Two Cases of Preaxial Polydactyly of the Foot: Important Implications for Plastic Surgeons.

Although polydactyly is quite common in general, preaxial polydactyly of the foot is rare (0.4 per 10,000 patients) and specifically associated with certain congenital abnormalities and syndromes, which can include craniosynostosis, corpus callosum agenesis, and renal malformations. We present 2 recent cases of preaxial polydactyly of the foot that highlight the importance of maintaining a high level of suspicion for associated abnormalities in these patients. The first patient, who presented with supernumerary preaxial digits on both feet, pre- and postaxial polydactyly of the hands, was also macrocephalic and hyperteloric; this presentation strongly suggested a diagnosis of Greig cephalopolysyndactyly, a GLI3-variant syndrome. The second patient, who had 2 preaxial digits on one foot, was found to also have a horseshoe kidney, a malformation that has been associated with limb defects as part of an acrorenal syndrome. These cases emphasize the importance of a thorough clinical approach to patients with preaxial polydactyly of the foot. Although many patients with this anomaly may be well known to geneticists, a child may be referred to a plastic surgeon for reconstruction of what is thought to be an isolated cosmetic or local functional issue. Plastic surgeons should be aware of the complex nature of preaxial polydactyly of the foot and potential syndromic presentation.

Pakistan Comprehensive Fistula Classification: A Novel Scheme and Algorithm for Management of Palatal Fistula/Dehiscence.

BACKGROUND: It is not easy to find a management-based classification of palatal fistula in the literature. A few attempts have been made to classify the wide variety of fistulae that do not describe the fistula details comprehensively and guide toward its management. The authors have come across a wide variety of fistulae that could not be classified according to any of the prevailing classification systems. The presented classification gives a clear and exact understanding of location and size of fistula/dehiscence. Palatal function has been included as one of the important determinants for devising a management plan. Based on this classification, the authors have proposed an algorithm that encompasses clear guidelines for surgical treatment of these fistulae. METHODS: Over the past 15 years, the authors' team operated on 2537 palatal fistula patients. The medical records of these patients were reviewed to determine the location, size, and velopharyngeal competence. A new classification and algorithm were developed. RESULTS: Of 2537 patients, 2258 had midline fistulae, 208 had lateral fistulae, and 53 had subtotal fistulae. There were 18 patients with dehiscence. Recurrence developed in 181 patients. CONCLUSION: The authors believe that this classification and algorithm can help follow a practical approach to manage palatal fistulae and dehiscence.

Primary Cleft Lip and Palate Repair in Assam, India: Does Preoperative Anthropometric Analysis Help Identify Patients With Increased Surgical Risk in a Clinically Prescreened Population?

OBJECTIVE: To compare anthropometric z-scores with incidence of post-operative complications for patients undergoing primary cleft lip or palate repair. DESIGN: This was a retrospective observational analysis of patients from a surgical center in Assam, India, and includes a cohort from a single surgical mission completed before the opening of the center. SETTING: Patients included in the study underwent surgery during an Operation Smile mission before the opening of Operation Smile's Guwahati Comprehensive Cleft Care Center in Guwahati, India. The remaining cohort received treatment at the center. All patients received preoperative assessment and screening; surgery; and postoperative care, education, and follow-up. PATIENTS, PARTICIPANTS: Our sample size included 1941 patients and consisted of all patients with complete information in the database who returned for follow-up after receiving primary cleft lip repair or primary cleft palate repair between January 2011 and April 2013. INTERVENTIONS: Preoperative anthropometric measurements. MAIN OUTCOME MEASURE(S): Postoperative complications. RESULTS: Anthropometric z-scores were not a significant predictor of adverse surgical outcomes in the group analyzed. Palate surgery had increased risk of complication versus lip repair, with an overall odds ratio of 5.66 (P < .001) for all patients aged 3 to 228 months. CONCLUSIONS: Anthropometric z-scores were not correlated with increased risk of surgical complications, possibly because patients were well screened for malnutrition before surgery at this center. Primary palate repair is associated with an approximate fivefold increased risk of developing postoperative complication(s) compared with primary lip repair.

Long-Term Outcomes of Rectosigmoid Neocolporrhaphy in Male-to-Female Gender Reassignment Surgery.

BACKGROUND: Favorable outcomes of rectosigmoid neocolporrhaphy have previously been reported. Unfortunately, rectosigmoid transfers are still perceived negatively, usually relegated to secondary vaginoplasties. This study aims to provide an objective investigation into the safety and efficacy of rectosigmoid neocolporrhaphy for vaginoplasty in male-to-female transsexual patients. METHODS: A retrospective review was performed on male-to-female patients who had undergone rectosigmoid neocolporrhaphy performed by the senior author. Patient data including demographics, medical history, complications, and the need for revision surgery were obtained. Direct inquires were conducted to determine patients' level of satisfaction with appearance, sexual function, and ease of postoperative recovery. RESULTS: Eighty-three patients were included over the course of 22 years, with an average clinical follow-up of 2.2 years (83 patients) and phone interview follow-up of 23 years (21 patients). Overall, the patients were healthy, with minimal comorbidities. Forty-eight patients (58 percent) had complications, but the majority (83.3 percent) were minor and consisted mainly of introital stricture or excessive protrusion of the corpus spongiosum. Smoking was associated with higher complication rates (p = 0.05), especially stricture formation. Excessive mucorrhea occurred in 28.6 percent but resolved after the first year. Overall patient satisfaction with appearance and sexual function was high. CONCLUSIONS: This study is one of the largest and longest reported series of rectosigmoid transfers for vaginoplasty in transsexual patients. Rectosigmoid neocolporrhaphies have many times been recommended for secondary or revision surgery when other techniques, such as penile inversion, have failed. However, the authors believe the rectosigmoid transfer is safe and efficacious, and it should be offered to male-to-female patients for primary vaginoplasty. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Globalization of Craniofacial Plastic Surgery: Foreign Mission Programs for Cleft Lip and Palate.

International Humanitarian Interchanges are a bona fide component of surgery and medicine. Additionally, these programs also provide substantial benefit both to the doers and the recipients.The foreign mission program is potentially a weapon of foreign policy which is underutilized and underestimated.Physician job dissatisfaction is increasing. However, the happiness and satisfaction of the participants in the short-term multidisciplinary trips, repeated, well-organized and respectful, with rather complete integration of the surgical system of the sister countries ("Plan B"), approaches 100%.The theory of the International Humanitarian Interchanges is based on substance, on medical theory. These trips are particularly successful in interchanges with medium-resourced countries.Furthermore, the academic visiting professor ("Plan A": hi-resource place to hi-resource place), the One Man Can Save the World model ("Plan C": to the low-resource place), and the intriguing Horton Peace Plan have possibilities for long-term benefit to the doer, recipient, the field of surgery, and the body of knowledge. In all of these, our country and the family of nations advance.The theoretical basis is not always religious nor the grand strategy plan; both have either proselytizing or political dominance as primary motives, and are mentioned as historically helpful.

A model humanitarian cleft mission: 312 cleft surgeries in 7 days.

BACKGROUND: There are many countries in the world where patients with cleft lip and palate cannot get access to specialized cleft care units. Cleft missions play an important role in providing surgical care to the areas of the world with limited resources. This article presents a model of cleft missions that can be adopted in many countries where expertise is available but resources are limited. Through proper utilization of local human resource, this type of mission can be a cost-effective and robust way of treating patients with cleft in countries with approximately 52% of the world's population. METHODS: We present a case series of patients of one of our cleft missions carried out in Khairpur, Pakistan, in March 2014 over a period of 7 days. Specific details concerning the organization of mission, gathering of patients, preparation for surgery, and carrying out surgical procedures in a safe and swift manner are presented. RESULTS: A total of 312 patients were operated on in 7 days. There were 145 patients with cleft lip and 167 patients with cleft palate. There were 187 male and 125 female patients with mean age of 7 years. Contemporary operative techniques were utilized to repair different types of cleft lip and palate. Of 167 patients, only 16 developed fistula. CONCLUSION: A locoregional cleft team can be more effective to care for the patients with cleft in countries where surgical and other expertise can be utilized by proper organization of cleft missions on a national level.

Neonatal Anesthesia Neurotoxicity: A Review for Cleft and Craniofacial Surgeons.

There is growing evidence that the commonly used anesthetic agents cause some degree of damage to the early developing brain. The animal evidence for anesthetic neurotoxicity is compelling. Numerous confounders in human research prevent researchers from drawing definitive conclusions about the degree of risk. For every surgery, it should be assessed whether the benefits of an early surgical procedure justify a potential but unquantifiable risk of neurotoxicity of anesthetic agents. The timing and number of surgeries in our treatment protocols may need to be reevaluated to account for these potential risks.

A survey of multidisciplinary cleft palate and craniofacial team examination formats.

We surveyed 229 multidisciplinary cleft and craniofacial teams listed in the American Cleft Palate-Craniofacial Association directory regarding frequency of meetings, numbers of patients treated, sources of funding, their format of examination of children, and their satisfaction with that format. One hundred fifteen (50%) of 229 surveys were completed. Thirty-seven percent of clinics report meeting monthly; 43% of clinics report actively following up 300 or less patients; 40% of clinics report funding by third-party insurance reimbursement, and 38% by government funding; 48% of clinics report the patients moving from one examination room to another to see specialists, in another 33%, the patient stays in 1 examination room while the specialists move, and in only 20%, all specialists see a patient simultaneously. Significantly more specialists are dissatisfied with clinics where they move to examine children; significantly more families are satisfied in clinics where specialists move to examine the child or examine them simultaneously.

Superficial granulomatous pyoderma of the face: a case report and review of the literature.

INTRODUCTION: Superficial granulomatous pyoderma (SGP) is a rare variant of pyoderma gangrenosum (PG) and differs from classic PG in its indolent clinical course, lack of associated underlying disease, the finding of a granulomatous infiltrate on histology, and better prognosis with less-aggressive therapies. METHODS: We report on a case of SGP involving the face following local reexcision of a biopsy scar. RESULTS: The patient developed an indolent ulceration following an excision of an unfavorable scar on her face. DISCUSSION: Superficial granulomatous pyoderma is usually responsive to conservative treatment with antibacterial or local anti-inflammatory agents. Facial involvement with SGP is particularly rare and tends to be more refractory to conservative management. Superficial granulomatous pyoderma involving the face appears to respond better to intensive treatment with systemic corticosteroids or immunosuppressants. To prevent poor cosmetic and functional outcomes in patients with nonhealing lesions, it is important for surgeons to recognize the clinical and histopathologic presentation of SGP and consider initiating a more aggressive management approach for SGP involving the face.