Risk Assessment of Sleep Disordered Breathing in Cleft Lip and/or Palate.

OBJECTIVE: Children with cleft lip and/or palate (CL/P) are at increased risk for Sleep Disordered Breathing (SDB), particularly Obstructive Sleep Apnea (OSA). At our institution, routine screening for SDB is performed using the Chevrin Pediatric Sleep Questionnaire (PSQ). This analysis is a practice audit looking at the outcomes of screening children with CL/P. DESIGN/SETTING/PATIENTS/PARTICIPANTS: A single-center, retrospective analysis was done of all non-syndromic patients with CL/P over the age of 36 months over a 4-year period. Children with known OSA were eliminated from analysis. MAIN OUTCOME MEASURES: Univariate logistic regression was used to assess predictors for SDB (PSQ score > 8) amongst various patient, disease, and treatment characteristics. Outcomes of those screened were tracked. RESULTS: Of the 239 patients in the study cohort, 43 (18%) had positive PSQs. These subjects were more likely to have class III dental occlusion with maxillary retrusion (OR = 2.65, 95% CI: 1.2-5.8, p = 0.02). There were no differences amongst age, type of cleft, Veau classification, BMI, or history of pharyngeal surgery. One third of the group did not complete recommended testing. Twenty-five subjects with positive sleep screening underwent subsequent polysomnography and 21 (84%) had OSA. CONCLUSION: Routine screening reveals a significant proportion of patients with CL/P with symptoms suggestive of OSA. While several patients did not complete confirmatory testing, those who completed a PSG had a high rate of identification of OSA. After excluding children with known OSA, patients with SDB are also likely to have class III dental occlusion and maxillary retrusion.

Assessment of Gender Disparities and Geographic Variations in Payments from Industry among Plastic Surgeons in the United States.

BACKGROUND: Various medical specialties have demonstrated gender disparities involving industry-supported payments. The authors sought to determine whether such disparities exist within plastic surgery. METHODS: Industry contributions to plastic surgeons practicing in the United States were extracted from the Centers for Medicare and Medicaid Services Open Payments 2013 to 2017 databases. Specialists' gender was obtained through online searches. Kruskal-Wallis tests compared payments (in U.S. dollars) by gender (overall and by payment category). Linear regression estimated the independent association of female gender with increased/reduced payments while controlling for state-level variations. RESULTS: Of 1518 plastic surgeons, 13.4 percent were female. Of $44.4 million total payments from the industry, $3.35 million were made to female plastic surgeons (p < 0.01). During the study period, female plastic surgeons received lower overall payments than male plastic surgeons [median, $3500 (interquartile range, $800 to $9500) versus $4160.60 (interquartile range, $1000 to $19,728.20); p < 0.01]. This trend persisted nationwide after normalizing for year [$2562.50/year (interquartile range, $770 to $5916.25/year) versus $3200/year (interquartile range, $955 to $8715.15/year); p = 0.02] and at the state level in all 38 states where there was female representation. Analysis of payment categories revealed that honoraria payments were significantly higher for male plastic surgeons [$4738 (interquartile range, $1648 to $16,100) versus $1750 (interquartile range, $750 to $4100); p = 0.02]. Within risk-adjusted analysis, female plastic surgeons received $3473.21/year (95 percent CI, $671.61 to $6274.81; p = 0.02) less than male plastic surgeons. CONCLUSIONS: Gender disparities involving industry payments exist in plastic surgery at both national and state levels. Factors contributing to this phenomenon must be explored to understand implications of this gap.

Change in Initial Tympanostomy Tube Placement Timing Yields Decreased Burden of Care Without Increased Complications in Patients With Cleft Lip and Palate.

OBJECTIVE: To report a practice audit of the consequences of a change in protocol in the timing of placement of tympanostomy tubes in infants with cleft lip and palate. PARTICIPANTS: All children with a diagnosis of cleft lip and palate, treated between November 1998 and May 2006 under the old protocol, and between December 2012 and July 2016 under a new protocol. Under the old protocol, tympanostomy tubes were first inserted at the time of lip repair at around age 2 months. Under the new protocol, tympanostomy tubes were deferred until the time of palate repair around the age of 9 months. Children with syndromic diagnoses other than Stickler syndrome and Van der Woude syndrome, and children who failed newborn hearing screen were excluded. MAIN OUTCOME MEASURES: Incidence of otorrhea from birth to 6 months after palate repair and presence of hearing loss at ages 1 and 2. RESULTS: Deferral of tympanostomy tubes until the time of palate repair decreases the burden of care due to otorrhea as compared to early tympanostomy tubes at the time of lip repair. There was no significant difference in the incidence of hearing thresholds at or below 15 dB at age 1 or 2. CONCLUSIONS: Placement of tympanostomy tubes at the time of palate repair balances the goals of minimizing the adverse effects from middle ear effusion and minimizing the burden of care on our patients and their families.

Koenen tumors in tuberous sclerosis: a review and clinical considerations for treatment.

Koenen tumors, or periungual and subungual fibromas, are a benign, cutaneous manifestation of tuberous sclerosis. They are disfiguring, painful, and challenging to treat as they frequently recur. Various laser and chemical ablation techniques have been described with variable long-term results and there is limited published literature to suggest a standard treatment. Through a review of the available literature and a successful experience with a patient with lower extremity Koenen tumor, we present treatment considerations for managing these troublesome tumors.

The safety of pelvic surgery in the morbidly obese with and without combined panniculectomy: a comparison of results.

PURPOSE: The purpose of our study was to evaluate the benefit of panniculectomy combined with pelvic surgery in the morbidly obese patient. Previous literature has found this combined procedure in this particular patient population to have increased morbidity and that it was not beneficial. METHODS: A chart review was performed an all patients who underwent pelvic surgery with or without a panniculectomy between June 2004 and June 2005. Only morbidly obese patients (body mass index of >40 kg/m2) were included in the study. Factors evaluated were operative times, intraoperative blood loss, weight of pannus resection specimen, length of hospital stay, wound infection rate, and other complications. All data were analyzed using Levene test for equality of variances and the t test for the equality of means. RESULTS: Thirty-six patients had combined panniculectomy and abdominal hysterectomy, 14 had an abdominal hysterectomy without a panniculectomy. The mean operative times for the combined procedure was 3.4 hours versus 2.6 hours without panniculectomy. The mean estimated blood loss was 526 mL for the combined procedure (CP) and 536 mL for hysterectomy alone (HA). There were 2 wound infections in the CP group (5.6%) versus 3 in the HA group (21.4%). There was one wound dehiscence in the CP group (2.8%) and one in the HA group (7.1%). There was one inadvertent enterotomy in the HA group (7.1%) and none in the CP group. There were no statistical differences noted for any variable including patient body mass index, mean operative time, estimated blood loss, or rate of complications. CONCLUSIONS: Our findings, in contrast to previous findings, reveal that panniculectomy combined with pelvic surgery in the morbidly obese is a safe procedure that can decrease the incidence of intraoperative complications and postoperative wound complications without significantly increasing operative time or blood loss.

Review of vascularized bone marrow transplantation: current status and future clinical applications.

In this review, we examine the applicability of the vascularized bone marrow transplant (VBMT) as an alternative to conventional bone marrow transplantation (BMT). As a new surgical approach, the VBMT is unique by transplantation of the stromal environment that eliminates the need for an engraftment period, provides critical signaling and modulatory functions, and may potentiate tolerance induction. Thus far, VBMT studies have demonstrated an absence of graft-versus-host disease (GVHD) and robust engraftment into nonmanipulated as well as irradiated recipients with evidence of immunological tolerance. Further investigation is needed to determine the applicability of VBMT as an alternative to BMT.

Pulse doppler and M-mode to assess viability of cardiac allografts using heterotopic femoral heart transplantation in rats.

Noninvasive assessment of heterotopic heart transplants using Doppler echocardiography was first described in two patients by Allen at Stanford in 1981. Since then, numerous experiments studying heterotopic heart transplantation in humans and large animals have confirmed its utility by employing either an intra-abdominal or cervical model. In rats, however, prior research investigating intra-abdominal heterotopic hearts has showed echocardiography to be ineffective. We have recently developed a new technique for heterotopic femoral heart transplantation in rats, which employs the novel use of trans-femoral echocardiography. Therefore, our goal was to re-examine the efficacy of echocardiography for detection of graft rejection.

A new modified technique for heterotopic femoral heart transplantation in rats.

BACKGROUND: Abbott developed the first experimental accessory heart transplant rat model in 1964. This intra-abdominal model required a labor-intensive aortic anastomosis. In 1971, Heron modified the operation by using sutureless cervical vessel anastomoses. Rao and Lisitza developed a femoral heart accessory transplant model in 1985. Our goal was to improve this femoral model for the study of cardiac transplantation between both syngeneic and allogeneic rats. METHODS: ACI and Lewis rats weighing 150 to 350 g were used as donors and recipients (n = 12). The left common carotid and left pulmonary arteries were anastomosed to the femoral artery and vein in an end-to-end fashion, respectively. Improved modifications included the use of hemostatic vessel clips, heparinization of both donor and recipient, a ventricular prolene stay-suture for secure graft placement, and transfemoral echocardiography (TFE). Total operative time averaged 61 +/- 12 minutes. RESULTS: Femoral accessory transplanted hearts (FATHs) allowed easier pulse palpation and access for TFE versus previously described cervical and intra-abdominal models. This modification allows precise detection of acute graft rejection (AGR) and is defined as absent ventricular contraction in the presence of anastomostic patency. CONCLUSIONS: Our new modified technique for heterotopic femoral heart transplantation in rats is a relatively easily learned and reproduced procedure that allows superior allograft access for palpation and improved echocardiographic assessment. Femoral heterotopic heart transplantation remains an effective model for allograft transplantation study.

From experimental rat hindlimb to clinical face composite tissue allotransplantation: historical background and current status.

The purpose of this article is to review the historical background and clinical status of composite tissue allotransplantation and to discuss the scientific evolution of clinical face transplantation. Composite tissue allotransplantation (CTA) rapidly progressed in the 1980s with the discovery of cyclosporine. Although the most success has been achieved with hand transplantation, others have made progress with allografts of trachea, peripheral nerve, flexor tendon apparatus, vascularized knee, larynx, abdominal wall, and most recently, partial face. The world's first partial face allotransplantation occurred in November 2005 in France. In April of 2006, there was a second performed in China. As of today, there are now multiple institutions with plans to attempt the world's first full facial/scalp transplant. Complete facial/scalp allotransplantation offers a viable alternative for unfortunate individuals suffering severe facial disfigurement and is a product of many decades of experimental research, beginning with rat hindlimb allografts.

Absence of graft-versus-host disease in the isolated vascularized bone marrow transplant.

An isolated vascularized bone marrow transplant (iVBMT) model was developed to study the contribution of the bone marrow component in a composite tissue allograft. We hypothesized that the iVBMT would be functional and cause graft-versus-host disease (GVHD) in a fraction of the recipients. Lewis iVBMT grafts were transplanted to Lewis-Brown Norway recipients. Animals were sacrificed at various times from 1 to 14 weeks. Polymerase chain reaction for microchimerism was performed on the host's marrow. No animals exhibited signs of GVHD at death. Histologic examination of the grafts showed a normal mix of hematopoietic and fatty elements and appeared to be functional. Tissues usually affected-tongue, ear, liver, and gut-also showed no evidence of disease. Polymerase chain reaction demonstrated microchimerism in both groups. These findings suggest that the vascularized bone marrow within a composite tissue allograft is not the component that causes GVHD; rather, it may serve an immunomodulatory function for tolerance induction.

An extraperitoneal isolated vascularized bone marrow transplant model in the rat.

An isolated vascularized bone marrow transplant (iVBMT) model was previously developed in the rat to specifically study the role of bone marrow and its environment in a composite tissue allotransplant. An extraperitoneal model was successfully created to avoid laparotomy and cross-clamping of the great vessels. The extraperitoneal iVBMT model consisted of a left donor femur that was harvested with its nutrient vessels, anastomosed to the right femoral vessels in a syngeneic host, and then placed subcutaneously in the abdominal wall. At explant, the graft vessels were grossly patent, and histology of the graft bones showed a viable marrow compartment. Polymerase chain reaction demonstrated peripheral chimerism in the recipients. This model is technically simple with minimal morbidity in the recipient animals. By using the iVBMT, future studies across semiallogeneic and allogeneic barriers will help define the role of the bone marrow compartment in composite tissue allotransplants to potentially induce immune tolerance.

Beyond easy answers: the plastic surgeon and prenatal diagnosis.

OBJECTIVE: To explore how plastic surgeons handle the issue of prenatal diagnosis of cleft lip and palate. DESIGN: Mail survey. PARTICIPANTS: The plastic surgeon listed as team contact in the team directory of the American Cleft Palate-Craniofacial Association was identified. In cases in which a plastic surgeon was not listed as a team contact, the first plastic surgeon listed as a team member was identified. A total of 211 surgeons were contacted. INTERVENTION: Each surgeon was mailed a survey asking for his/her experience in prenatal diagnosis for cleft conditions. Ethical issues concerning the surgeon's personal beliefs about abortion and the potential influence of the surgeon's presentation of information were explored. RESULTS: A 50% response rate was obtained. Eighty-five percent of respondents were experienced in prenatal counseling; 92% offer consults on a routine basis. Ninety-six percent indicated they did so because they felt it was helpful to families. Treatment (98%), appearance of clefts (96%), cleft etiology (94%), and associated problems (40%) were discussed most commonly. Termination was rarely discussed (5%). Of those who had not met with a family, 82% said they had never been asked to do so. Most respondents felt families sought consultation for information and rarely sought consultation to decide on abortion. The majority felt their personal beliefs about abortion did not influence their willingness to meet with parents. The majority of surgeons in both groups felt it was ethical to give an opinion on pregnancy termination if asked (55% of experienced surgeons, 44% of inexperienced surgeons); however, a significantly larger number of the surgeons who had not met with a family were unsure of their opinion. CONCLUSIONS: Prenatal counseling of parents of a fetus with cleft lip/palate is common among plastic surgeons. There is uniformity in the information discussed. There is no agreement among surgeons about the ethical issues of pregnancy termination and the surgeon's role in that discussion.