"Long-Term Outcomes of Smile Reconstruction in Möbius Syndrome.”

No abstract available

“Quality of Life in Adults with Non-Syndromic Craniosynostosis”

Background: While studies have analyzed quality of life (QOL) in children with non-syndromic craniosynostosis (NSC), to date nobody has investigated long-term QOL in adults with NSC. The purpose of this study is to compare QOL in adult NSC patients with a cohort of unaffected controls. Methods: We queried our institution's prospectively maintained craniofacial registry for NSC patients 18 years and older, and administered the validated World Health Organization Quality of Life (WHOQOL-BREF) questionnaire. Responses were compared, using a two-sample t-test, to an age-matched, United States, normative database provided by the World Health Organization (WHO). Results: 151 adults met inclusion criteria: 52 were successfully contacted and 32 completed the WHOQOL-BREF. Average age of respondents was 23.0±6.1 years old (range, 18.1 to 42.1). 12 subjects had metopic synostosis, 15 had unicoronal, and 5 had sagittal. NSC patients had a superior quality of life compared to comparative norms in all domains: physical health (17.8±2.7 vs. 15.5±3.2, p0.05), while all individual subtypes maintained superior or equivalent QOL relative to controls. Demographic variables, Whitaker score, and number of surgical interventions did not correlate with differences in QOL. Conclusion: Adult patients previously treated for NSC perceive their quality of life to be high, superior to that of a normative United States sample. Future work will seek to analyze additional patients and better understand the reasons behind these findings. Financial Disclosure: None of the authors has a financial interest in any of the products, devices, or drugs mentioned in this manuscript. Conflicts of Interest: None of the authors listed have any conflicts of interest to report. Funding source: This study did not have any funding sources. IRB: This study was granted approval by the Institutional Review Board for research at the Children's Hospital of Philadelphia. Corresponding author: Scott P. Bartlett, MD, Chief of Plastic and Reconstructive Surgery, The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Colket Translational Research Building, 3501 Civic Center Blvd, 9th floor, Philadelphia, PA 19104, Email: bartletts@email.chop.edu, Telephone: 215-590-2214, Fax: 215-590-2496 ©2018American Society of Plastic Surgeons

Genetics of non-syndromic craniosynostosis

SUMMARY: Occurring once in every 2,000 live births, craniosynostosis is one of the most frequent congenital anomalies encountered by the craniofacial surgeon. Syndromic craniosynostoses account for ~15% of cases and demonstrate Mendelian patterns of inheritance with well-established genetic etiologies1,2, however non-syndromic craniosynostoses (NSC), which account for ~85% of cases2, are genetically heterogeneous and largely unexplored. NSC is sporadic in >95% of affected families3, thus surgeons have suggested for decades that NSC is likely a fluke occurrence. Contrary to this, recent studies have established that genetics underlie a substantial fraction of NSC risk. Given the predominantly sporadic occurrence of disease, parents are often bewildered by the primary occurrence of NSC or even recurrence in their own families and request genetic testing. Existing genetic testing panels are useful when the phenotype strongly resembles a known syndrome, wherein the risk of disease recurrence can be accurately predicted for future offspring of the parents as well as the future offspring of the affected child. The diagnostic utility of existing panels for NSC, however, is extremely low, while these tests are quite costly. Recent genetic studies have identified several novel genes and pathways that cause NSC, providing genetic evidence linking the pathoetiology of syndromic and non-syndromic craniosynostoses, and allowing for genotype-based prediction of risk of recurrence in some non-syndromic families. Based on analysis of exome sequence data from 384 families, we provide recommendations for a new genetic testing protocol for children with NSC, which include testing non-syndromic cases of sagittal, metopic, and coronal craniosynostosis. Financial Disclosure Statement: No authors have any disclosures. Presented at: N/A Correspondence should be addressed to: Andrew T. Timberlake PhD, John A. Persing MD, Section of Plastic and Reconstructive Surgery, Yale School of Medicine, 330 Cedar Street, 3rd Floor Boardman Building, New Haven, CT 06520, Andrew.timberlake@yale.edu, John.persing@yale.edu ©2018American Society of Plastic Surgeons

Acellular Human Dermal Allograft as a Graft for Nasal Septal Perforation Reconstruction

Objective: Nasal septal perforations pose a troubling source of morbidity for patients and a difficult problem for the Otolaryngologist. Multiple surgical techniques have been tried with inconsistent success. Prosthetic nasal buttons also have limitations, including patient intolerance and dissatisfaction. Acellular human dermal allograft, AlloDerm™ (LifeCell Branchburg, NJ) has been previously described as an alternative material for septal perforation repair. We aim to demonstrate objective and subjective outcomes, including quantification of patient's symptoms in septal perforation repair with AlloDerm. Methods: A prospective cohort study of twelve patients with 1-2cm anterior septal perforations that were recruited from a tertiary care practice. Patients with admitted smoking or cocaine use in the previous three months, vascular or granulomatous diseases were excluded. Subjective SNOT-22 scores along with objective nasal endoscopy and acoustic rhinometry measures were collected at baseline and 2, 4, and 12 weeks postoperatively, patients were followed for re-perforation 9-20 months post operatively. Data was normalized to baseline values and analyzed using ANOVA and Bonferroni correction. Results: Successful closure of the septal perforation was obtained in 10/12 patients and confirmed with rigid nasal endoscopy. Nasal symptom scores (SNOT-22) were significantly reduced to 52.8% (95%CI[35.1%-70.5.%];p

New Developments Are Improving Flexor Tendon Repair

Summary: New developments in primary tendon repair over the past decades include stronger core tendon repair techniques, judicious and adequate venting of critical pulleys, followed by a combination of passive and active digital flexion and extension. During repair, core sutures over the tendon should have sufficient suture purchase (no shorter than 0.7 to 1 cm) in each tendon end and must be sufficiently tensioned to resist loosening, forming gaps. Slight or even modest bulkiness in the tendon substance at the repair site is not harmful, though marked bulkiness should always be avoided. To expose the tendon ends and reduce restriction to tendon gliding, the longest annular pulley in the fingers, i.e., the A2 pulley, can be vented partially with an incision over its distal or proximal sheath no longer than 1.5 to 2 cm; the annular pulley over the middle phalanx, i.e., the A4 pulley, can be vented entirely. Surgeons have not observed adverse effects on hand function after judicious and limited venting. The digital extension-flexion test to check the quality of the repair during surgery has become increasingly routine. A wide-awake surgical setting allows patient to actively move the digits. After surgery, surgeons and therapists protect patients in with a short splint, flexible wrist positioning, and are now moving towards out-of-splint freer early active motion. Improved outcomes have been reported over the last decade with minimal or no rupture during postoperative active motion and lower rates of tenolysis. Financial disclosure: None Corresponding author: Jin Bo Tang, MD, Department of Hand Surgery, The Hand Surgery Research Center, Affiliated Hospital of Nantong University, 20 West Temple Road, Nantong 226001, Jiangsu, China; email: jinbotang@yahoo.com., Fax: 513-85110966, Phone: 86-513-85052524 ©2018American Society of Plastic Surgeons

Requirements for successful trachea transplantation; a study in the rabbit model

Background: Although creating a tracheal tube de novo might appear straightforward, the first clinical applications have shown that reconstruction of long-segment tracheal defects remains challenging. In this study, we aimed to refine the baseline requirements of successful trachea transplantation by means of three proof-of-concept models in the rabbit. Methods: In each model, one characteristic of a perfect tracheal transplant was eliminated. The first model was developed to map out the immunological response of vascularized allogenic trachea, transplanted without immunosuppression (n = 6). The second model studied the need for wrapping the transplant with a highly-vascularized flap, and the source of angiogenesis after autologous trachea-transplantation (n = 18). In the third model, we examined the importance of an inner epithelial covering (n = 12). All models were compared to a control group of heterotopically transplanted vascularized autologous tracheae (n = 6). Results: Embedded in an avascular matrix, allogenic chondrocytes were protected from an overt immune response. Orthotopic transplantation without additional external vascular wrap was successful in a well-vascularized environment. Nonetheless, an external vascular source was essential to maintain viability of the construct. Epithelial covering was necessary to prevent secondary healing. Epithelial migration from the anastomoses or graft was not sufficient to cover long-segment defects. Conclusions: These experiments provided ample evidence of the importance of baseline requirements when designing a tracheal-transplant study. This study confirmed that different tracheal cell-types possess different immunological sensitivities. External revascularization, preferably in a two-stage procedure, and fast reepithelialization were both paramount to successful transplantation. Financial disclosure: The authors of this manuscript have no conflicts to disclose as described by Plastic and Reconstructive Surgery. None of the authors has a financial interest in any of the products, devices, or drugs mentioned in this manuscript. Acknowledgements: This work was supported by the predoctoral fellowship of the Research Foundation Flanders (FWO; 11I0413N) of Margot Den Hondt. Corresponding Author: Margot Den Hondt, margot.denhondt@uzleuven.be, +32 494 18 64 83 ©2018American Society of Plastic Surgeons

Assessing technical performance and determining the learning curve in cleft palate surgery using a high fidelity cleft palate simulator

Introduction: Technical skills assessment can provide objective measures of surgical performance. This study assessed technical performance in cleft palate repair using a newly developed assessment tool and high fidelity cleft palate simulator through a longitudinal simulation training exercise. Methods: Three residents performed five and one resident performed nine consecutive endoscopically recorded cleft palate repairs using a cleft palate simulator. Two fellows in pediatric plastic surgery and two expert cleft surgeons also performed recorded simulated repairs. A cleft palate objective structured assessment of technical skill (CLOSATS) scoring scale and end-product score were developed to assess performance. Two blinded cleft surgeons assessed the recordings and the final repairs using the CLOSATS, end-product scores and a previously developed global rating scale. Results: The average procedure specific (CLOSATS), global and end-product scores increased logarithmically after each successive simulation session for the residents. Reliability of the CLOSATS (average item ICC=0.85±0.093) and global ratings (average item ICC=0.91±0.02) amongst the raters was high. Reliability of the end-product assessments was lower (average item ICC=0.66±0.15). Standard setting linear regression using an overall cutoff score of 7 out of 10 corresponded to a pass score for the CLOSATS, and global rating score of 44 (maximum 60) and 23 (maximum 30) respectfully. Using logarithmic best fit curves, 6.3 simulation sessions are required to reach the minimum standard. Conclusions: A high fidelity cleft palate simulator has been developed that improves technical performance in cleft palate repair. The simulator and technical assessment scores can be used to determine performance before operating on patients. Financial disclosure: The cleft palate simulator is available commercially and sold by Simulare Medical Corp. (Toronto, Ontario, Canada). Drs. Podolsky, Fisher, Wong, Drake and Forrest are each shareholders of Simulare Medical Corp. Corresponding author: Dale J Podolsky, Division of Plastic and Reconstructive Surgery, The Hospital for Sick Children, 5430-555 University Avenue, Toronto, Ontario, M5G 1X8. E-mail: dale.podolsky@mail.utoronto.ca. ©2018American Society of Plastic Surgeons

A novel small animal model of irradiated, implant based breast reconstruction

PURPOSE: There is currently a need for a clinically relevant small animal model for irradiated, implant based breast reconstruction. Present models are inadequate in terms of suboptimal location of expander placement and mode of radiation delivery, correlating poorly with the human clinical scenario. We hypothesized that by delivering fractionated radiation and placing an expander under the scalp of the animal, we would achieve histologically analogous soft tissue changes seen in human irradiated, implant based breast reconstruction. METHODS: This study consisted of eleven immunocompetent, hairless rats divided into three groups: an untreated control (n=3), tissue expanded scalps (n=4) and fractionated radiation plus tissue expansion of the scalp (n=4). At the completion of the experiment for each group, skin tissue samples were analyzed histologically for vascularity, epidermal and dermal thickness, and collagen fiber alignment or scar formation. RESULTS: Expanded rat epidermis was significantly thicker and dermis was more vascular than non-expanded skin. We observed a greater degree of collagen fiber alignment in the expanded group compared with non-expanded skin. The combination of radiation and expansion resulted in significant dermal thinning, vascular depletion and increased scar formation compared with expanded skin alone. CONCLUSIONS: We describe a novel small animal model for irradiated, implant based breast reconstruction where histologic analysis shows structural changes in the skin consistent with known effects of radiation and expansion in human skin. This model represents a significant improvement from previous ones and as such, holds the potential to be used to test new therapeutic agents to improve clinical outcomes. Financial Disclosure Statement: The authors have no disclosures. Internal funding from the University of Virginia School of Medicine Research and Development Grant was used for this research. This article has been approved by the Institutional Animal Care and Use Committee at the University of Virginia Acknowledgements: We would like to thank Quan Chen, PhD and Brian Neal, PhD for their participation in this work. Corresponding Author/Reprints: Kant Y. Lin, MD, FACS, Department of Plastic and Reconstructive Surgery, University of Virginia Health System, P.O Box 800376, Charlottesville VA, 22908, Kyl5s@hscmail.mcc.virginia.edu, Phone: 434-924-2528, Fax: 434-924-1333 ©2018American Society of Plastic Surgeons

Targeted muscle reinnervation: considerations for future implementation in adolescents and younger children

Summary: Prosthetic options for patients with proximal upper limb absence are limited. Current above elbow prostheses may restore basic motor functions for crucial activities, but they are cumbersome to operate, lack sensory feedback, and are often abandoned. Targeted muscle reinnervation (TMR) is a novel surgical procedure that enhances the ability of patients with above elbow amputations to intuitively control a myoelectric prosthesis. By transferring multiple severed peripheral nerves to a robust target muscle, TMR restores physiologic continuity and enables more intuitive prosthetic control. Although reports have been limited to adults, TMR has great potential for application in a pediatric population with congenital or acquired proximal upper limb absence. In this review, we describe the rehabilitative challenges of proximal upper limb amputees and outline the objectives, techniques, and outcomes of TMR. We then discuss important considerations for adapting TMR to pediatric patients, including etiology of upper limb absence, central plasticity, timing of prosthesis fitting, role of the family, surgical feasibility, and bioethical aspects. We believe that carefully screened school-aged children and adolescents with bilateral proximal upper limb absence, as well as adolescents with unilateral proximal upper limb absence, should be seriously considered for TMR by an experienced surgical and rehabilitation team. Financial Disclosure Statement: The authors have nothing to disclose. Corresponding Author: Dr. Gregory Borschel, MD, FACS, FAAP , Associate Professor, Division of Plastic & Reconstructive Surgery, Assistant Professor, Institute of Biomaterials and Biomedical Engineering, University of Toronto, The Hospital for Sick Children, 555 University Avenue, Room 5547, Hill Wing, Toronto, ON M5G 1X8, Tel: (416) 813-7654, ext. 228197, Fax: (416) 813-6637, Email: gregory.borschel@sickkids.ca ©2018American Society of Plastic Surgeons

Response Re: Five Step to Internal Mammary Vessel Preparation in Less than Fifteen Minutes

No abstract available

Prophylactic Nipple-Sparing Mastectomy and Direct-to-Implant Reconstruction of the Large and Ptotic Breast: Is Preshaping of the Challenging Breast a Key to Success?

No abstract available

RE: Macro textured breast implants with defined steps to minimize bacterial contamination around the device.

No abstract available

Re: Five Steps to Internal Mammary Vessel Preparation in Less than 15 Minutes

No abstract available

Vertical growth phase as a prognostic factor for sentinel lymph node positivity in thin melanomas: a systematic review and meta-analysis

Background: The 2010 AJCC guidelines recommended consideration of sentinel lymph node (SLN) biopsy for thin melanoma (Breslow thickness IV. Seven studies reported on VGP, which was strongly associated with SLN positivity (odds ratio 4.3; 95% CI, 2.5- 7.7). Conclusion: To date, this is the largest meta-analysis to examine predictors of SLN biopsy positivity in thin melanoma. VGP had a strong association with SLN biopsy positivity, providing support for its inclusion in standardized pathological reporting. The authors have no conflicts of interest to declare ACKNOWLEDGEMENTS: This work was supported in part by a Capital Health Trainee Research Award. The study sponsor had no role in design, collection, analysis or interpretation of the data, and writing the manuscript. The authors thank Kara Thompson and the Research Methods Unit at Dalhousie University for assistance in the meta-analysis and statistics, and Penny Logan from the Capital Health Halifax Infirmary Library for help with the literature search. The authors also wish to thank Dr. Noreen Walsh of the Division of Clinical Dermatology & Cutaneous Science, Department of Pathology, Dalhousie University, for her insightful comments and critique of this manuscript. Corresponding author: Michael Bezuhly, Division of Plastic and Reconstructive Surgery, Dalhousie University, IWK Health Centre, 5850/5980 University Avenue, PO Box 9700, Halifax, Nova Scotia, Canada, B3K 6R8; Tel: +1-902-470-8168, Fax: +1-902-470-7939; E-mail: mbezuhly@dal.ca ©2018American Society of Plastic Surgeons

Prophylactic Nipple-Sparing Mastectomy and Direct-to-Implant Reconstruction of the Large and Ptotic Breast: Is Preshaping of the Challenging Breast a Key to Success? – Reply to Dr. Bonomi

No abstract available

Utilizing “Black Bone” MRI in Craniofacial Virtual Surgical Planning: A Comparative Cadaver Study

Background: The use of MRI for virtual surgical planning has not yet been described. In the US, over 600,000 CT scans are performed on children annually, who are at higher risk for developing cancer caused by ionizing radiation compared to adults. The aim of this study is to demonstrate that 3D printed craniofacial surgical guides created from Black Bone MRI are comparable in accuracy to those created from CT scans. Methods: A mock craniosynostosis surgery translocating four calvarial segments was virtually planned and performed in ten cadavers. For five specimens, this planning was performed and 3D-printed guides created using Black Bone MRI scans. Five other specimens underwent standard planning using CT scans. The reconstructed skulls underwent CT scans and 3D-reconstruction. Surgical accuracy was then compared to the virtually-planned surgery. Results: The pre-op Black Bone MRI scan had an average deviation from the pre-op CT scan of 1.37mm. There was no statistically significant difference in the accuracy of guide fit between MRI versus CT-created guides. Average deviation of post-operative anatomy from pre-operative plan was within 1.5mm for both MRI and CT-created guides, with no statistically significant difference in accuracy between the two methods. Planned versus postoperative skull volume was not statistically significant different when MRI versus CT was used. Conclusion: This study demonstrates that virtual surgical planning and 3D surgical guide creation for craniofacial surgery can be performed using Black Bone MRI with comparable accuracy to CT scans. This could dramatically reduce radiation exposure for pediatric and adult craniofacial reconstruction patients. Financial Disclosure Statement: There are no financial disclosures to report. Presented at: Mayo Clinic Chang Gung Symposium in Reconstructive Surgery, Munich, Germany, October 21, 2016 Acknowledgments: This work supported by a generous gift from the Tribuno Family. We would like to thank Kyle Iverson from Mayo Clinic for help with MRI scanning, and Shelby Marks, Cyndi Hoffmeister, and Katie Weimer from 3D Systems for their support and help with scan analysis, segmentation, guide design, and postoperative analysis. We would like to acknowledge the Mayo Clinic Anatomy Department, especially Shaun Heath, Karen Mills, Andy Wilhorn, and Terry Regnier, as well as the noble generosity of the Mayo Clinic's whole body donors whose altruistic gift made this study possible. Corresponding author: Samir Mardini, MD, Professor of Surgery, Mayo Clinic College of Medicine, Program Director, Plastic Surgery, Mayo Clinic, Rochester, MN, Email: mardini.samir@mayo.edu ©2018American Society of Plastic Surgeons

Skin Research and Technology, Ahead of Print.

Skin Research and Technology, Ahead of Print.

Skin Research and Technology, Ahead of Print.

Skin Research and Technology, Ahead of Print.

Celulitis cervical odontógena

Publication date: Available online 24 March 2018
Source:Actas Dermo-Sifiliográficas
Author(s): P. García-Montero, G. González-Pérez, N. Blázquez-Sánchez

Riesgo fotocarcinogénico asociado a la fototerapia ultravioleta B de banda estrecha

Publication date: Available online 24 March 2018
Source:Actas Dermo-Sifiliográficas
Author(s): J. Aguilera

Mejorando en la calidad de vida de pacientes con queratosis actínicas

Publication date: Available online 24 March 2018
Source:Actas Dermo-Sifiliográficas
Author(s): N. Blázquez-Sánchez