-6), "neutral" (7-8), and "supportive" (9-10). RESULTS: Sixty-five surveys were completed out of a total of 406, with an overall response rate of 16%. Kruskal-Wallis statistical analysis demonstrated that region and rank were not significant in perception of hospital or departmental support for educational activities. Respondents rated their departments as more supportive than their institutions (P < 0.05), and average perceived value rating of institutions was "unsupportive." Financial support was associated with higher ratings with respect to support of institutions and departments. Mid-career faculty displayed a trend toward lower ratings of perception of support. CONCLUSIONS: The majority of respondents perceived their institutions and departments as unsupportive of educational effort. Direct compensation to physicians for teaching efforts may improve faculty retention in academia and reduce physician burnout.

Perioperative antibiotic use in diabetic patients: A retrospective review of 670 surgeries.

PURPOSE: Carpal tunnel syndrome (CTS) has a high incidence in diabetic patients, with a reported incidence up to 21%. In severe cases of CTS, patients may undergo carpal tunnel release (CTR) surgery, which involves the risk of infection and other complications. To decrease the risk of infection, some physicians provide prophylactic antibiotics. Our study examines the effects of prophylactic antibiotic use, especially in a high-risk, diabetic population. METHODS: A total of 469 CTR surgeries performed by plastic surgery specialists were reviewed for diabetic status at the time of surgery and perioperative antibiotic use. Postoperative infections occurring at the surgical site were recorded. Associations between perioperative antibiotic use and infection in diabetics and nondiabetics were then analyzed. RESULTS: No significant decrease in infection rate was seen in those who were given perioperative antibiotic use. This relationship held true for diabetics as well. CONCLUSIONS: No benefit of antibiotic use during CTR surgery was seen. There was, however, a trend toward a protective effect in patients with uncontrolled diabetes mellitus, suggesting that such patients may benefit from perioperative antibiotic use. LEVEL OF EVIDENCE: III (Retrospective cohort study), Therapeutic.

Cleft and Craniofacial Clinic Formats in the United States: National and Institutional Survey.

BACKGROUND: Craniofacial teams employ multidisciplinary clinics to optimize patient care. Different clinic formats exist among teams. Formats include providers rotating from room to room as separate specialties, patients rotating from room to room to either separate specialties or as 1 group, as well as providers rotating together as 1 group. Surveys were used to study family preferences between the different formats and to compare them with trends of national practices. METHODS: Families of the authors' team clinic patients were surveyed from November 2012 to February 2013, after a clinic format change from patients moving between rooms to see providers, to providers moving between rooms to see patients. This survey focused on patient satisfaction, clinic format preference, and their perception of efficiency. A second, national survey was distributed to 161 American craniofacial teams approved by the American Cleft Palate-Craniofacial Association to survey clinic formats, provider satisfaction, and experience with other formats. Institutional survey data were tabulated as percentages and further analyzed using the Mann-Whitney Test. The national survey data was then tabulated and compared with authors' institutional results. RESULTS: Thirty-nine of 54 (72.2%) families responded to the institutional survey. Providers moving between rooms were associated with greater patient satisfaction (mean 4.8 of 5, 5 being most satisfied) (0<0.0001), shorter perceived clinic time (76.9%), and an increased sense of comfort (84.6%). The difference in satisfaction rates was statistically significant (P <0.0001) between the primary clinic formats of providers rotating (mean of 4.8) and patients rotating (mean of 2.4).The national survey had 93 responses of 161 (57.7%). 54.9% of respondents have providers rotating between examination rooms, and 32.3% have patients moving between rooms. Other formats included the entire team moving as a group between rooms (10.8%) and specialties sitting together in 1 room while patients rotate (9.7%). Respondents were satisfied with current formats (mean 4.24 of 5, 5 being most satisfied). 22.2% had tried a different format previously. CONCLUSION: The most common American cleft and craniofacial clinic format is providers moving between rooms; however, all formats have high provider satisfaction. At our institution, patients prefer when providers move between rooms. Our study suggests that clinic formats do not need to be standardized, and the clinic format utilized should be tailored to the individual needs of the institution.

A Novel Single-Staged Technique for the Treatment of Soft Tissue in an Oblique Facial Cleft.

INTRODUCTION: Oblique facial clefts are extremely rare and cause significant morbidity. Treatment of these clefts is complex and requires a fundamental understanding of cleft classification and techniques used for treatment of clefts. METHODS: We describe a novel single-staged technique to repair the Tessier no. 4 soft tissue cleft and reconstruct the buccal sulcus and bilaminar lower eyelid by preserving normally excised tissue combined with standard procedures. We also present a case report demonstrating the technique in an adolescent female. The procedure incorporates turnover flaps from soft tissue preservation within the cleft, a Mustarde cheek advancement flap, an anatomical subunit lip repair, a dorsal nasal Rieger flap for ala repositioning, and a lateral nasal flag flap. RESULTS: The single-staged soft tissue repair eliminated the Tessier no. 4 cleft while simultaneously reconstructing the bilaminar lower eyelid and buccal lining. Our patient had no complications within the perioperative period. CONCLUSIONS: This novel single-staged technique for the treatment of the soft tissue Tessier no. 4 cleft not only repairs the cleft but also reconstructs the buccal sulcus and bilaminar lower eyelid with turnover flaps preserved from the normally discarded excess soft tissue within the cleft. The novel repair allows for the creation of a deeper fornix to aid with placement of an orbital prosthesis and is ideal for use in underserved or remote locations.

Social and Support Services Offered by Cleft and Craniofacial Teams: A National Survey and Institutional Experience.

BACKGROUND: A multidisciplinary approach to patients with craniofacial abnormalities is the standard of care by the American Cleft Palate-Craniofacial Association (ACPA). The standards of team care, however, do not require provision of social support services beyond access to a social worker. The purpose of this investigation is to study social support services provided by ACPA teams, funding sources for services, and family interest in services. METHODS: A survey was submitted to ACPA cleft and craniofacial team leaders (N = 161), which evaluated the provision of potentially beneficial social support services, and their funding sources. A second survey administered to patient families at our institution gauged their level of interest in these services. Statistical analysis evaluated the level of interest among services. RESULTS: Seventy-five of 161 (47%) teams and 39 of 54 (72%) families responded to the surveys. Services provided included scholarships (4%), summer camp (25%), social media (32%), patient support groups (36%), parties (42%), parent support groups (46%), other opportunities (56%), and social workers (90%). The majority of funding for social workers was by the institution (61%) whereas funding for ancillary services varied (institution, team, fundraisers, grants, and other sources). Families indicated an average interest of 2.4 ±â€Š1.41 for support groups, 2.5 ±â€Š1.63 for summer camps, 2.92 ±â€Š1.66 for parties, 3.16 ±â€Š1.65 for social media, and 3.95 ±â€Š1.60 for scholarships (P value <0.05). CONCLUSIONS: The ACPA standards of team care do not require teams to provide social support services beyond access to a social worker. Among our survey respondents, the authors found that in addition to a social worker, teams offered social support services, which were not required. The social worker position is usually institutionally funded, whereas funding sources for additional services varied. Respondents at our center desired additional social support services. The authors recommend a hybrid model of hospital and nonhospital funding to provide social and support services to patients with craniofacial deformities.

Primary cutaneous vs. parotid mucoepidermoid carcinoma of the scalp: A case report.

Primary cutaneous mucoepidermoid carcinoma remains a rare occurrence. This is the first report of a case of primary cutaneous mucoepidermoid carcinoma originating on the scalp and subsequently metastasizing to the parotid gland. The patient was a 53-year-old female who presented with a purple mass on her scalp since 5 months prior to examination. Histopathology revealed nests and islands of atypical epithelioid cells with pleomorphism, medium to prominent nucleoli, and scattered mucin deposition highlighting with a mucicarmine stain. The atypical cells demonstrated intravascular involvement. These findings were compatible with metastatic adenocarcinoma. Later, fine needle aspiration of the patient's parotid lesion revealed malignant cells from a poorly differentiated carcinoma that appeared similar to the patient's previously excised scalp lesion. In addition to summarizing this patient's presentation, clinical course, and management, we discuss the diagnostic challenges posed by this atypical presentation. Primary cutaneous mucoepidermoid carcinoma should be considered in the differential diagnosis of patients presenting with a scalp mass. Moreover, patients with primary cutaneous mucoepidermoid carcinoma originating on the scalp should be evaluated for possible metastases.

Volumetric analysis of simulated alveolar cleft defects and bone grafts using cone beam computed tomography.

BACKGROUND: Cone beam computed tomography allows for a significantly lower radiation dose than conventional computed tomographic scans, with generation of accurate images of the maxillofacial skeleton. The authors investigated its accuracy in the volumetric analysis of alveolar cleft defects and simulated bone grafts. METHODS: Five simulated alveolar clefts were created using a burr drill in three dry pediatric skulls and filled with simulated bone grafts. Pregrafting and postgrafting cone beam computed tomographic scanning of skulls was performed using specialized imaging software. The authors compared actual volumes of the simulated bone grafts obtained using a water displacement technique with scan-derived volumes of both the grafts and the defects. RESULTS: The average of the five simulated bone grafts calculated by cone beam computed tomography scanning was 0.380 ml, which was lower than their mean volume of 0.392 ml calculated by water displacement. The percentage difference between measurements ranged from 2.9 to 8.6 percent (mean, 4.86 percent). The mean of the simulated defects of 0.399 ml derived from scanning was higher than the actual mean volume of 0.392 ml derived by water displacement. The mean difference in defect comparison was 2.52 percent. There was no statistically significant difference between real volume and scan-derived graft and defect volume. CONCLUSIONS: Cone beam computed tomography calculation of simulated alveolar cleft and bone graft volume is precise and accurate. The volume of bone graft needed to fill alveolar defects can be accurately predicted using volume measurements of the bony defect. These findings further validate its use in the perioperative assessment of alveolar grafting.

Beyond Beauty: Onobotulinumtoxin A (BOTOX®) and the Management of Migraine Headaches.

Based on the conducted anatomic studies at our institutions as well as clinical experience with migraine surgery, we have refined our onobotulinumtoxin A (BOTOX®) injection techniques. Pain management physicians are in unique position to be able to not only treat migraine patient, but also to be able to collaborate with neurologists and peripheral nerve surgeons in identifying the migraine trigger sites prior to surgical deactivation. The constellation of migraine symptoms that aid in identifying the migraine trigger sites, the potential pathophysiology of each trigger site, the effective methods of botulinumtoxin and nerve block injection for diagnostic and treatment purposes, as well as the pitfalls and potential complications, will be addressed and discussed in this paper.

The bioethics of separating conjoined twins in plastic surgery.

The incidence of craniopagus twins approximates four to six per 10 million births. Although rare, surgical separation of conjoined twins poses significant technical and ethical challenges. The present report uses the case of craniopagus twins AD and TD to examine the bioethical issues faced by a multidisciplinary medical team in planning the separation of craniopagus twins. AD and TD are craniopagus twins conjoined at the head. TD's head is conjoined to the back of AD's head. Neurologically, AD has the dominant cerebral circulation. TD has two normal kidneys, whereas AD has none. AD depends on TD's renal function and, on separation, will require either a kidney transplant or lifelong dialysis. This case report reviews one approach to analyzing and solving complex ethical dilemmas in pediatric plastic surgery. The principles reviewed are (1) autonomy and informed consent, focusing especially on the role of children in the informed consent process; (2) beneficence and nonmaleficence, two intricately intertwined principles because separation could potentially cause irreversible harm to one twin while improving the quality of life for the other (as separation is not a life-saving procedure, is it ethical to perform a procedure with unknown surgical risk to improve children's quality of life?); and (3) justice (is it fair to allocate excessive medical resources for the twins' separation?). The present report explores the ethics behind such decisions with respect to the separation of conjoined twins.

Ellipsoid analysis of calvarial shape.

PURPOSE: The purpose of this research was to develop a novel quantitative method of describing calvarial shape by using ellipsoid geometry. The pilot application of Ellipsoid Analysis was to compare calvarial form among individuals with untreated unilateral coronal synostosis, metopic synostosis, and sagittal synostosis and normal subjects. METHODS: The frontal, parietal, and occipital bones of 10 preoperative patients for each of the four study groups were bilaterally segmented into six regions using three-dimensional skull reconstructions generated by ANALYZE imaging software from high-resolution computed tomography scans. Points along each segment were extracted and manipulated using a MATLAB-based program. The points were fit to the least-squares nearest ellipsoid. Relationships between the six resultant right and left frontal, parietal, and occipital ellipsoidal centroids (FR, FL, PR, PL, OR, and OL, respectively) were tested for association with a synostotic group. RESULTS: Results from the pilot study showed meaningful differences between length ratio, angular, and centroid distance relationships among synostotic groups. The most substantial difference was exhibited in the centroid distance PL-PR between patients with sagittal synostosis and metopic synostosis. The measures most commonly significant were centroid distances FL-PR and FL-PL and the angle OR-FR-PR. Derived centroid relationships were reproducible. CONCLUSION: Ellipsoid Analysis may offer a more refined approach to quantitative analysis of cranial shape. Symmetric and asymmetric forms can be compared directly. Relevant shape information between traditional landmarks is characterized. These techniques may have wider applicability in quantifying craniofacial morphology with increase in both specificity and general applicability over current methods.

A survey of cleft team patient experience in obtaining dental care.

OBJECTIVE: To assess patient experiences in obtaining dental care in a team setting without an affiliated dental school. DESIGN AND PARTICIPANTS: Three hundred seventy-four patients in the cleft team database met inclusion criteria of diagnosis of cleft lip and/or palate, and current age of 7 to 12 years. Demographic information and experiences in obtaining dental care were ascertained using a standardized series of questions. A callback protocol was employed to maximize response rate. Results were analyzed with t-tests using contingency tables. OUTCOME MEASURES AND RESULTS: One hundred seventy-one parents/caregivers were interviewed of a possible 374 (response rate 45.7%). Mean age was 9.87 years. The insurance distribution was as follows: 113 private insurance (66.1%), 35 Medicaid (20.5%), and 23 had no insurance (13.5%). The dental checkup distribution was as follows: 145 regular dental checkups (84.8%) and 26 no regular checkups (15.2%). Patients with private insurance were more likely to obtain dental care than were patients with Medicaid (p = .002) or patients without insurance (p = .0027). Patients with Medicaid were more likely to report provider refusal of care than were patients with private insurance (p = .0001) or patients without insurance (p = .0001). Patients with private insurance were more likely to report satisfaction with their dental care than were patients with Medicaid (p = .0003). CONCLUSIONS: We report an 84.8% regular checkup rate among our study population and a significantly different reported experience in obtaining care depending on insurance type. The reasons underlying the differences between privately insured patients and Medicaid patients appear multifactorial.

Le premier siècle: one hundred years of progress in the treatment of Apert syndrome.

The year 2006 marked the 100th anniversary of the publication of Eugene Apert's article, De l'acrocephalosyndactylie in the Bulletin de la Société des médecins des hôspitaux de Paris. During the last century, much progress has been made in the understanding and treatment of this condition. A translation of Apert's original article is provided as is an overview of what has been learned during the last 100 years and what the future treatment of this condition may be.

Functional neuroanatomy of lexical processing in children with cleft lip and palate.

BACKGROUND: Patients with palatal clefts are predisposed to developing speech and language abnormalities. Emerging evidence indicates that children with cleft lip and/or cleft palate have higher rates of learning disabilities than the general population and differences in brain morphology. METHODS: Magnetic resonance imaging of 12 individuals with isolated unilateral complete clefts of the lip and palate produced functional images during three lexical processing tasks: generation of verbs, opposites, and rhymes. Direct statistical comparisons were made between subjects with cleft lip and palate and controls (matched for age and performance) from an extant data set, both as a group and individually. RESULTS: Two types of differences were found. Compared with unaffected controls, subjects with clefts showed a delayed and elongated blood oxygen level-dependent response in regions found throughout the cerebrum, including in the prefrontal cortex, cingulate gyrus, right precuneus, and right temporal gyrus. A right middle frontal gyrus region was activated by these tasks in controls but not in subjects with clefts. Developmental analysis showed that subjects 14.5 years and older (n = 5) had a larger number of age-related regions differing in blood oxygen level-dependent response from controls than did younger subjects (n = 7). Single-patient analysis demonstrated substantial individual variability. CONCLUSIONS: Children with cleft lip and palate, performing lexical processing tasks at a comparable level of proficiency, use a similar but nonidentical functional neuroanatomy than peers without clefts. Differing neural circuitry for language tasks and differing developmental trajectories could help explain the predisposition to velopharyngeal dysfunction and learning disabilities in this population.

Comparative osseous and soft tissue morphology following cleft lip repair.

OBJECTIVE: To quantify comparative improvement between osseous and soft tissue asymmetry following primary lip repair. DESIGN: Retrospective analysis of preoperative and postoperative computed tomography scans of infants with unilateral cleft lip and palate. Sixteen soft tissue landmarks were placed using an exploratory two-/three-dimensional image processing system and compared for asymmetry. PATIENTS: Computed tomography scans were obtained on 26 patients (13 boys, 13 girls) of Chinese ethnicity (mean age = 0.25 years) prior to Millard lip repair. Nineteen of these contributed to follow-up comparative studies prior to palatoplasty at a mean age of 0.92 years. There were 18 left-sided and eight right-sided clefts. MAIN OUTCOME MEASURE: Euclidean distance matrix asymmetry analysis was used to determine the amount of soft tissue asymmetry pre- and postlip repair. Similar analyses of the same scans were performed for 41 osseous landmarks. RESULTS: Soft tissue landmarks had 36/39 (92%) preoperative and 13/39 (33%) postoperative asymmetric pairs. Osseous distances demonstrated 77/125 (61%) asymmetric pairs preoperatively and 60/125 (48%) postoperatively. Soft tissue and osseous distances of the lip region demonstrated 32% and 39% postoperative asymmetry, respectively. Soft tissue and osseous distances of the nasal region demonstrated 52% and 72% postoperative asymmetry, respectively. Soft tissue and osseous distances of the facial landmarks demonstrated 24% and 34% postoperative asymmetry, respectively. CONCLUSIONS: Primary lip repair appears to effect gains in symmetry in soft tissue and provides sufficient molding forces to cause correlating symmetry changes in underlying osseous structures.