Systematic Review of Medpor Versus Autologous Ear Reconstruction.

ABSTRACT: Ear reconstruction is 1 of the most technically challenging sub-specialties of craniofacial and reconstructive plastic surgery. The reconstructive ear must not only fulfil the requirement of being aesthetically pleasing but must also have good vascularity with a low complication rate. Several ear reconstructive techniques have been developed such as the autologous ear reconstruction technique using costal cartilage and ear reconstruction with high-density porous polyethylene or Medpor (Porex Surgical, Inc, College Park, GA). Autologous ear reconstructive techniques have advantages of durability and low infection rates however are associated with poorer aesthetic outcomes such as poor projection of the ear. Medpor has advantages of a more consistent three-dimensional definition without the need to harvest costochondral cartilage and create a donor site. However, due to its alloplastic material properties, Medpor has historically been reported as having a higher rate of extrusion and infection. This is the first systematic review to compare the outcomes of both techniques. The 6 studies that were reviewed were analyzed against 3 evaluative criteria: aesthetic outcome, complication rate, and convenience of intervention. This is so a comprehensive, evidence-based decision can be made by the surgeon and patient when ear reconstruction is required. The results showed heterogeneity in data and a lack of detailed descriptions of the assessment for aesthetic outcomes and convenience, hence were inconclusive. The results however showed that there were more complications with Medpor framework with 15% of total cases resulting in either extrusion or infection compared to 2% of autologous ear reconstruction framework.

Empowerment of Parents of Children With Cleft Lip and Palate by Objective Scoring of Patient Information Websites.

BACKGROUND: Whether a new diagnosis or for ongoing care, the Internet is now an established and massively frequented resource for parents and patients with cleft lip and/or palate. The purpose of this study was to assess the correlation between the first 50 ranked websites for cleft lip and palate via the Google search engine versus those ranked with an objective patient information scoring tool. METHODS: The first 50 websites ranked by Google were recorded for the search items "Cleft Lip," "Cleft Palate" and "Cleft Lip and Palate." Quality assessment was performed using the DISCERN score, an objective and validated patient information website scoring tool. The Google rank was compared to the DISCERN rank to assess for correlation. The top five websites for each search item were then ranked by blinded cleft health professionals for quality. RESULTS: Based on Google ranking, 36% of websites were the same across the search terms used. The DISCERN ranking scores demonstrated no evidence of positive or negative correlation when compared to Google ranking. In the top 10 DISCERN ranked websites for each search item, 4 websites appear in the top 10 Google rankings. CONCLUSION: This is the first study that demonstrates that high-quality information on cleft lip and palate is available on the Internet. However, this may be difficult and confusing for parents and patients to access due to the ranking system used by internet search engines. Cleft healthcare professionals should be aware of these problems when recommending websites to families and patients.

Versatility of Pedicled Perforator-Based V-Y Advancement Flaps for Reconstruction of the Upper Limb: A Case Series and Review of the Literature.

INTRODUCTION: The aim of any reconstruction is to provide a robust and cosmetically pleasing result that does not significantly alter function. We describe our experience of using the V-Y principle in advancement flaps designed around a distinct perforator to reconstruct soft tissue defects of the upper limb. The shortcomings of fasciocutaneous and fascial flaps requiring skin grafting can be eliminated. METHODS: This was a 10-year retrospective review of patients who had V-Y flaps based on a distinct perforator for defects of the shoulder, axilla, arm, elbow, forearm, wrist, and hand. Defects of the digits and thumb were excluded. RESULTS: There were 59 flaps in 52 patients with an average age of 44 years (18-72 years). Skin malignancy was the most common primary etiology. The average defect size was 35 cm (9-80 cm). There were no total flap failures; however, there were 4 partial losses, which healed by secondary intention. Seven flaps had to be explored for the hematoma evacuation. CONCLUSIONS: The use of V-Y flaps based on distinct perforators in the upper limb retains limb aesthetics, allows early mobility and is a safe and reliable technique.

Propranolol for Surgeons in the Treatment of Infantile Hemangiomas.

INTRODUCTION: Beta-blocker (Propanolol or Timolol maleate) treatment of infantile hemangiomas (IH) is a safe and effective treatment in the outpatient setting. The authors report a single surgeon's initial experience with setting up an outpatient service of beta-blocker treatment for head and neck IH at a tertiary children's hospital. METHODS: A prospective study of children with head and neck IHs commenced in January 2015 with the end point being December 2018. Each child started either oral propranolol (2 mg/kg/day) or topical Timolol 0.5%. RESULTS: Thirty-eight patients commenced a beta-blocker during the study duration. The mean age at time of starting therapy was 9 months (range 3 weeks to 116 months). Four patients were older than 12 months at commencement. The mean duration of treatment was 9 months. The response to treatment was excellent or complete in 29% (n = 11), good in 50% (n = 18) and mild in 10% (n = 4). The non response rate was 10% (n = 4). No major adverse effects occurred but 29% (n = 11) experienced minor side effects. CONCLUSION: Low dose propranolol and topical Timolol is been safe and easy to use for surgeons who may not be regular prescribers or unfamiliar with treating children with IHs with beta-blocker therapy. In patient monitoring is unnecessary and parents can be taught easily to recognise side effects. Treating children from the start builds a trusting relationship with the family before the child requesting cosmetic revision of the fibro-fatty remnant.

First Pediatric Experience With a Novel, Adhesive Adapter Retained, Bone Conduction Hearing Aid System.

OBJECTIVES: To assess the audiological outcomes, practicalities, and impact on quality of life of a new, nonimplantable, adhesive retained bone conduction hearing aid in children. STUDY DESIGN: A prospective, single-subject repeat measure, cohort study. SETTING: Community and in pediatric assessment center. PATIENTS: Twenty-one children aged between 5 and 15 years with a conductive hearing loss of >/=25 dB HL in the better hearing ear. INTERVENTION: Audiological comparisons were made using pure-tone thresholds; unaided, with a softband aid, and with the new adhesive retained bone conducting system. MAIN OUTCOME MEASURES: Comparison of hearing threshold levels. Data analysis via paired t-testing, significance set at p value <0.01. Quality of life was assessed via the Glasgow Children's Benefit Inventory and a 10 cm linear analogue scale. A hearing aid review questionnaire provided insight into practical use. RESULTS: Statistically significant improvement in thresholds of 7.3 dB HL (p=0.0001) was demonstrated with the adhesive system as compared with softband aids. After 4 weeks of usage, the mean hearing thresholds for the adhesive hearing system improved from 55 dB HL ±â€Š2.4 to 31 dB HL± 7.9 in unaided and aided conditions.Improvements in QOL were demonstrated with LAS and GCBI. Four children reported mild skin reactions. Eighty-six percent reported improved self-confidence. CONCLUSION: The adhesive aid produces comparable audiological results to the commercial softband hearing aids. It provides an excellent alternative in the treatment of conductive hearing loss without the possible complications and costs of a surgical intervention. Furthermore, it preserves skin envelope over the mastoid for those who wish to proceed with an autologous pinna reconstruction in the future.

Surrogate Outcome Measures for Corneal Neurotization in Infants and Children.

BACKGROUND: Corneal anesthesia is a rare and challenging condition, particularly in young children. The insensate cornea leads to abnormal epithelial cell metabolism and loss of trophic influences supplied by the corneal nerve fibers. This results in recurrent spontaneous epithelia erosion and eventual loss of sight. Corneal reinnervation is a definitive treatment option for neuropathic keratitis. The outcome measures in young children following corneal sensitization are different to adults as esthesiometry is unachievable. METHODS: The authors have undertaken corneal reinnervation in a young patient using a sural nerve graft. Surrogate measures suitable for pediatric patients were used for assessment of the outcome. RESULTS: Postoperatively there was evidence of improved corneal healing and function after 8 weeks. At 10 months postprocedure, the cornea was completely free of vascularization. CONCLUSION: Resensitization of the cornea using nerve grafts has previously been reported in older children and adults. This is the first time the procedure has been undertaken in a young child. Although the technique is still in its infancy with only 4 patients reported worldwide including our report, it seems to hold promise of improvement to this challenging cohort of patients.

Microtia and Social Media: Patient Versus Physician Perspective of Quality of Information.

INTRODUCTION: Previous research demonstrates that patients seek high-quality information on the World Wide Web, especially in rare conditions such as microtia. Social media has overtaken other sources of patient information but quality remains untested. This study quantifies the quality of information for patients with Microtia on social media compared with nonsocial media websites and compares physician and patient scoring on quality using the DISCERN tool. METHODS: In phase 1, quality of the top 100 websites featuring information "Microtia" was ranked according to quality score and position on Google showing the position of social media websites among other nonsocial media websites. Phase 2 involved independent scoring of websites on microtia compared with a patient group with microtia to test whether physicians score differently to patients with t test comparison. RESULTS: Social media websites account for 2% of the scored websites with health providers linking to social media. Social media websites were among the highest ranked on Google. No correlation was found between the quality of information and Google rank. Social media scored higher than nonsocial media websites regarding quality of information on microtia. No significant difference existed between physician and patient quality of information scores on social media and nonsocial media websites (p 1.033). CONCLUSION: Physicians and patients objectively score microtia websites alike. Social media websites have higher use despite being few in number compared with nonsocial media websites. Physicians providing links to social media on information websites on rare conditions such as microtia are engaging in current information-seeking trends.

Empowerment of Parents of Children With Craniosynostosis by Objective Scoring of Patient Information Websites.

INTRODUCTION: Parental anxiety may be caused by inappropriate information on the world wide web regarding craniosynostosis. The aim of this study was to study the correlation between the first 100 websites ranked on the Google search engine and those ranked based on objective scoring with patient information scoring tool. The results of these findings can then be used to recommend websites based on the quality of information that may not initially appear first on a search engine. METHODS: The DISCERN patient information scoring tool was chosen as a scientific way of measuring the quality of patient information based on previous research by the Picker Institute in Oxford. The word "craniosynostosis" was entered into the Google internet search engine. Patient information provided by the first 100 websites was studied and scored using the DISCERN scoring tool. From this score, each website was ranked with the highest scoring website at the top and worse scoring website at the bottom. This ranking based on the DISCERN tool score was correlated against the ranking of the website by Google. Positive correlation between DISCERN and Google ranking would be demonstrated if a website high in the ranking using DISCERN was also at the top of the first 100 websites on Google. RESULTS: No correlation could be found between those websites ranked highly for patient information on craniosynostosis using the DISCERN tool to the ranking provided by Google. DISCERN scores ranged from 17 to 72 (the lowest possible DISCERN tool score being 15 and the highest 85). The website ranking highest in terms of quality appeared only 50th in the Google rank. CONCLUSION: High-quality patient information on craniosynostosis does exist on the world wide web but may be difficult to find due to the complexity of factors used to rank websites on internet search engines. This results in some high-quality websites not appearing at the top of an internet search. Therefore, parents risk missing useful information relevant to their child's diagnosis. Healthcare professionals can use objective scoring of patient information websites to empower their patients to seek higher quality information.

Isolated Unilateral Frontosphenoidal Suture Synostosis in Six Patients: Lessons Learned in Diagnosis and Treatment.

INTRODUCTION: Due to the rarity of isolated frontosphenoidal suture synostosis clinical diagnosis can be challenging. This study of 6 patients aims to review the clinical, radiological findings, and operative techniques used to correct the underlying pathology. METHODS: Patients with isolated frontosphenoidal suture craniosynostosis were selected from a retrospective review of 88 patients with unicoronal synostosis treated during a 3-year period. Two-dimensional photography of patients' soft tissue morphology from the vertex view allowed assessment of the following morphology: frontal bossing, brow depression, nasal tip deviation, and ear position. Quantitative measure of the extent of bony deformity was measured using various angles measured from two-dimensional axial views of computerized tomography scans. Last, technical variations in correction of isolated frontosphenoidal craniosynostosis were collected from operative notes. RESULTS: On the side of isolated frontosphenoidal craniosynostosis, contralateral bossing and ipsilateral brow depression was present in all 6 patients. Ipsilateral nasal tip deviation was seen in 3 out of the 6 patients. Ear position was symmetrical in the cranial-caudal and anterior-posterior axes. No radiological evidence of harlequin deformity was seen on skull X-ray in all 6 patients, but computerized tomography scans demonstrated isolated frontosphenoidal suture craniosynostosis. The angle drawn between the foramen magnum, sella turcica, and anterior cribriform plate in 3 of 6 patients showed deflection of the anterior cranial fossa opposite to the side of isolated frontosphenoidal suture craniosysnotosis. There was no difference in the angle between the petrosal pyramid and the midline. In all patients, operative technique involved taking a deeper fronto-orbital bandeau to capture and reshape the pathological suture. CONCLUSIONS: In isolated frontosphenoidal suture craniosynostosis, contralateral bossing and ipsilateral flattening of the forehead were the most consistent clinical features with nasal tip deviation away from the side of pathology less consistent. Ear position is unaffected. Measurements of various angles of the skull base were not consistent. A deeper vertical osteotomy at the site of isolated frontosphenoidal suture craniosysnotosis on removing the fronto-orbital bandeau was 1 operative technical variation.

Matador versus taurus: bull gore injury.

Bull fighting is a reality and the injuries sustained by the matador cause a bizarre pattern of injury that the trauma surgeon must appreciate since they are inflicted in unique circumstances. This article highlights the mechanism of a bull gore injury, the pattern of wounds, and the most appropriate management.

Eccrine porocarcinoma: A case report and review of the literature.

Eccrine porocarcinoma is a rare form of skin cancer that is often confused with other types of skin malignancy. The present paper highlights a typical case to remind plastic surgeons of the natural history, pathological findings and current literature on the management of this cancer.

Le porocarcinome eccrine est une rare forme de cancer cutané souvent confondue avec d'autres types de malignité cutanée. Le présent article met en lumière un cas type pour rappeler aux plasticiens l'évolution naturelle, les observations pathologiques et la documentation scientifique actuelle sur la prise en charge de ce type de cancer.