Initial Experience With a New Intraoral Midface Distraction Device.

Maxillary hypoplasia that necessitates surgical advancement affects approximately 25% of patients born with cleft lip and palate. Syndromic conditions such as Crouzon may also be accompanied by significant maxillary hypoplasia. Severe maxillary hypoplasia can result in airway obstruction, malocclusion, proptosis, and facial disfigurement. For optimal stability, severe hypoplasia is best addressed with maxillary distraction osteogenesis. Twenty-two patients (15 boys, 7 girls, ages 6-16 years, mean age 10 years) with severe midface hypoplasia underwent midface distraction with new internal maxillary distraction (IMD) device at our institution. Total distraction distances ranged from 15 to 30 mm. There were no major complications, and all of them had improvement in functional and aesthetic parameters. There were 2 minor complications and 2 patients failed to distract the full distance because of converging vectors. Early maxillary distraction in patients with severe midface hypoplasia is a useful technique to provide interval correction of severe maxillary hypoplasia before skeletal maturity and definitive orthognathic surgery is contemplated, and it is a good tool to improve occlusion, aesthetics, and self-perception in younger patients.

Immediate mandibular distraction in mandibular hypoplasia and upper airway obstruction.

Distraction osteogenesis of the mandible has become an alternative to tracheostomy in infants and children who present with upper airway obstruction due to micrognathia. To avoid prolonged intubation during distraction, we have implemented a protocol of immediate distraction at the time of distractor placement, which results in acute airway improvement. Over 2 years, 22 patients with micrognathia and severe airway obstruction have undergone mandibular distractor placement. Indications for surgery were apnea and desaturations with feeding. Resorbable distraction devices were placed bilaterally and activated to 5 to 8 mm. Recombinant human bone morphogenetic protein 2 was placed in the gap. Distraction was implemented at postoperative day 2 at 2 mm/d. Forty-four distraction devices were placed in 22 patients (68% male, 32% female) with a mean age of 24.1 months (range, 3 days to 5.5 years). The average distance of distraction performed in the operating room was 5 mm. The average total distraction was 24 mm performed over 12 days. Overall, 89% of patients were extubated after distractor placement in the operating room. Two patients with difficult intubations were extubated 7 days later in the operating room with otolaryngology. Of the 4 tracheostomy patients, 1 patient was decannulated, whereas 3 patients are pending postoperative sleep studies. One patient had a minor wound complication. Tracheostomy and prolonged intubation in patients with mandibular hypoplasia have significant morbidity and mortality. We have implemented a successful protocol of immediate distraction in the operating room with placement of bone morphogenetic protein. Immediate distraction appears to be an effective method of avoiding postoperative intubation and tracheostomy.

Burn resuscitation index: a simple method for calculating fluid resuscitation in the burn patient.

The Parkland formula is the standard for calculating the initial intravenous fluid rate for resuscutation after thermal injury. However, it is cumbersome when used by those with modest burn training. We propose an easier method to calculate fluid requirements that can be initiated by first-line providers. Burn size is estimated by using the Burn Size Score (BSS), which is then crossreferenced with the patient's weight on a preprinted Burn Resuscitation Index (BRI), based on the Parkland formula, to determine initial hourly fluid rate. Seventy-two residents and faculty in the Departments of Surgery and Emergency Medicine were surveyed. Participants were shown a diagram of a burn patient and asked to calculate the initial fluid rate using the Parkland formula from memory. The study was repeated with a different diagram, and the participants were asked to calculate the initial fluid rate using the BRI (a preprinted card with written instruction pertaining to its use). Statistical analysis was performed with the McNemar test. Using the Parkland formula, 33% of surgeons and 17% of emergency medicine physicians were able to calculate the initial fluid rate. Using the BRI, 56% of surgeons and 77% of emergency medicine physicians were able to calculate the fluid rate correctly (P < .01 and P < .001, respectively). Fifty-four percent of physicians surveyed believed that the BRI was easier to use. The accuracy of determining initial fluid rate was low using the Parkland formula and "rule of nines" from memory. Accuracy increased when the BRI was used. The BRI serves as a visual aid and provides some instruction, allowing the user to calculate fluid resuscitation with greater accuracy than with rote memorization of a formula. The BRI might be a useful tool for providers with minimal burn training. However, further investigation is warranted.

Laparoscopic appendectomy after 30 weeks pregnancy: report of two cases and description of technique.

Appendicitis and pregnancy are both common conditions, and when they co-exist, both the general surgeon and obstetrician are presented with unique challenges. Acute appendicitis is the most common cause of the acute abdomen during pregnancy, effecting 0.1-0.3 per cent of pregnancies each year. With an estimated 4 million deliveries per year in the United States, there are potentially as many as 12,000 cases of acute appendicitis to be managed by the general surgeon during pregnancy (Eur J Surg 1992;158:603-6; Curr Surg 2003;60:164-73). Laparoscopic appendectomy has become a routine procedure and is now widely performed in North America. Although laparoscopic appendectomy has been discussed during pregnancy, limited data is available on the role of laparoscopic appendectomy in the third trimester of pregnancy. In fact, some authors have advocated a gestational age of 26-28 weeks to be the upper gestational limit for successful completion of laparoscopic surgery (Obstet Gynecol Surg 2001;56:50-9). In this paper, we present two recent cases of successful laparoscopic appendectomy during late pregnancy without immediate complication to mother or fetus and a description of our operative technique.

Factors that influence the completion of breast reconstruction.

Post mastectomy breast reconstruction continues to evolve in both timing and technique; however, multiple surgical procedures are usually required. The purpose of this report was to determine the number of secondary procedures required to complete the breast reconstruction and factors that influence this process. All patients who underwent breast reconstruction at Emory University Hospital between 1975 and 2000 were reviewed. The end point and inclusion criterion was completion to nipple reconstruction. Secondary procedures were determined per patient for either unilateral or bilateral reconstructions, and defined as any surgical manipulation of the reconstructed breast, contralateral breast, or donor site. The cohort was stratified by timing and method of reconstruction. Additional variables included risk factors, radiation therapy, and complications. A total of 888 patients completed the reconstructive process (738 unilateral and 150 bilateral). The average number of secondary procedures was 3.99 for unilateral, and 5.54 for bilateral. Delayed reconstructions had a higher number of secondary procedures in both groups. Transverse rectus abdominus musculocutaneous flap reconstruction tended to have more secondary procedures than implant or latissimus dorsi with or without implant reconstructions. Radiation therapy increased the number of secondary procedures in unilateral (3.9 versus 4.6, P < 0.001) and in bilateral reconstructions (5.7 versus 6.4, P = 0.032). The number of secondary procedures also increased exponentially with the number of risk factors (0-4), and patients with any complication had a higher number of secondary procedures for unilateral (4.5 versus 3.6, P < 0.001) and bilateral reconstructions (6.4 versus 4.5, P < 0.001). Secondary breast and donor site procedures were used as an outcome measure to formulate comparisons. Autologous tissue reconstruction required more secondary procedures, likely in part to donor site revisions. Delayed reconstruction, the need for radiation therapy, any complication, and more risk factors significantly increased the number of secondary procedures required to complete the reconstructive process.

Importance of right subcostal incisions in patients undergoing TRAM flap breast reconstruction.

The presence of a preexisting subcostal incision alters the approach to breast reconstruction and is thought to predispose to donor site skin complications and flap loss. The purpose of this study was to determine whether the presence of a subcostal scar affects breast or donor site morbidity adversely after transverse rectus abdominis musculocutaneous (TRAM) flap breast reconstruction. Twenty-six patients with a right subcostal incision (group A) underwent TRAM flap breast reconstruction (13 immediate, 13 delayed). The average age was 51 years, and the patients had an average body mass index of 25.3. There were 15 right, 10 left, and 1 bilateral reconstruction (4 free flaps, 22 pedicled). Outcome measures were compared with 126 age- and risk-matched patients (group B) who underwent TRAM flap reconstruction without any preexisting abdominal scar. The average age in group B was 46.7 years, and the patients had an average body mass index of 24.8. The average length of stay in group A was 5.9 days, compared with 4.8 days in group B ( < 0.05). There were no significant differences in breast-related complications. Donor site complications were higher in group A, with abdominal wall skin necrosis being significantly higher in patients with a subcostal incision (25%) compared with those patients without abdominal wall scars (5%; = 0.02). Multivariate analysis revealed a 6.5-fold increase in donor site complications in patients with a subcostal incision and a smoking history ( < 0.05). When adjusted for radiation treatment, the increased incidence in donor site complication rate was only marginally significant ( = 0.08). TRAM flap breast reconstruction in patients with preexisting right subcostal scars is effective with certain technical modifications; however, there is a slight predisposition to increased abdominal wall complications. Smoking influenced outcome further in patients with a subcostal incision, stressing the importance of proper patient selection.

Trends in unilateral breast reconstruction and management of the contralateral breast: the Emory experience.

Recent trends in breast reconstruction have transitioned toward the skin-sparing type of mastectomy and immediate reconstruction using autologous tissue. This study was designed to document trends in the management of patients with unilateral breast cancer and to determine how they influence management of the contralateral breast. All patients who underwent unilateral breast reconstruction at Emory University Hospitals from January of 1975 to December of 1999 were reviewed. The cohort was stratified by timing of reconstruction (immediate versus delayed), method of reconstruction, and mastectomy type (skin-sparing versus non-skin-sparing). The methods of reconstruction included implant, latissimus dorsi flap, and transverse rectus abdominis musculocutaneous (TRAM) flap. Contralateral procedures to achieve symmetry included augmentation, mastopexy, augmentation/mastopexy, and reduction. A total of 1394 patients were evaluated, including 689 delayed and 705 immediate reconstructions. Sixty-seven percent of delayed-reconstruction patients (462 of 689) had a symmetry procedure performed on the opposite breast, compared with 22 percent for the immediate-reconstruction patients (155 of 705) (p