Surgical Techniques for the Repair of Webbed Neck: A Scoping Review.

Webbed neck is a rare condition characterized by bilateral subcutaneous bands, which extend from approximately the mastoid to the acromion. Given its rarity, the literature lacks a review of the techniques used in the repair of this condition. We performed a scoping review to define and summarize the surgical techniques been used in the treatment of webbed neck, with the goal of better equipping the surgeons' armamentarium. Two databases, PubMed and Scopus, were searched from inception through December 27, 2021. Studies were considered for inclusion if they (1) described the webbed neck condition and (2) reported results of surgical correction of this condition. Surgical outcomes and follow-up durations were reported as available. Twenty-two manuscripts were analyzed and included data on 60 patients. The most common syndrome associated with webbed neck was Turner syndrome (48 patients). The most frequently documented procedure technique was a Z-Plasty (38 patients). Other procedures described included: butterfly correction, V-Y Plasty, posterior cervical lift, skin excision, tissue expansion plus skin excision, T to M rearrangement, and subcutaneous fascial excision. Documented complications included hypertrophy of procedure scars or webbed neck recurrence. In summary, we present the first full literature review of the surgical techniques used in the repair of webbed neck. When selecting the technique for repair of the webbed neck, function and cosmesis are important considerations. Future studies should collect standardized outcomes data to appropriately assess and compare the described procedures.

Modification of the Fetal Profile Line to Measure Reversal of Forehead Slope after Early Repair of Frontoethmoidal Encephalocele.

Objective Congenital frontoethmoidal encephaloceles are associated with a shallow sloping forehead. We (1) sought to determine if early repair reverses abnormal forehead slope, and (2) assessed a modification of the fetal profile (FP) line to assess results. Design Study of two cases. Participants Newborns with frontoethmoidal encephaloceles repaired prior to the age of 4 months with cranial base bone grafting. Main Outcome Measures Forehead slope was assessed using a modification of the FP line, defined as the line that passes through the anterior border of the mandible and nasion, on pre and postoperative magnetic resonance imaging (MRI) in the midsagittal plane. A modified FP (mFP) line anterior to the forehead was " - ", while a posterior (normal) mFP line was " + ." The largest distance from the mFP line to the forehead was measured. Results Both infants underwent bifrontal craniotomy, excision of encephalocele, and repair of cribriform plate defect using full-thickness autologous parietal bone before the age of 4 months. Preoperatively, the mFP line was -20.6 mm in case 1, and -9.8 mm in case 2. In both cases, follow-up MRI showed excellent reversal of forehead slope and normal calvarium development. The mFP line improved to +7.4 (age = 16 months) in case 1, and +7.6 (age = 11 months) in case 2. The parietal bone donor site ossified completely within 3 months in both cases. Conclusion Early repair with bone grafting can promote normal frontal bone development and improve forehead slope. The mFP line is a useful method to measure degree of forehead slope.

Transport of patients with giant disfiguring cranial tumors from Africa to the US for collaborative multidisciplinary treatment.

BACKGROUND: Giant disfiguring cranial tumors are exceptionally rare and develop over the course of many years, typically in patients who lack access to medical care. Here, we describe four patients who were flown to our center for treatment by a multidisciplinary surgical team, who had previously been turned down for treatment at multiple international centers in Africa, Europe, and the United States (US) due to complexity and financial concerns. The case series describes socioeconomic implications and the feasibility of offering such care to patients from outside the US. CASE DESCRIPTIONS: Four patients with giant skull disfiguring tumors were flown internationally and treated by a surgical team consisting of a complex cranial neurosurgeon, a craniofacial reconstructive plastic surgeon, and an oculoplastic surgeon. All patients underwent aggressive surgical therapy with the aim of complete tumor removal and simultaneous cranial reconstruction. A patient with osteogenic sarcoma underwent two additional resections in 3 years, with delayed reconstruction. They returned home but ultimately succumbed to the disease. A patient with ossifying fibroma required two follow-up procedures for cosmetic reconstruction and sought asylum in the US, where they remain today. Two additional patients, one with a giant plexiform neurofibroma and one with a cerebellopontine angle meningioma, achieved good results and returned to Africa 1 month and 3 weeks after surgery, respectively. CONCLUSION: Resection of giant disfiguring cranial tumors and reconstruction of the impacted region requires an experienced multidisciplinary team. These cases can be managed by transporting such patients from areas without access to medical care to specialized centers able to provide excellent care.

Velopharyngeal Muscle Morphology in Children With Unrepaired Submucous Cleft Palate: An Imaging Study.

OBJECTIVE: To identify quantitative and qualitative differences in the velopharyngeal musculature and surrounding structures between children with submucous cleft palate (SMCP) and velopharyngeal insufficiency (VPI) and noncleft controls with normal anatomy and normal speech. METHODS: Magnetic resonance imaging was used to evaluate the velopharyngeal mechanism in 20 children between 4 and 9 years of age; 5 with unrepaired SMCP and VPI. Quantitative and qualitative measures of the velum and levator veli palatini in participants with symptomatic SMCP were compared to noncleft controls with normal velopharyngeal anatomy and normal speech. RESULTS: Analysis of covariance revealed that children with symptomatic SMCP demonstrated increased velar genu angle (15.6°, P = .004), decreased α angle (13.2°, P = .37), and longer (5.1 mm, P = .32) and thinner (4 mm, P = .005) levator veli palatini muscles compared to noncleft controls. Qualitative comparisons revealed discontinuity of the levator muscle through the velar midline and absence of a musculus uvulae in children with symptomatic SMCP compared to noncleft controls. CONCLUSIONS: The levator veli palatini muscle is longer, thinner, and discontinuous through the velar midline, and the musculus uvulae is absent in children with SMCP and VPI compared to noncleft controls. The overall velar configuration in children with SMCP and VPI is disadvantageous for achieving adequate velopharyngeal closure necessary for nonnasal speech compared to noncleft controls. These findings add to the body of literature documenting levator muscle, musculus uvulae, and velar and craniometric parameters in children with SMCP.

Intraoperative Imaging Changes Management in Orbital Fracture Repair.

PURPOSE: Intraoperative imaging is gaining widespread use in the management of facial fracture repair. The aim of this study was to determine whether intraoperative imaging changes the management of orbital fracture repair. MATERIALS AND METHODS: A retrospective case series was performed of all cases of orbital fracture repair from 2008 to 2015 in which the intraoperative O-arm was used at Regions Hospital (St Paul, MN), a level I trauma center. The primary outcome variable was a change in management, ranging from orbital plate repositioning to proceeding with orbital floor exploration. RESULTS: The study sample was composed of 101 patients with a mean age of 40 ± 15 years. Approximately 75% (76 of 101) of patients were male and 25% (25 of 101) were female. All cases were secondary to assault, motor vehicle accident, fall, or gunshot wounds. Use of the O-arm resulted in a change in management in 44% (44 of 101) of cases. In 48% (21 of 44) of these cases in which intraoperative imaging resulted in a change in management, the orbital plate was repositioned to optimize repair. In 16% (7 of 44) of these cases, the orbital plate was exchanged for a different size or type of plate. In 7% (3 of 44) of these cases, the orbital plate was reshaped by bending to improve contour for the repair. In another 7% (3 of 44) of these cases, the orbital plate was reshaped by trimming the plate to optimize the length or width of the plate for repair. In 7% of these cases, the orbital floor required exploration based on intraoperative imaging. In 5% of these cases, the orbital floor was found to be adequately reduced after zygoma reduction based on intraoperative imaging and did not require exploration. CONCLUSIONS: Use of intraoperative imaging allows the surgeon to make real-time changes in operative management ranging from orbital plate repositioning to deciding whether to proceed with orbital floor exploration. This not only allows for immediate optimization of repair but also could decrease the need for revision procedures, thus decreasing patient morbidity and improving patient outcomes.

Veritas® bovine pericardium for immediate breast reconstruction: a xenograft alternative to acellular dermal matrix products.

BACKGROUND: The technical advantages in utilizing human acellular dermal matrix (ADM) products as pectoral extenders in immediate breast reconstruction with tissue expanders or implants are well documented in the medical literature. In this study, the authors examine a commonly used biologic xenograft product that has not yet been described in the medical literature for use in immediate breast reconstruction to determine whether a lower overall complication rate is identified compared to published data on ADM products. METHODS: A retrospective multicenter medical record review of data on 54 subjects in 93 tissue expander/implant-based, consecutive, immediate breast reconstructions from three surgeons at different institutions was performed in which Veritas® bovine pericardium was used as the biologic graft material for the pectoral extender. RESULTS: Over a 24-month period with an average of 11-month follow-up, complication rates using Veritas® in breast reconstruction for seroma formation (7.5 %), marginal skin flap necrosis (5.4 %) infection (6.5 %), and capsular contracture (0 %) were found to compare equally or favorably with statistically significant lower overall complications relative to one comparison study and lower rates of marginal skin flap necrosis relative to two comparison studies based upon previously published data from multisurgeon studies using ADM products. CONCLUSIONS: Overall complications were found to be lower with Veritas® than ADM products in comparable multisurgeon studies, though this was found to be statistically significant in only one comparison study. Level of Evidence: Level II, theraputic study.

Dandruff-associated Malassezia genomes reveal convergent and divergent virulence traits shared with plant and human fungal pathogens.

Fungi in the genus Malassezia are ubiquitous skin residents of humans and other warm-blooded animals. Malassezia are involved in disorders including dandruff and seborrheic dermatitis, which together affect >50% of humans. Despite the importance of Malassezia in common skin diseases, remarkably little is known at the molecular level. We describe the genome, secretory proteome, and expression of selected genes of Malassezia globosa. Further, we report a comparative survey of the genome and secretory proteome of Malassezia restricta, a close relative implicated in similar skin disorders. Adaptation to the skin environment and associated pathogenicity may be due to unique metabolic limitations and capabilities. For example, the lipid dependence of M. globosa can be explained by the apparent absence of a fatty acid synthase gene. The inability to synthesize fatty acids may be complemented by the presence of multiple secreted lipases to aid in harvesting host lipids. In addition, an abundance of genes encoding secreted hydrolases (e.g., lipases, phospholipases, aspartyl proteases, and acid sphingomyelinases) was found in the M. globosa genome. In contrast, the phylogenetically closely related plant pathogen Ustilago maydis encodes a different arsenal of extracellular hydrolases with more copies of glycosyl hydrolase genes. M. globosa shares a similar arsenal of extracellular hydrolases with the phylogenetically distant human pathogen, Candida albicans, which occupies a similar niche, indicating the importance of host-specific adaptation. The M. globosa genome sequence also revealed the presence of mating-type genes, providing an indication that Malassezia may be capable of sex.

Isolation and expression of a Malassezia globosa lipase gene, LIP1.

Dandruff and seborrheic dermatitis (D/SD) are common hyperproliferative scalp disorders with a similar etiology. Both result, in part, from metabolic activity of Malassezia globosa and Malassezia restricta, commensal basidiomycete yeasts commonly found on human scalps. Current hypotheses about the mechanism of D/SD include Malassezia-induced fatty acid metabolism, particularly lipase-mediated breakdown of sebaceous lipids and release of irritating free fatty acids. We report that lipase activity was detected in four species of Malassezia, including M. globosa. We isolated lipase activity by washing M. globosa cells. The isolated lipase was active against diolein, but not triolein. In contrast, intact cells showed lipase activity against both substrates, suggesting the presence of at least another lipase. The diglyceride-hydrolyzing lipase was purified from the extract, and much of its sequence was determined by peptide sequencing. The corresponding lipase gene (LIP1) was cloned and sequenced. Confirmation that LIP1 encoded a functional lipase was obtained using a covalent lipase inhibitor. LIP1 was differentially expressed in vitro. Expression was detected on three out of five human scalps, as indicated by reverse transcription-PCR. This is the first step in a molecular description of lipid metabolism on the scalp, ultimately leading toward a test of its role in D/SD etiology.

Data requirements for protein identification using chemically-assisted fragmentation and tandem mass spectrometry.

Many laboratories identify proteins by searching tandem mass spectrometry data against genomic or protein sequence databases. These database searches typically use the measured peptide masses or the derived peptide sequence and, in this paper, we focus on the latter. We study the minimum peptide sequence data requirements for definitive protein identification from protein sequence databases. Accurate mass measurements are not needed for definitive protein identification, even when a limited amount of sequence data is available for searching. This information has implications for the mass spectrometry performance (and cost), data base search strategies and proteomics research.

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.