Single Oral Z-Plasty: A Clinical Validation of a Technique for Palatal Lengthening in Primary and Secondary Cleft Palate Repair.

BACKGROUND: In cleft palate repair, palate length is associated with improved speech outcomes. Although direct closure offers poor palatal lengthening, use of two opposing Z-plasties may reorient palatal musculature and lengthen the velum. The authors previously described a novel overlapping intravelar veloplasty to achieve longitudinal closure of the nasal mucosa with a single oral Z-plasty (1ZP), lengthening the palate in cadaver studies. This study aims to corroborate this finding in clinical cases. METHODS: A retrospective comparative study of patients with a cleft palate was conducted. Patients underwent cleft palate closure with 1ZP or intravelar veloplasty with straight-line closure. Preoperative and postoperative measurements of the palate along four dimensions were recorded. Analysis was conducted on preoperative and postoperative measurements within and between groups using the Mann-Whitney-Wilcoxon or chi-square test. RESULTS: Eighty-five patients were included (1ZP, n = 65; straight-line closure, n = 20). 1ZP increased soft palate length (SPL) by 33% ( P < 0.001) and total palate length (TPL) by 10% ( P < 0.001). Primary 1ZP increased SPL by 33% ( P < 0.001) and TPL by 10% ( P < 0.001). Secondary 1ZP increased SPL by 28% ( P < 0.001) and TPL by 8% ( P < 0.001). When comparing between primary and secondary 1ZP, 1ZP was equal with regard to percentage lengthening in SPL ( P > 0.9) and TPL ( P > 0.3). When compared with straight-line closure, 1ZP showed superior percentage lengthening in SPL ( P < 0.001) and TPL ( P = 0.038). CONCLUSIONS: 1ZP results in a statistically significant increase in palate length in both primary and secondary cleft palate repair. This technique provides an effective alternative in patients for whom 2ZP is not feasible. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

A Cost-effective, 3D Printed Simulation Model Facilitates Learning of Bilobed and Banner Flaps for Mohs Nasal Reconstruction: A Pilot Study.

SUMMARY: Flap design for Mohs reconstruction is a complex 3-dimensional decision-making process. Simulation offers trainees the chance to practice techniques safely, prior to opportunities in the operating room. To aide in teaching, we developed a high-fidelity, cost-effective model of the face using three-dimensional (3D) printing to simulate flap reconstruction following Mohs surgery. We describe the design of this model and its impact on the comfort and proficiency of trainees.

Lateral Canthotomy Revisited: A Refined Surgical Approach for Orbital Access.

The transconjunctival incision is a common and effective approach for establishing surgical exposure to the orbital floor. When access to the lateral orbit is also required, this incision may be extended by an accompanying lateral canthotomy, which releases the tarsal plates from the conjunctiva. Although this approach broadens surgical access through a simple extension, it is often remarked for unpredictable healing patterns and negative aesthetic sequelae, such as rounding of the lateral canthal angle. Traditionally, lateral canthotomy is performed by a transverse incision through a natural skin crease of the lateral palpebral fissure. Herein, we discuss our experience with a less common approach to lateral canthotomy, in which only the inferior crus of the lateral canthal tendon is divided. This approach limits manipulation of delicate orbital anatomy and aims to minimize unsightly scarring while still affording excellent visualization of the lateral orbit and orbital floor.

Operative technique for a combined transcaruncular-transconjunctival approach to double-walled orbital fractures.

Double-walled orbital fractures involving the floor and medial wall are commonly encountered in instances of significant midface trauma. Operative intervention is indicated in the presence of persistent diplopia, significant enophthalmos, or muscle entrapment. Surgical repair of these injuries may be challenging due to large fracture sizes or loss of bony supports. The transconjunctival and transcaruncular approaches have been popularized to reconstruct isolated floor and medial wall fractures, respectively. However, surgical approaches for fractures involving both these walls have not been well described in the literature. In this technical note, we detail a combined transcaruncular-transconjunctival approach that is safe, effective, and aesthetically sensitive.

Plastic Surgery Closure of Complex Spinal Wounds.

Wound breakdown and infection are common complications after complex spine surgery and may occur in up to 40% of high-risk patients. These are challenging scenarios which can result in a prolonged hospital stay, revision surgery, and elevated costs. Reconstructive specialists can do prophylactic closures for high-risk groups to potentially reduce the risk of developing a wound complication. These plastic surgery techniques often involve multilayered closure, with the addition of local muscle and/or fasciocutaneous flaps. The goal of this study was to review the literature for risks associated with wound complications, identification of high-risk patients, and the advantages of using plastic surgery techniques. In addition, we elaborate on the multilayered and flap closure technique for complex spine surgery which is done at our institution.

The Role of Antibiotics in Nasal Fractures after Closed Reduction.

Nasal fractures represent the most common fracture in facial trauma. The role of prophylactic antibiotics in these injuries is debated, given low infection rates and demonstrated risks of antibiotics. We studied the isolated effect of prophylactic antibiotics on infection rate in patients with nasal fracture after closed reduction. Methods: Retrospective cohort study of a prospectively maintained facial trauma database was conducted. Demographics, comorbidities, fracture classifications, and management of patients who received antibiotics at the time of closed nasal reduction were compared against those who did not receive antibiotics. Infection rates between groups were analyzed. Multivariate analysis was conducted to control for confounding variables. Qualitative analysis was performed for patients who experienced infection following nasal fracture. Results: A total of 282 patients met inclusion criteria (n = 144, antibiotic; n = 138, nonantibiotic). Six patients experienced infection. There was no difference in infection rate between antibiotic and nonantibiotic groups (2.0% versus 2.2%; P = 0.90). On multivariate regression, antibiotics did not significantly decrease odds of infection (OR 1.7 [0.17-13.6]; P = 0.64). Moreover, patients with open nasal fractures did not have significantly higher odds of infection (OR 1.9 [0.08-20.8]; P = 0.64). Similarly, increasing severity of injury based on Rohrich classification did not significantly impact odds of infection (OR 0.68 [0.23-1.9]; P = 0.46). All six infections were managed at the bedside, with zero infections following operating room management (P = 0.32). Conclusions: Prophylactic antibiotics do not decrease infection rates following nasal fractures managed by closed reduction. Bedside management may be a risk factor for the development of infection; however, this finding requires further evaluation.

Taming the Tongue: The Surgical Approach to Macroglossia.

While traditionally in the realm of otorhinolaryngology or oral maxillofacial surgery, conditions involving the tongue may also be managed by plastic surgeons. The authors present an unusual case of acquired macroglossia resulting from angiotensin-converting enzyme inhibitor-induced angioedema and review the literature to discuss its surgical management from a plastic surgery perspective. A 62-year-old female suffered severe airway obstruction, respiratory arrest, and anoxic brain injury from angioedema-associated macroglossia. After tracheostomy, the patient was managed nonsurgically, with bite wound care and medications to minimize angioedema to marginal effect. Ultimately, a partial glossectomy was planned. The edematous distal tongue was amputated and closed primarily. On postoperative day 2, she was successfully weaned off mechanical ventilation and no longer suffers trauma from tongue biting. The simple anterior tongue resection described in this paper was an appropriate approach for our patient. More research is needed to guide plastic surgeons in an optimal approach for clinical scenarios.

Comparing diagnosis of midfacial fractures by radiologists and plastic surgeons.

BACKGROUND: Clinicians who manage facial fractures often rely on radiologist interpretations to help with assessment and management. Among treating physicians, facial fractures are categorized into clinically relevant patterns of injury. On the other hand, while radiologists are unsurpassed at identifying individual breaks in the bone, larger fracture patterns are not always conveyed in radiology reports. PURPOSE: This study aims to assess the frequency with which the terminology describing midfacial fracture patterns is concordant among radiologists and treating clinicians. METHODS: The authors identified patients with different patterns of midfacial injury including Le Fort I, Le Fort II, Le Fort III, naso-orbito-ethmoid (NOE), and zygomaticomaxillary complex (ZMC) fractures. Plastic surgery consult notes and radiological imaging reports were reviewed for concordance in documentation of injury patterns. Identification of individual fractures consistent with the diagnosed fracture pattern was also recorded. RESULTS: Radiologists were noted to be highly successful in describing individual fractures of the facial bones, identifying at least two defining components of a fracture pattern in 96% of Le Fort, 88% of NOE, and 94% of ZMC injuries. However, when injury patterns were considered, only 32% of Le Fort, 28% of ZMC, and 6% of NOE fractures were explicitly identified in radiology reports. CONCLUSIONS: Radiologists are highly skilled in discerning individual fractures in facial trauma cases. However, less reliability was seen in the identification of fracture patterns in midfacial injury, with particular weaknesses in descriptions of NOE and ZMC fractures. This data suggests that greater focus on patterns of midfacial injury would improve the clinical applicability of radiological reports.

Anaplastic Carcinoma of the Pancreas: Clinical and Morphological Characteristics.

Anaplastic pancreatic carcinoma is a very rare histological subtype of pancreatic cancer, which is characterized by a more aggressive course than for conventional ductal adenocarcinoma. In this article, we consider the features of the clinical course, the difficulties of diagnosis in connection with the absence of pathognomonic signs of pancreatic cancer, and the morphological picture of this disease in a patient 60 years of age. This clinical case clearly demonstrates the complexities of the pancreatic carcinoma diagnosis, fast disease progression, and extremely unfavorable prognosis. It is important for clinicians to remember that this pathology often has a subclinical course, and the oncomarker levels are not always true.

The potassium channel Kcne3 is a VEGFA-inducible gene selectively expressed by vascular endothelial tip cells.

Angiogenesis is largely driven by motile endothelial tip-cells capable of invading avascular tissue domains and enabling new vessel formation. Highly responsive to Vascular Endothelial Growth-Factor-A (VEGFA), endothelial tip-cells also suppress angiogenic sprouting in adjacent stalk cells, and thus have been a primary therapeutic focus in addressing neovascular pathologies. Surprisingly, however, there remains a paucity of specific endothelial tip-cell markers. Here, we employ transcriptional profiling and a lacZ reporter allele to identify Kcne3 as an early and selective endothelial tip-cell marker in multiple angiogenic contexts. In development, Kcne3 expression initiates during early phases of angiogenesis (E9) and remains specific to endothelial tip-cells, often adjacent to regions expressing VEGFA. Consistently, Kcne3 activation is highly responsive to exogenous VEGFA but maintains tip-cell specificity throughout normal retinal angiogenesis. We also demonstrate endothelial tip-cell selectivity of Kcne3 in several injury and tumor models. Together, our data show that Kcne3 is a unique marker of sprouting angiogenic tip-cells and offers new opportunities for investigating and targeting this cell type.