New resorbable plate and screw system in pediatric craniofacial surgery.

Early forms of resorbable fixation induced foreign body reactions requiring surgical removal of the fixation material. Most current plating systems attempt to circumvent this phenomenon by altering the composition of the α esters involved. ResorbX (KLS Martin, Jacksonville, FL), a plating system derived from 50:50 poly(D,L)lactide, boasts short resorption times, minimal foreign body reaction, and adequate strength for bony fixation. We present our experience with 134 patients undergoing correction of primary craniosynostosis, using ResorbX. One hundred thirty-four consecutive craniosynostosis patients underwent correction with calvarial remodeling by the senior author between April 2002 and March 2008. Five patients had 2-stage repairs. Postoperative analysis included plate visibility or palpability, head contour, and the incidence of complications. The mean age at repair was 17.0 months, with the median age being 9.0 months (range, 2.5-137 months). Postoperative follow-up visits were recorded at 3-month intervals from 0 to 24 months. Synostosis diagnoses were as follows: 43 metopic, 37 sagittal, 27 coronal, 5 lambdoid, and 27 multisutural synostosis. There were 3 complications requiring operative intervention. Three plates became exposed through the coronal excision, requiring removal, for an overall complication rate of 2%. Forty-four patients (31.7%) had a visible mass at the site of fixation at some point postoperatively; all of these resolved through observation only. Overall postoperative head aesthetics were deemed satisfactory to excellent, and no instances of contour regression occurred. This study documents the safety and efficacy of ResorbX in pediatric cranial vault remodeling. The system is easy to use, and with the advent of an ultrasonic pin, more abbreviated operating and anesthesia times are achievable.

Outpatient reduction mammaplasty: an eleven-year experience.

BACKGROUND: In the last 15 years, reduction mammaplasty has been increasingly performed on an outpatient basis. Despite this evolution, few outcome studies have been published regarding outpatient breast reduction surgery. OBJECTIVE: The authors documented clinical outcomes of reduction mammaplasty performed in an outpatient setting over an 11-year period and compared these results with published normative values in the plastic surgery literature. METHODS: A retrospective review was undertaken of 884 reduction mammaplasties in 444 patients at a single outpatient surgical center performed by the senior author (W.G.S.) from 1995 through 2006. In all cases, a laser-assisted, inferior pedicle, Wise pattern, reduction mammaplasty was performed. In addition to demographic and surgical data, complication frequency and type were recorded. Complication data were further stratified into minor and major categories. Potential minor complications included seroma, hematoma, soft tissue infection, dog-ears requiring revision, and small incisional breakdowns or delayed healing of less than 2 cm. Potential major complications included large incisional breakdowns or delayed healing of greater than 2 cm, nipple/areolar necrosis, need for blood transfusion, deep vein thrombosis, pulmonary embolus, myocardial infarction, and death. RESULTS: The mean patient age was 38 years (range, 16 to 73 years). Mean body-mass index was 27 (range 17 to 47). The reported preoperative brassiere cup sizes ranged from a 34 C to a 38 K, with a DD being the most common size. The mean preoperative sternal notch-to-nipple distance was 29 cm (range 22 to 54 cm). Forty patients smoked (9%). Mean clinical follow-up was 13 months. Mean total resection weight of breast tissue was 1228 g (range 100 to 5295 g). Mean operative time for reduction mammaplasty was 115 minutes (range 50 to 195 minutes). Nineteen percent of patients underwent multiple procedures, including abdominoplasty, lipoplasty, and facial procedures, with a mean operative time of 132 minutes (range 75 to 345 minutes). The overall complication rate was 14%, with 70 minor complications occurring in 62 patients. Specific minor complications included one seroma, four hematomas, eight soft tissue infections, two of which required a short course of intravenous antibiotics, one patient with dog-ears requiring surgical revision, and 56 small incisional wound breakdowns (< 2 cm). The small incisional breakdowns, which represented the largest group of complications, were further subdivided into 44 minor T-zone wounds, 3 nipple-areolar complex wounds, and 9 wounds of the vertical and horizontal incisions. Three major complications (0.67%) were recorded. Two patients had development of partial nipple/areolar necrosis. A third patient required anticoagulation for a pulmonary embolus diagnosed 10 days after surgery. Statistical analysis of the complication data revealed one significant relationship. Patients with a body mass index above the mean had a 21% complication rate as compared with a 12% rate for those below the mean. Of note, there was no increase in complication rate in the context of multiple procedures. CONCLUSIONS: This retrospective series is the largest to date involving outpatient reduction mammaplasty. Complication data derived from this series are comparable to previously published studies and thus support the safety and efficacy of outpatient reduction mammaplasty performed in an accredited facility.

Clinical experience with a fourth-generation textured silicone gel breast implant: a review of 1012 Mentor MemoryGel breast implants.

BACKGROUND: Since the introduction of fourth- and fifth-generation silicone gel implants, manufacturers have conducted several prospective, multicenter trials to examine their safety and efficacy. However, these studies were not standardized with regard to surgeon skill, pocket placement, operative technique, adjunct therapies, or postoperative management. OBJECTIVE: The purpose of this study was to examine the surgical outcomes of a single surgeon (WGS) in a consecutive series of breast augmentation cases using a fourth-generation cohesive silicone MemoryGel breast implant (Mentor, Santa Barbara, CA). METHODS: A retrospective chart review was conducted to identify all patients who underwent silicone breast augmentation within the Mentor Adjunct Silicone MemoryGel breast implant by a single surgeon (WGS) within a single free-standing outpatient surgical center over a 13-year period (1992 to 2006). For each patient, demographic information, comorbidities, and surgical information (implant size and concomitant surgery) were recorded. In addition, outcomes were analyzed to identify complications and the need for surgical revision. RESULTS: A total of 1012 fourth-generation, textured, cohesive silicone gel implants were placed in 511 patients during the 13-year study period. The overall complication rate per implant was 5.5% (n=56 implants in 43 patients). The most common complication was capsular contracture (n=26; 2.6 %) followed by abnormal scarring (n=11; 1.1%). The overall revision rates per patient and per implant were 8.0% (n = 41 patients) and 6.8% (n = 69 implants), respectively. The average time interval between initial implantation and revision was 18.5 months (range, 2 weeks to 26 months). The most common indication for surgical revision was patient desire for implant size change (n=15 patients) followed by Baker class III or IV capsular contracture (n=13 patients). The presence of previous surgery for capsular contracture was not statistically correlated to the need for revision (P= .326). Age (P= .568), previous history of breast surgery (P= .704), and history of smoking (P= .138) were also not statistically correlated to revision. Placement of the implant in the subglandular position (n=30 implants), however, was statistically correlated with need for revision (P< .01). CONCLUSIONS: Mentor fourth-generation cohesive silicone gel implants possess a complication and revision profile that is superior to earlier-generation silicone gel implants. Implantation with MemoryGel implants, when standardized with regard to surgeon and operative technique, can have significantly reduced complication and revision rates compared to the Mentor Core Data.

Management of vasospastic disorders with botulinum toxin A.

BACKGROUND: Surgical digital artery sympathectomy is indicated when medical management has failed to control rest pain, impending infarction of digits, or healing of ischemic ulcerations caused by profound vasospasm that is associated with other systemic diseases. After digital artery sympathectomy, recurrence or persistence of vasospasm may compromise hand function and ultimately result in amputation of all or portions of both lower and upper extremities. METHODS: The authors present a case series of 11 patients with vasospasm producing intractable rest pain, digital ulcerations, and digit infarctions that failed aggressive medical therapy and that were then treated by perivascular injections of botulinum toxin A (Botox). Before Botox injection, the level of pain, cutaneous temperatures, color, and ulcerations and infarctions were documented RESULTS: The authors' longest follow-up was 30 months. All patients reported highly significant pain reduction, 10 of 10 to 0 to 2 of 10, within 24 to 48 hours after injection, persisting for months after the injection. Nine of 11 patients with nonhealing ulcers spontaneously healed small ulcers and areas of infarction after surgical debridement. Two cases required small skin grafts. Nine of 11 patients reported decreased severity and frequency of vasospastic episodes. CONCLUSIONS: Hand injection of botulinum toxin A appears to be an effective treatment for intractable digital ulcerations and rest pain in patients with severe vasospastic disorders. Because of the complexity of surgical digital artery sympathectomy along with its associated high risk of persistent symptoms, the authors conclude that the therapeutic use of botulinum toxin A injections represents an attractive alternative therapy.

Treatment modalities for mandibular angle fractures.

PURPOSE: Management of mandibular angle fractures is often challenging and results in the highest complication rate among fractures of the mandible. Optimal treatment for angle fractures remains controversial. Historically, treatment of mandible fractures included intraoperative maxillomandibular fixation (MMF) along with rigid internal fixation. More recently, noncompression plates miniplates, which produce only relative stability, have gained popularity. The absolute necessity of intraoperative MMF as an adjunct to internal fixation has also become controversial. The current trends in the management of simple, noncomminuted mandibular angle fractures are examined. MATERIALS AND METHODS: A survey was submitted to North American and European AO ASIF (Arbeits-gemeinschaft fur Osteosynthesefragen Association for the Study of Internal Fixation) faculty in July 2001. Statistical analysis of results included both Fisher's exact and chi-square tests. Results were considered significant if P <.05. RESULTS: One hundred ten of 127 potential responses were received (87%). Among 104 surgeons who treat mandible fractures, 86 (83%) treat more than 10 mandibular fractures per year. Preferred techniques for simple, noncomminuted mandibular angle fractures in this group were: single miniplate on the superior border (Champy technique) with or without arch bars (44 surgeons, 51%); tension band plate on the superior border and nonlocking, bicortical screw plate on the inferior border (11 surgeons, 13%); dual miniplates (9 surgeons, 10%); a locking screw plate on the inferior border only (6 surgeons, 7%), and 3-dimensional plates (5 surgeons, 6%). Eleven surgeons (13%) gave multiple answers. Although only 13% of surgeons surveyed primarily use the combination of tension band and nonlocking, bicortical screw plates, many surgeons (73%) continue to use this technique in certain circumstances. Within this group, 32 (51%) place screws in a neutral position, while 31 (49%) place screws in an eccentric position, resulting in compression. For simple noncomminuted angle fractures, the number of surgeons performing internal fixation without MMF were: 14 often (16%); 20 occasionally (23%); 17 seldom (20%); and 35 never (41%). Surgeons treating more than 10 versus those who treat less than 10 fractures per year, International versus North American faculty, and Oral and Maxillofacial surgeons (OMS) versus non-OMS surgeons were compared. Surgeons who treat more than 10 fractures per year favor the Champy technique over the tension band and bicortical plate combination (44 [51%] vs 11 [13%]), while those surgeons who treat less than 10 per year favor the tension band and bicortical plate combination over the Champy technique (9 [50%] vs 3 [17%]; P < .01, Fisher exact test). International faculty are less likely to use intraoperative MMF than North American faculty (29 [81%] vs 31 [43%]; P < .01, Fisher exact test). OMS surgeons are less likely to use the tension band and bicortical plate combination than non-OMS surgeons (22 [56%] vs 42 [90%]; P < .017, Fisher exact test). CONCLUSION: This survey suggests an evolution in the management of mandibular angle fractures. A single miniplate plate on the superior border of the mandible has become the preferred method of treatment among AO faculty. When using large, inferiorly based plates more surgeons are now favoring neutral rather than eccentric screw placement. Intraoperative MMF is not considered mandatory by some surgeons in certain circumstances.

Analysis of breast reduction complications derived from the BRAVO study.

BACKGROUND: Analysis of complication data derived from the Breast Reduction Assessment: Value and Outcomes (BRAVO) study, a 9-month prospective, multicenter trial, is presented. METHODS: Data derived from 179 patients were analyzed, including bivariate associations between complications and single predictor variables (Fisher's exact test or chi-square testing) or continuous variables (two-sample t test) and, finally, logistic regression. RESULTS: The overall complication rate was 43 percent (77 patients). Simple, bivariate analysis linked preoperative breast volume, shoulder strap grooving, and a vertical incision with an increased incidence of complications (p < 0.05, 0.02, and 0.02, respectively). Delayed wound healing, the most common complication, correlated directly with average preoperative breast volume (p < 0.045), average resection weight/breast (p < 0.027), and smoking (p < 0.029) and inversely with age (p < 0.011). Vertical incision techniques were associated with an increased complication frequency (p < 0.05) without a link to specific complications. Logistic regression analysis associated resection weight as the sole variable for increased risk of complications (p = 0.05) and with absolute number of complications [mean resection weight of 791 g for patients without complications versus 847, 882, and 1752 g for patients with one, two, and three complications, respectively (p = 0.0022)]. Each 10-fold increase in resection weight increased the risk of complication 4.8 times and increased the risk of delayed healing 11.6 times. CONCLUSIONS: Complication data revealed several significant features: (1) resection weight correlated with increased risk and absolute number of complications; (2) delayed healing correlated directly with resection weight and inversely with increasing age, anesthesia times, and preoperative Short Form-36 bodily pain score; (3) a vertical incision may be associated with increased incidence of complications but requires further analysis; and most importantly, (4) the presence of complications had no negative effect on improvement in Short Form-36 and Multidimensional Body-Self Relations Questionnaire scores.

Multifactorial refractory heterotopic ossification.

Ectopic bone formation or "heterotopic ossification" can follow surgery, trauma, or neurologic injury, but the process is usually self-limited, localized to the site of injury, and responds to surgical treatment when necessary. Aggressive, systemic forms of heterotopic ossification exist that generate lesions that often resist surgical treatment and produce a high rate of recurrence. These entities typically manifest during infancy as genetic syndromes such as fibrodysplasia ossificans progressiva or progressive osseous heteroplasia. The authors describe a case of aggressive, systemic heterotopic ossification in an adult that followed a motor vehicle accident and multiple surgeries. The patient developed a large nonhealing wound around a focus of ectopic bone. Skin grafts failed as a result of the recurrence of ectopic bone, and the patient eventually required aggressive debridement and delayed rotational flap closure. A brief review of the clinical features and surgical treatment of heterotopic ossification is outlined.

Temporal dermoids: three cases and a modified treatment algorithm.

Congenital orbitofacial dermoids can be segregated into frontotemporal, orbital, and nasoglabellar regions. Although 10% to 45% of nasoglabellar dermoids present with sinus tracts and occasional intracranial extension, it is rare for frontotemporal dermoids to do so. Frontotemporal dermoids typically manifest as superficial, slow-growing masses that are treated by simple excision. In this retrospective review of 24 patients with congenital orbitofacial dermoids, the authors noted three cases of temporal dermoids with sinus tracts and bony involvement. All three patients were female, with an average presenting age of 4.2 years. Two lesions appeared on the left and one on the right. Each lesion involved the sphenotemporal suture, requiring debridement of the outer cranial table to prevent recurrence. In light of their experience, the authors offer an amendment to the current treatment algorithm for congenital orbitofacial dermoids. A congenital frontotemporal dermoid with a sinus tract should have preoperative radiological evaluation with computed tomography or magnetic resonance imaging to define the pathological anatomy. If bony invasion exists, aggressive exposure and resection of at least the outer cranial table is necessary to prevent recurrence. Temporal dermoids may represent a distinct entity that requires a separation classification from frontotemporal dermoids.

Incorporation of titanium mesh in orbital and midface reconstruction.

Several authors have demonstrated the safety and effectiveness of titanium in orbital reconstruction. One question posed by clinicians is what happens to large pieces of titanium in communication with the paranasal sinuses or nasal-oral-pharyngeal area. This question becomes increasingly relevant as titanium is used to reconstruct extensive defects for which the destruction of bony architecture requires the placement of mesh in proximity to these areas. The objective of this study was to examine the gross and histologic soft-tissue response to large segments of titanium mesh in the setting of orbital and midface reconstruction, particularly when exposed to the nasal-oral-pharyngeal area and paranasal sinuses. In this study, large segments of titanium mesh were used in eight patients to reconstruct orbital and midface defects, with direct communication between the mesh and nasal-oral-pharyngeal area and paranasal sinuses. Four patients had suffered self-inflicted gunshot wounds; as a result, much of their midface was missing, including the inferior and medial orbital floor, maxilla, nose, naso-orbital-ethmoid complex, and hard palate. Extensive sheets of titanium mesh were used to reconstruct their medial and inferior orbital walls, nasal bridge, and maxilla. In the fifth patient, titanium mesh was used to reconstruct the maxilla after resection of a squamous cell carcinoma of the nasolacrimal duct. In the sixth and seventh patients, mesh was used to reconstruct the nasal bridge after severely comminuted nasal fractures resulted in the loss of bone and mucosa. Finally, the eighth patient had titanium mesh used to replace cocaine-induced bone loss involving the left medial orbital floor and wall and part of the maxilla. On gross examination by either endoscopy or direct inspection, all eight patients had rapid soft-tissue incorporation of the titanium mesh. Initial examination typically revealed budding of soft tissue through mesh interstices, followed by progressive incorporation. One patient's mesh was covered in only 15 days. Two patients underwent biopsies of this newly formed soft tissue. One had biopsies performed at 3, 15, and 31 months after the original operation. Biopsy examination at 3 months revealed incorporation of the titanium with fibrous soft tissue covered by ciliated respiratory epithelium, goblet cells, and squamous epithelium with metaplasia. In addition, the dense, acute inflammation present at 3 months evolved into mild, chronic inflammation at 31 months. The second patient had a single biopsy 4 months after secondary orbital reconstruction for delayed enophthalmos. Biopsy examination revealed a fibrous soft-tissue sheath lined by squamous epithelium with metaplasia. Again, mild chronic inflammation was present within the soft tissue. This study provides evidence of titanium's compatibility with soft tissue. The mesh underwent progressive incorporation with soft tissue that was then resurfaced by indigenous cells, including respiratory epithelia and goblet cells. This phenomenon occurred despite communication with the nasal-oral-pharyngeal area and paranasal sinuses.

Safety of titanium mesh for orbital reconstruction.

During the past several decades, the standard of care for orbital reconstruction after trauma has been autogenous bone grafts. Complications of bone grafts, including donor site morbidities such as scar alopecia and graft resorption with delayed enophthalmos, have inspired an interest in the use of alloplastic substitutes such as titanium. Titanium's role in orbital reconstruction was limited originally to small orbital defects, and as an adjunct to bone grafts. More recently, clinical studies have documented the sole use of titanium mesh to reconstruct large orbital defects. This study sought to document further the safety and efficacy of titanium mesh in reconstructing large orbital defects after facial trauma, with more extensive follow-up compared with previous studies. In the current study, 55 patients with 67 orbital fractures underwent orbital reconstruction with titanium mesh over a 5-year period. Associated fractures were reduced anatomically and fixed rigidly. For the analysis, 44 patients with 56 orbital fractures had adequate follow-up (mean, 44 months). An abscess developed in one patient who received high-dose steroids for 72 hours before reconstruction. She was treated with broad-spectrum intravenous antibiotics and bedside incision and drainage, and did not require removal of the titanium mesh. No patient in the current series required removal of the titanium mesh. A single case of uncorrected enophthalmos was treated with bone grafting rather than mesh revision. Large orbital defects can be reconstructed using titanium mesh with good functional results and minimal risk for infection. This study covered the authors' first 5 years using titanium. They have now used titanium mesh in orbital reconstructions for more than 10 years, without any additional cases of infection.