Effects of Cleft Width and Veau Type on Incidence of Palatal Fistula and Velopharyngeal Insufficiency After Cleft Palate Repair.

BACKGROUND: Postoperative fistulae and velopharyngeal insufficiency (VPI) are 2 important complications after cleft palate repair. The effects of preoperative cleft width on outcomes after cleft palate repair have been rarely studied. METHODS: A retrospective review of all patients undergoing primary cleft palatoplasty by a single surgeon between 2004 and 2011 was performed. Primary outcomes were palatal fistula and VPI, defined as the need for corrective surgery after failing conservative speech-language therapy. Logistic regression analysis was performed to identify factors associated with the primary outcomes. RESULTS: One hundred seventy-seven patients (84 men and 93 women) were identified. Median age at repair was 10 months with median follow-up of 3.80 years. Preoperative cleft width was 10 mm or less for 72 (41%) patients, 11 to 14 mm for 54 (30%) patients, and 15 mm or greater for 51 (29%) patients. Palatal fistula was observed in 8 (4.5%) patients, but required surgical repair in only 2 (1.1%). Fistula was overall associated with Veau IV classification (odds ratio, 8.13; P < 0.01) but not with cleft width. Velopharyngeal insufficiency needing surgical intervention occurred in 9 patients (7.38% of patients older than 4 years) and was associated with increasing cleft width (odds ratio, 1.29; P = 0.011). Outcomes were similar for patients undergoing surgery in the earlier and later halves of the study. CONCLUSIONS: This retrospective review is one of the first from the United States to explore the associations between measured cleft width and outcomes after palatoplasty. Overall rates of palatal fistula and VPI were low, corroborating previous studies showing good outcomes with the 2-flap palatoplasty. After adjusting for multiple variables including Veau type, cleft width was associated with higher VPI rates but not with fistula formation. Cleft width is a unique preoperative factor that should be considered and studied as a potential predictor of outcomes.

Velopharyngeal Insufficiency Rates After Delayed Cleft Palate Repair: Lessons Learned From Internationally Adopted Patients.

Most surgeons recommend cleft palate repair between 6 and 12 months of age. Internationally adopted patients often undergo delayed repair due to social circumstances. There are few outcomes studies on this population. We conducted a 13-year retrospective review of all patients undergoing primary cleft palate repair at a single tertiary-care academic medical center between 1993 and 2006. The primary outcome was velopharyngeal insufficiency, defined as the recommendation for corrective surgery after multiple formal speech assessments. Two hundred one patients (102 males and 99 females) were identified. One hundred eighty-three repairs were performed before 18 months of age (standard repair group). Eighteen repairs were performed after 18 months of age (delayed repair group), with international adoption being a circumstance in 16 cases. The delayed and standard repair groups were similar with regard to sex, presence of craniofacial syndrome, Veau class, cleft size and laterality, type of repair, and operating surgeon. Mean follow-up was 9.3 years, with minimum follow-up of 5.0 years. Six (33%) of 18 patients in the delayed repair group developed velopharyngeal insufficiency compared to 23 (13%) of 183 in the standard repair group (P = 0.03 by Fisher exact test). These data demonstrate that internationally adopted patients undergoing delayed palate repair suffer especially poor speech outcomes. Physiologic differences in patients undergoing late repair, as well as social factors including adaptation to a new language and culture, may be factors. Early repair should be performed when possible.

Rectal pain of neural origin: resection of sensory rectal branches of pudendal nerve.

BACKGROUND: A neural origin should be considered in the differential diagnosis of rectal pain if the onset of the pain is in relationship to previous surgery on the anus or rectum. STUDY DESIGN: A retrospective cohort was identified by computer search of office files from May 2010 to December 2012. Seven patients, two males, and five females, were identified who have been treated surgically for complaints of isolated rectal pain arising from coloproctectomy in three patients (inflammatory bowel disease) and after hemorrhoidectomy in three patients and one patient with mesh placed for urinary incontinence. Patient's mean age was 52.5 years. Mean duration of pain was 29.9 months (range, 9-120 months). Diagnosis was demonstrated by an anesthetic block of the pudendal nerve. Surgical approach was excision of rectal sensory branches of the pudendal nerve in the ischiorectal fossa and implantation of these nerves into the gluteus maximus muscle. RESULTS: Outcome data are available, with a mean follow-up of 17.7 months (range, 13-30 months). Of the three coloproctectomy patients, two are considered excellent results and one a poor result. All three of the hemorrhoidectomy patients are excellent results. The one patient who had the mesh placement for urinary incontinence required two attempts to remove all sensory rectal branches and then achieved excellent pain relief. CONCLUSION: Chronic rectal pain should be considered to have a pudendal neural origin after previous anal/rectal surgery. Resection of all rectal sensory branches can give excellent and lasting relief of pain.

Face transplantation surgical options and open problems in cadaveric models: a review article.

Being first conceptualized in 2005-2006, total face transplantation is now a clinical reconstructive option in the treatment of patients with acquired facial deformity. The authors propose a review on the status of total face transplantation based on their clinical experience in dealing with traditional microsurgical head and neck reconstructions and on the basis of their published pre-clinical research investigating technical aspects of the facial allotransplantation procedure in cadaveric models. The authors first discuss the harvesting options and propose two facial flaps which address different reconstructive needs. Next, the concept of donor-recipient anatomical compatibility is introduced, and the possible outcome of the chimeric face is studied, following the insetting of a fasciocutaneous facial allograft. Finally, the authors address the major technical challenges associated with transplanting the most complex osteomyocutaneous allograft. Significant improvement has been made in the field of vascularized composite tissue allotransplantation over the last 5-6 years. The results of the 13 face transplants performed worldwide are encouraging both functionally and aesthetically, when compared with traditional reconstructive procedures.

Outcome of endoscopic carpal tunnel release in patients with chronic nonhand pain compared with those without chronic pain.

PURPOSE: This prospective observational study compared the outcomes of single-port endoscopic carpal tunnel release in patients taking narcotic pain medication chronically for back, neck, leg, or other bodily pain for more than 3 months, with patients not taking chronic narcotic pain medication (control group). METHODS: Patients undergoing endoscopic carpal tunnel release completed the Levine-Katz carpal tunnel questionnaire (primary outcome) and the Disabilities of the Arm, Shoulder, and Hand questionnaire preoperatively, at 2, 4, 6, and 12 weeks, and at 1 year after surgery. We measured subjective satisfaction with surgery at each postoperative time point as well. RESULTS: There were 14 patients in the chronic narcotic pain group and 68 in the control group. Both groups showed significant improvement in the Levine-Katz symptom and functional scores and in the Disabilities of the Arm, Shoulder, and Hand score (compared with preoperative) at nearly all times. The control group showed better scores at the early time points, but by 6 weeks, there was no difference between groups. Patient satisfaction was excellent in both groups. CONCLUSIONS: Patients who had carpal tunnel syndrome and who were receiving narcotic pain medication chronically for nonhand pain benefited from endoscopic carpal tunnel release. These patients experienced a longer recovery period but ultimately achieved the same outcomes as patients without chronic pain, as measured by the Levine-Katz scores and the DASH score. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic I.

Internal mammary intercostal perforators instead of the true internal mammary vessels as the recipient vessels for breast reconstruction.

BACKGROUND: Free tissue transfer has become a mainstay in breast reconstruction, with the internal mammary system frequently used as the recipient vessels. Sacrificing the internal mammary artery, however, eliminates the potential to use this vessel as a coronary artery bypass conduit in the future and potentially increases recipient-site morbidity. The authors' goal was to evaluate the learning curve and effectiveness of their use of the internal mammary intercostal perforators for microsurgical breast reconstruction. METHODS: The authors reviewed one surgeon's consecutive series of 100 abdominal adipocutaneous perforator flap breast reconstructions (72 patients) from July of 2005 through January of 2007. The internal mammary perforators were used as recipient vessels in 23 flaps, the traditional internal mammary vessels were used in 66, and the thoracodorsal vessels were used in 11. To see if there was a learning curve, flaps were analyzed in five consecutive cohorts of 20. RESULTS: A learning curve was shown: internal mammary perforators were used in 5 percent of the first cohort and 45 percent of flaps in the final cohort. Flap survival was 99 percent; the one failure occurred in a traditional internal mammary flap reconstruction. Small palpable areas of fat necrosis were observed in one internal mammary perforator flap (4.3 percent) and in five traditional internal mammary or thoracodorsal flaps (6.5 percent). CONCLUSIONS: In all the authors' cohorts, internal mammary perforator vessels were used safely without increasing the incidence of flap failure or fat necrosis seen with the traditional approach. The learning curve for this technique resulted in increased use of these internal mammary perforators, indicating that operator experience is critical.

A treatment strategy for postburn neck reconstruction: emphasizing the functional and aesthetic importance of the cervicomental angle.

The authors describe an algorithm for reconstruction of both the soft tissue and skeletal components of severe postburn neck deformities. The critical functional and aesthetic importance of the cervicomental angle is emphasized. The neck is subdivided into 3 anatomic subunits: (1) lower lip/chin subunit, (2) submental subunit, and (3) anterior neck subunit. After release of contractures, platysmaplasty is performed to prevent recurrence and to deepen the cervicomental angle. In cases where chin retrusion is present, sliding genioplasty is performed. The 3 subunits are resurfaced individually by skin grafts and free flaps. The combined scapular and parascapular bilobed free flap is an ideal flap for cases involving 2 subunits. Fifty patients with severe postburns neck contractures were treated. After excision and release of scar, 47 (94%) patients underwent platysmaplasty, and 12 (24%) patients underwent sliding genioplasty. Defects were covered with skin grafts alone in 20 (40%) patients, with free flaps only in 22 (44%) patients, and with a combination of skin grafts and free flaps in 8 (16%) patients.

Triple chimeric flap based on anterior tibial vessels for reconstruction of severe traumatic injuries of the hand with thumb loss.

BACKGROUND: Reconstruction of severe traumatic injuries of the hand with digit loss may require multiple procedures over a prolonged period. The authors present a clinical series of patients in which these types of injuries were reconstructed in a single operation. METHODS: A chimeric flap based on the anterior tibial vessels is described. A total of three free tissue transfers included an anterior tibial flap, a dorsalis pedis flap, and a great toe wrap-around flap. These triple flaps were transferred to resurface the defects of the mutilated hand, which was involved in the thumb, first web space, volar palm, thenar eminence, or radial aspect of wrist. The cumulative size of the defects ranged from 9 x 11 cm to 12 x 18 cm. RESULTS: From 2002 to 2007, six patients with multiple defects of the hand and thumb underwent reconstruction using the described technique. The donor sites were covered by means of split-thickness skin grafting. All flaps survived and patients were satisfied with the functional and aesthetic outcome postoperatively at 6 to 12 months' follow-up. The average improvement of thumb opposition was 4.8 on the Kapandji scale. Sensory recovery of the thumb tip of S3 was achieved. There were no major donor-site complications. CONCLUSION: A chimeric flap based on the anterior tibial vessels is an excellent method of reconstruction of severe multilevel injuries of the hand, including thumb loss.

The helical arcade: anatomic basis for survival in near-total ear avulsion.

Survival of the ear based on a single vascular pedicle has been previously documented. The anatomic basis for this survival remains incompletely described. In the 3 clinical cases of inferior-to-superior near-total ear avulsion presented herein, the authors have observed that the ear can survive based on a narrow pedicle along the helical root. In an anatomic study to further investigate the relevant vascular anatomy, the common carotid artery system of 6 fresh human cadaver specimens was injected with latex. The superficial temporal artery and its branches located at the helical root were examined. This anatomic study showed that the upper auricular branch of the superficial temporal artery continues into the ear as the helical artery supplies an arterial arcade, which we have termed the helical arcade. This arcade seems to allow for communication between the anterior and posterior arterial systems of the ear and allows the helical artery to provide sufficient arterial supply to the entire ear.

Metabolic and functional characterization of human adipose-derived stem cells in tissue engineering.

BACKGROUND: The use of adipose-derived stem cells for tissue engineering involves exposing them to metabolically adverse conditions. This study examines the metabolism, proliferation, and differentiation of adipose-derived stem cells under various conditions. METHODS: Adipose-derived stem cells were cultured in 16 media conditions containing 0.6, 2.4, 4.3, or 6.1 mM glucose; 0.1, 2.5, 4.1, or 6.1 mM glutamine; and then grown in either 0.1% or 20% oxygen. Conditioned media were collected and assayed for glucose, lactate, and pyruvate. Cell proliferation and cell death were measured at several time points. Osteogenic differentiation was analyzed by alizarin red staining/quantification and alkaline phosphatase activity, measured weekly over 4 weeks. RESULTS: Adipose-derived stem cells remained metabolically active in all nutrient and oxygen conditions tested. Glucose consumption and lactate production increased under hypoxic conditions, but pyruvate consumption was jointly dependent on oxygen and glucose concentration. The 20% oxygen environment produced greater proliferation and cell death compared with the hypoxic environment. Osteogenic differentiation of adipose-derived stem cells was observed only when glucose and/or oxygen concentrations were physiologically normal to high. CONCLUSIONS: Adipose-derived stem cells are an excellent source of multipotent cells and are capable of advancing current tissue engineering methodologies. These data show that adipose-derived stem cells remain viable under adverse conditions of low glucose, glutamine, and oxygen concentrations. However, there are variable levels of differentiation in the various culture conditions, which could lead to challenges in de novo osteogenesis and other forms of tissue engineering. Therefore, these results should be used in developing specific strategies to ensure successful application of adipose-derived stem cells in bone engineering and similar applications.

Strategy for reoperative free flaps after failure of a first flap.

BACKGROUND: Free vascularized tissue transfer is generally associated with high success rates, but failures do occur. After a flap failure, the decision is often made to perform a second, reoperative free flap. METHODS: A retrospective review of all microsurgical free tissue transfers performed at the authors' institution identified 13 patients who underwent a second, reoperative free flap after a failed primary flap. The records of these patients were reviewed, with particular emphasis on identifying changes in treatment strategy between the initially failed and the reoperative free flap. RESULTS: Thirteen patients were identified as having undergone a reoperative free flap. In nine of 13 primary free flaps, at least one likely cause for the failure was identified (69 percent). In the approach to the second free flap, strategy changes were performed in 10 of 13 cases (77 percent); 11 were successful (85 percent). One of the two patients with a failed reoperative free flap underwent a third attempt at free tissue transfer, which also failed. CONCLUSIONS: The authors' overall approach to the failed free flap includes the following four steps: (1) reconsideration of the need for vascularized free tissue transfer, (2) a sensitive psychosocial approach to the patient and family, (3) analysis of the cause of the first flap failure, and (4) change in microsurgical strategy. Based on the authors' experience, they consider two previously failed free flaps without an obvious cause to be a contraindication to a third attempt.

Extended applications of vascularized preauricular and helical rim flaps in reconstruction of nasal defects.

BACKGROUND: Composite auricular chondrocutaneous grafting is a well-established technique for reconstructing alar defects. It can provide excellent results because it matches nasal tissue well in terms of color, texture, and contour. However, the size of composite graft that can be transferred is limited by its lack of blood supply. The authors reviewed their experience with the free vascularized preauricular and helical rim flaps for use in the reconstruction of large, full-thickness, nasal subunit defects. METHODS: The vascularized preauricular and helical rim flap is based on the superficial temporal vessels. Depending on the nature and size of the nasal defect, the crus helicis, helical rim, preauricular skin, superficial temporal fascia, and temporal bone can be harvested. In addition, a posterior auricular flap is designed to reconstruct the donor site. The authors performed a retrospective review of 63 clinical cases. RESULTS: All 63 patients had full-thickness nasal defects that were reconstructed using this technique between 2001 and 2006. There were 36 unilateral alar defects, 20 alar and sidewall defects, three tip and columellar defects, and one patient with an entire lower third of the nose missing. Another three patients had large composite defects involving the nose and maxilla. The lateral femoral circumflex vessels were used as interpositional vascular grafts in most cases. Flap survival occurred in 61 of 63 cases (rate 97 percent). The functional and aesthetic outcome was satisfactory in the majority of patients. CONCLUSIONS: The free vascularized preauricular and helical rim flap is a reliable method of reconstructing nasal defects and has wide clinical applications.

Treatment of metronidazole-refractory Clostridium difficile enteritis with vancomycin.

BACKGROUND: Clostridium difficile infection of the colon is a common and well-described clinical entity. Clostridium difficile enteritis of the small bowel is believed to be less common and has been described sparsely in the literature. METHODS: Case report and literature review. RESULTS: We describe a patient who had undergone total proctocolectomy with ileal pouch-anal anastomosis who was treated with broad-spectrum antibiotics and contracted C. difficile refractory to metronidazole. The enteritis resolved quickly after initiation of combined oral vancomycin and metronidazole. A literature review found that eight of the fifteen previously reported cases of C. difficile-associated small-bowel enteritis resulted in death. CONCLUSIONS: It is important for physicians who treat acolonic patients to be aware of C. difficile enteritis of the small bowel so that it can be suspected, diagnosed, and treated.

A retrospective analysis of facial fracture etiologies.

The medical records of 437 patients with 929 facial fractures were retrospectively analyzed. Fracture patterns were classified based on the presence or absence of fractures in each of 4 anatomic subunits (frontal, upper midface, lower midface, and mandible). The most common etiology of trauma was assault (36%), followed by motor vehicle collision (MVC, 32%), fall (18%), sports (11%), occupational (3%), and gunshot wound (GSW, 2%). The most common fracture type was nasal bone fracture (164). MVC was found to be a significant predictor of panfacial fractures, as was GSW. Sports injuries were a significant predictor of isolated upper midface fractures, and assault was a significant predictor for isolated mandible fractures. MVC and GSW each were found to lead to significantly higher severity of injury than assault, fall, and sports. The results confirm intuitive aspects of the etiology of facial fractures that have been anecdotally supported in the past.

Osteocutaneous face transplantation.

BACKGROUND: Facial transplantation has the potential to become a viable option in the treatment of acquired and congenital facial deformities. Transplantation of the bony maxillofacial skeleton with the soft tissues (osteocutaneous face transplantation) has not been performed clinically nor has it been described experimentally in a human cadaver model. METHODS: A mock osteocutaneous face transplant procedure was carried out on a cadaver model. The face was harvested in the subperiosteal plane and included the Le Fort III osseous segment. The allograft was inset by rigid internal fixation and soft tissue approximation. RESULTS: The face transplant procedure was technically feasible. On the basis of this experiment, review of prior investigations, and our experience in craniofacial surgery, the authors have identified 10 topics that present technical challenges specific to osteocutaneous transplantation of the face: customisation of the bony segment, sensory and motor innervation, extra-ocular movements, dentition, mastication, speech and swallowing, airway, vascular considerations, immunologic considerations, and identity issues. CONCLUSIONS: Once further advances in immunomodulatory therapy are made, face transplantation will likely still be reserved for only the most severe facial defects. Defects of such severity will likely include a substantial bony component in need of reconstruction. In addition to the challenges associated with facial allo-transplantation in general, there are many technical challenges associated specifically with osteocutaneous face transplantation. It is necessary to consider and discuss these challenges in anticipation of future advances that may allow composite face transplantation to become safe and clinically efficacious. This modality of transplantation has the potential to provide substantial benefit compared with autologous reconstruction.

A financial analysis of operative facial fracture management.

BACKGROUND: The financial impact of operative facial fracture management has not been systematically investigated. This study aims to provide a descriptive financial analysis of patients undergoing operative facial fracture management at a single academic medical center and the financial impact on the health system. METHODS: The records of 202 patients who underwent operative facial fracture management over a 3-year period (2003 to 2005) were analyzed. All physician (professional) and hospital charges related to fracture management were included. Professional charges were subdivided by specialty and by payer type; hospital charges included operating room, recovery room, intensive care unit, hospital bed, supply charges, pharmaceuticals, laboratory charges, and radiographs. For comparison, similar data were obtained for the general plastic surgery population and for orthopedic surgery patients. RESULTS: The sum of all professional charges billed was $2,478,234 (average, $12,268 per patient). Collections for these professional services totaled $675,434, yielding an overall reimbursement rate of 27 percent. Reimbursement rates ranged from 38 percent for critical care physicians to 24 percent for surgery and neuroradiology. The highest collection rates occurred in children covered by the State Children's Health Insurance Program and in prison inmates (53 percent and 99 percent, respectively). The lowest collection rates were obtained from uninsured patients (10 percent total billing over collections). Total hospital charges were $18,120,027 (average, $89,703 per patient); the total collections were $2,770,115 (15 percent reimbursement rate). CONCLUSIONS: This study provides a descriptive financial analysis of operative facial fracture management. The unfavorable financial circumstances associated with facial trauma care may present a challenge to academic medical centers and plastic surgeons.

Concomitant injuries in patients with panfacial fractures.

BACKGROUND: Patients with panfacial fractures comprise a small portion of the overall facial fracture patient population. Because of the forces necessary to cause panfacial injury, these patients often have other concomitant injuries. The timing of operative facial fracture management remains controversial. METHODS: A 3-year review of all patients with facial fractures was conducted at Duke University Medical Center (2003-2005, 437 total patients). All patients with panfacial fractures, defined as fractures involving at least three of the four facial segments (frontal, upper midface, lower midface, and mandible), were analyzed. RESULTS: Panfacial fractures were present in 38 patients (9% of overall facial fracture population). Twenty (53%) of these patients suffered concomitant injuries. The most common mechanism of trauma was motor vehicle collision, and the most common category of concomitant injury was intracranial injury or hemorrhage. Other commonly occurring categories of injury included abdominal organ injury, pneumothorax, pulmonary contusion, spine fracture, rib or sternum fracture, extremity fracture, and pelvic fractures. There was no significant difference in day of operation for the management of facial fractures between those with isolated facial injuries and those with other concomitant injuries (hospital day 2.1 vs. hospital day 2.9, not significant). CONCLUSIONS: Concomitant injuries to all parts of the body are found in patients with panfacial trauma. In our experience, these injuries do not significantly delay or have an adverse effect on the treatment of facial fractures. A treatment strategy for consistent timely management of facial fractures is described.

Efficacy of ethyl nitrite in reversing surgical vasospasm.

Vasospasm leading to thrombosis is a major cause of free flap failure. Flap blood flow may improve by application of vasodilating agents to the pedicle. The purpose of this study is to evaluate the effect of a novel S-nitrosylating agent, O-ethyl nitrite, on flap blood flow and pedicle vessels diameter in a rat model, after induction of vasospasm. Two hours after surgery, the arterial diameter was significantly (P < .05) dilated by treatment with O-ethyl nitrite, lidocaine, or lidocaine + O-ethyl nitrite. None of these treatments had a statistically significant effect on blood flow or venous diameter. Twenty-four hours following surgery, both O-ethyl nitrite- and lidocaine-treated groups had larger arteries than the control group (P < .05). The O-ethyl nitrite-treated animals also had significantly (P < .05) elevated blood flow compared with control animals, but lidocaine-treated animals did not demonstrate any improved flow at 24 hours. O-Ethyl nitrite may become clinically useful in microvascular surgery procedures.