Surgical Technique Selection in the Management of Pediatric Gynecomastia.

INTRODUCTION: Although the majority of pubertal onset gynecomastia is self-resolving in nature, persistent deformity may require surgical intervention. This study aims to identify patient factors associated with surgical technique selection and proposes an algorithm for the surgical management of pediatric gynecomastia. METHODS: A retrospective analysis was performed of all surgically managed pediatric gynecomastia patients operated on at a single institution from 2012 to 2022. Charts and patient photos were analyzed for patient and operative demographics, endocrinologic comorbidities, complications, and outcomes. Data were analyzed using bivariate and logistic regression analysis. RESULTS: Fifty-six surgically managed gynecomastia patients less than 18 years of age were included. The average age at surgery was 16.1 years old, with a mean BMI of 26.9. Most patients were overweight or obese (54.8%) and had Simon grade IIb or greater gynecomastia (55.4%) at presentation. All patients underwent 1 of 4 mastectomy techniques with or without liposuction: inferior periareolar (n=25, 44.6%), circumareolar (n=13, 23.1%), transverse with pedicled nipple (n=4, 7.1%), or free nipple graft (n=14, 25.0%). Bivariate and logistic regression analysis revealed significant differences in sternal notch-to-nipple distance, nipple-to-inframammary fold distance, breast resection weight, and gynecomastia grade between the 4 surgical techniques used in this study. An algorithm incorporating these factors was devised to guide surgical decision-making. CONCLUSIONS: The proposed algorithm guides surgical technique selection for pediatric gynecomastia and is contingent upon the degree of ptosis and skin excess, anticipated resection weight, and skin quality.

Practice Trends in the Management of Asymptomatic Breast Reconstruction Patients with Textured Implants: A Survey Analysis.

Despite the increasing prevalence of breast implant associated anaplastic large cell lymphoma, there remains a paucity of literature guiding management of asymptomatic patients with textured breast implants. This risk can be anxiety provoking in breast reconstruction patients given their history of cancer or increased future risk. The purpose of this study is to evaluate current practice trends when managing the concerned asymptomatic patient following textured implant-based breast reconstruction. Methods: An electronic survey was distributed to members of the American Society of Plastic Surgeons, regarding management of asymptomatic breast reconstruction patients with textured devices. Anonymous responses were collected, and statistical analysis was performed. Results: A total of 304 responses were received. Of respondents, 237 (92%) have managed asymptomatic patients with textured devices. Historically, the overwhelming majority (89%) used textured devices; however, only 25% report current use. Regarding management of asymptomatic breast reconstruction patients, 87% recommend conservative management, while 13% recommend surgical management. When surgery is performed, 16.3% of respondents elected for implant exchange, 33.8% recommended implant exchange with partial capsulectomy, and 49.8% elected for implant exchange with total capsulectomy. Evaluation of practice patterns based on demographics demonstrated statistically significant differences in current use of textured devices and management of acellular dermal matrix. Conclusions: Despite decreased current use, there is a significant population of asymptomatic breast reconstruction patients with a history of textured devices concerned for risk of breast implant associated anaplastic large cell lymphoma. This survey demonstrates ongoing variability in surgeon recommendations regarding conservative and surgical management of these patients and the need for continued development of evidence-based guidelines.

Efficacy of Demineralized Bone Matrix for Revision Alveolar Bone Grafting in Patients Previously Treated with Bone Morphogenetic Protein 2 (BMP-2).

OBJECTIVE: This study investigates the effectiveness of demineralized bone matrix (DBX) to close alveolar clefts in patients previously treated with bone morphogenic protein-2 (BMP-2) who remained with bone nonunion. DESIGN: This is an IRB-approved retrospective, single-center study. SETTING: This study was conducted at a tertiary academic center. PATIENTS/PARTICIPANTS: We searched for all surgical encounters with the Current Procedural Terminology (CPT) code 42210 from the years 2013-2019. Included patients were diagnosed with cleft alveolus, previous BMP-2 exposure and required revision bone grafting during mixed dentition for persistent alveolar defects. INTERVENTIONS: 17 patients underwent revision alveolar bone grafting (ABG) with either DBX (n = 10) or autograft (n = 7) to repair persistent bony cleft. MAIN OUTCOME MEASURE(S): The primary study outcome measured was alveolar bone graft revision failure described as continued alveolar nonunion. RESULTS: The median age at revision ABG was 13.1 ± 3.3 years, with a mean follow-up time of 4.9 years (1.1-9.2 years). Patients were 53% male, 47% had a unilateral cleft lip and alveolus. 58.8% of patients were treated with DBX in the cleft, 41.2% treated with autograft from iliac crest. Overall, 11.8% (n = 2) of all revisions failed, requiring a second revision. The average time to reoperation was 2.06 years, and both were re-grafted with autograft. There was no statistically significant difference between the type of bone graft source used and the failure rate obtained (P = .1544). CONCLUSIONS: DBX and autologous iliac crest bone grafts achieve similar alveolar union rates during revision ABG in patients treated with previous BMP-2 to the alveolar cleft.

Pediatric Juxtaepiphyseal Phalangeal Fractures Are Distinct from Salter-Harris Type II Fractures and More Frequently Need Operative Fixation.

BACKGROUND: Salter-Harris type II fractures are the most common pediatric phalangeal fracture. A juxtaepiphyseal fracture is a distinct fracture pattern that, although similar in radiographic appearance, occurs 1 to 2 mm distal to the growth plate. Although subtle, there are important differences in the behavior and management of these fracture types. The purpose of this study was to compare these two fracture patterns in terms of clinical features and treatment. METHODS: An institutional review board-approved retrospective chart review was conducted of patients presenting to our tertiary care pediatric hospital. One hundred fifty-eight patients with either Salter-Harris type II or juxtaepiphyseal phalangeal fractures were identified. Primary outcomes analyzed included angulation at initial presentation, stability of reduction if attempted in the emergency department, and need for operative fixation with and without Kirschner wire fixation, with final angulation measurements. RESULTS: Salter-Harris type II fractures were more common than juxtaepiphyseal fractures (83 percent versus 17 percent, respectively). There was no significant difference between the two fracture types in the patient's age, sex, or mechanism of injury. Juxtaepiphyseal fractures were radiographically more angulated on presentation than Salter-Harris type II fractures (p = 0.02). Juxtaepiphyseal fractures required significantly more operative fixation by closed reduction and percutaneous pinning compared to Salter-Harris type II fractures (42.9 percent versus 10.8 percent, respectively; p = 0.002). There was no difference in final outcomes obtained between the two groups. CONCLUSIONS: Juxtaepiphyseal phalangeal fractures are a distinct entity from Salter-Harris type II fractures. Presenting with significantly more radiographic angulation and clinical instability, juxtaepiphyseal fractures more frequently required operative fixation. Recognizing the differences between these pediatric fracture types is important to help guide clinical management for successful healing. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, II.

Detailed Anatomy and Reconstructive Approach of a Wassel VI Thumb Duplication.

Thumb duplication is a congenital hand difference that occurs in 0.08 of every 1000 live births and is categorized by level of duplication by the Wassel classification system. The anatomy and reconstruction of type VI thumb duplication is not well described, likely due to its rarity. In this report, we detail the anatomy and reconstruction of an ulnar-dominant Wassel VI thumb duplication, with particular attention paid to management of the first CMC joint and intrinsic muscle rebalancing of the preserved digit.

Defining Ideal External Female Genital Anatomy via Crowdsourcing Analysis.

BACKGROUND: Despite existing anthropometric data in the literature regarding the variation of female external genital anatomy, the ideal aesthetic characteristics have yet to be defined. OBJECTIVES: The authors utilized crowdsourcing to better evaluate preferred anatomic characteristics of external female genitalia. METHODS: Fifty-six total images were digitally created by altering the proportions of the labia minora, labia majora, and clitoral hood. Images with differing ratios were presented in pairs to Amazon Mechanical Turk (Seattle, WA, USA) raters. Three different experiments were performed with each varying 2 of the 3 image characteristics to permit 2-factor modeling. The Bradley-Terry-Luce model was applied to the pairwise comparisons ratings to create a rank order for each image. Preferences for each anatomic variable were compared with chi-squared tests. RESULTS: A total of 5000 raters participated. Experiment 1 compared differing widths of the labia majora and labia minora and determined a significant preference for larger labia majora width and mid-range labia minora width (P = 0.007). Experiment 2 compared labia minora width vs clitoral hood length and showed a statistically significant preference for wider majoras (P < 0.001) but no significant preference in clitoral hood length (P = 0.54). Experiment 3 compared clitoral hood length vs labia minora width and showed a statistically significant preference for mid-range labia minora widths (P < 0.001) but no significant preference in clitoral hood length (P = 0.78). CONCLUSIONS: Raters preferred a labia majora to labia minora width ratio of 3:1 with minimal preference in clitoral hood length.

Pediatric Trigger Digit Presenting in the Setting of Trauma.

BACKGROUND: Pediatric trigger digit is a relatively rare condition with incompletely understood etiology. In our practice, we noted a series of children presenting with pediatric trigger digit after an associated local trauma to the hand, which has not been previously described. The aim of this study was to analyze the nature of presentation of trigger digits, the accuracy of initial diagnosis, and the impact on treatment strategies used. METHODS: An institutional review board-approved retrospective review of our institution's experience with pediatric trigger finger from 2001 to 2015 was performed. RESULTS: Twenty-two patients with 26 affected digits were identified. Eighty-eight percent of patients were diagnosed with trigger thumb, whereas 3 patients (12%) had small finger triggering. Thirteen patients (59%) presented as outpatients, whereas 9 (41%) presented through the emergency department. All patients presenting to the emergency department were in the setting of recent minor trauma. Of this subset of patients, 67% had an incorrect initial diagnosis, leading to an average delay in treatment of 60 days. Ten patients (45% of total) were initially treated with immobilization versus surgical release of the A1 pulley. However, all but 2 of these patients required eventual A1 pulley release for persistent or recurrent triggering (88%). CONCLUSIONS: The cause of trigger digit in children remains incompletely understood and may be multifactorial. In this series, a traumatic component to presentation was found in a significant number of patients. This association with minor trauma may contribute to misdiagnosis and delay in definitive treatment. Although initial treatment with immobilization does not seem to impact surgical outcome, we found a high rate of failure with initial immobilization. Most patients required eventual surgical management, regardless of whether or not the initial presentation was associated with trauma. When performed, we found that A1 pulley release alone has safe, reliable results.

Pediatric craniofacial pseudoaneurysm with a variable history of antecedent trauma.

A pseudoaneurysm (PA) is a vascular lesion occurring along an artery most often associated with previous trauma. It presents clinically as a compressible, pulsatile mass, which can be painful, growing, and associated with headaches. We report a series of 4 pediatric patients referred for management of a "cyst" who had superficial craniofacial PAs arising in a variety of different locations with a variable history of antecedent trauma.This is an institutional review board-approved study of 4 consecutive patients presenting to the pediatric plastic surgery division with a diagnosis of PA between July 2012 and November 2013.The patients were initially referred for management of cyst. Each presented with compressible, pulsatile masses arising in varying locations along the superficial temporal or occipital arteries of the face and scalp. Three of the patients did not have a history of recent previous trauma. In the patients without history of trauma, further workup with duplex ultrasound was performed. In cases where the entire course of the artery could not be visualized by ultrasound, magnetic resonance angiography was performed to rule out an intracranial source of the lesion. Three lesions were excised with pathologic confirmation of the diagnosis of PA. All masses and associated symptoms resolved after the excision.Craniofacial PAs can occur in the pediatric population with a variable history of antecedent trauma. Awareness of this clinical phenomenon can help guide proper diagnosis for planning of safe, effective treatment. Surgical excision provides a safe, aesthetic result.

Catfish noodling forearm injury requiring urgent surgical treatment: a case report and review of the literature.

"Noodling" is an ancient form of hand fishing recently gaining in popularity as a hobby and sport. We present one of the first case reports of a noodling injury in an adolescent male seeking to land a large catfish, and also review the literature on catfish-related injuries.

Understanding the unfavorable result after otoplasty: an integrated approach to correction.

The correction of an unfavorable outcome after otoplasty requires a thorough understanding of the anatomy of prominent ear and recognition of the spectrum of secondary deformities and their origin. The goal of this article is to describe the causes of postotoplasty deformity, including both undercorrection and overcorrection. The latter presents the more complicated reconstructive problem, as both skin shortage and permanent cartilage disruption need to be addressed. The authors propose an algorithm for revision otoplasty based on clinical findings and patient concerns. Finally, a case with overcorrection secondary to both skin deficiency and cartilage disruption is illustrated showing the sequential steps needed for optimal correction.

Pediatric frontal mucocele secondary to a bifid frontal sinus septum.

A mucocele is a mucus-containing sac lined with epithelium that arises within a sinus when its drainage is compromised. The frontal sinus is the most common location, with frontal mucocele development occurring when the nasofrontal duct becomes obstructed because of polyps, bone tumors, prior surgery, sinusitis, trauma, or anatomic variation. We report an unusual case of a sterile pediatric frontal mucocele presenting as a slowly enlarging forehead mass due to a bifid frontal sinus septum. A 9-year-old girl presented to the craniofacial clinic for evaluation of a right frontal mass that had been slowly growing over the past year. She was otherwise healthy and had no history of previous trauma or sinus infections. Computed tomography (CT) scan results revealed a localized frontal fluid collection with protrusion and thinning of the anterior frontal bone between 2 midline bony septii. Surgical cranialization of the frontal sinus was performed. The anatomy of her lesion seen both on CT scan and intraoperatively likely explains this unusual case presentation. Instead of the usual inciting event of an intact frontal sinus drainage system becoming blocked, this patient seemed to have a primary developmental lack of any drainage system that led to her mucocele. During formation of her frontal sinus, she developed a bifid septum within the midline that excluded a portion of her frontal sinus from the lateral nasofrontal ducts. With mucus-producing epithelium trapped within these bony confines, pressure began to mount with expansion and thinning of the bone both anteriorly and posteriorly. The lack of any infectious symptoms and sterile culture results may support that this space developed primarily and was never in continuity with the external drainage system. Only 4 other patients have been reported with asymptomatic forehead swelling as the only presenting symptom, with the age ranging from 33 to 79 years. This patient represents the first clinical report of a congenital developmental mucocele.

Outcome analysis of our first 75 spring-assisted surgeries for scaphocephaly.

BACKGROUND: Spring-assisted surgery (SAS) has demonstrated promising results for the treatment of sagittal craniosynostosis. The purpose of this study was to assess the outcomes of the first 75 cases compared with a prospectively collected group of patients treated with cranial expansion (cranial vault remodeling [CVR]). METHODS: Seventy-five children with scaphocephaly have completed this institutional review board-approved study. Patients underwent cranial surgery with removal of a 1-cm strip of sagittal suture and insertion of a mean of 2 spring distractors. Clinical outcome assessment included analysis of changes in cephalic index, shape, and volume on three-dimensional laser scans for both the SAS and the CVR treatments. Perioperative variables for both techniques were also compared. RESULTS: All patients successfully underwent SAS without significant complications with a mean follow-up of 46 months. Perioperative variables including odds ratio, time, blood loss, transfusion requirements, intensive care unit and hospital stay lengths, and hospital costs differed significantly in favor of SAS. The mean cephalic index improved from 69 preoperatively to 75.4 after SAS, comparable with the change from 66 to 72.5 for CVR. This correction was maintained at 3- and 5-year follow-ups. Anterior frontal bossing was corrected on three-dimensional scan volume measurements. CONCLUSIONS: Spring-assisted surgery is a safe, effective, minimally invasive treatment of scaphocephaly. It combines the low morbidity and the operative time of a strip craniectomy with dynamic reshaping techniques while the implanted spring gradually distracts the skull, improving head shape. Our 7 years of experience has shown that SAS effectively corrected cranial shape including frontal bossing with maintained results over time.

Subatmospheric pressure wound therapy and the vacuum-assisted closure device: basic science and current clinical successes.

This article reviews the development, current theories behind the mechanism of action and clinical use of subatmospheric pressure wound therapy with the vacuum-assisted closure device. An evolving list of indications for subatmospheric pressure therapy is discussed including its use in chronic wounds, traumatic wounds and orthopedic salvage, infected sternal wounds, management of the open abdomen, enterocutaneous fistulae, burn wounds, skin grafts and dermal substitutes, as well as systemic disease processes, such as myoglobinuria. The vacuum-assisted closure device Instill system is also reviewed, in which subatmospheric pressure therapy has been combined with the instillation of therapeutic solutions for the treatment of difficult infected wounds.