Dorsal Augmentation With the Dorsal Extension Spreader Graft.

Spreader grafts traditionally are used to improve airflow through opening the internal nasal valve, as well as enhance the cosmetic appearance of the nose. The graft's versatility proves useful in surgical correction of several nasal profiles by enhancing dorsal aesthetic lines and by maintenance of the nasal pyramid at midline. The authors describe a modified spreader graft that adds an additional benefit of dorsal augmentation in patients with underprojected or saddle noses. This technique utilizes harvested septal cartilage and fixation of the graft that extends beyond the septal and upper lateral cartilage dorsal border to improve nasal dorsum height. Patients who received this operative technique by the senior author were identified and their operative courses and surgical outcomes were analyzed. Case examples are provided to illustrate indications and outcomes. This grafting technique allows for improved functionality, defined dorsal aesthetic lines, changes in nasal width, and a more balanced profile in patients with underprojected noses.

Methods of Sentinel Lymph Node Identification in Auricular Melanoma.

Sentinel lymph node biopsy is used to evaluate for micrometastasis in auricular melanoma. However, lymphatic drainage patterns of the ear are not well defined and predicting the location of sentinel nodes can be difficult. The goal of this study was to define the lymphatic drainage patterns of the ear and to compare multiple modalities of sentinel node identification. METHODS: A retrospective review of a prospectively maintained database evaluated 80 patients with auricular melanoma who underwent sentinel lymph node biopsy by comparing preoperative imaging with intraoperative identification of sentinel nodes. Patients were placed into two cohorts, based on the modality of preoperative imaging: (1) planar lymphoscintigraphy only (n = 63) and (2) single-photon emission computerized tomography combined with computerized tomography (SPECT-CT) only (n = 17). Sites of preoperative mapping and sites of intraoperative identification were recorded as parotid/preauricular, mastoid/postauricular, and/or cervical. RESULTS: In patients that underwent planar lymphoscintigraphy preoperatively (n = 63), significantly more sentinel nodes were identified intraoperatively than were mapped preoperatively in both the parotid/preauricular (P = 0.0017) and mastoid/postauricular (P = 0.0047) regions. Thirty-two nodes were identified intraoperatively that were not mapped preoperatively in the planar lymphoscintigraphy group (n = 63), two of which were positive for micrometastatic disease. In contrast, there were no discrepancies between preoperative mapping and intraoperative identification of sentinel nodes in the SPECT-CT group (n = 17). CONCLUSIONS: SPECT-CT is more accurate than planar lymphoscintigraphy for the preoperative identification of draining sentinel lymph nodes in auricular melanoma. If SPECT-CT is not available, planar lymphoscintigraphy can also be used safely, but careful intraoperative evaluation, even in basins not mapped by lymphoscintigraphy, must be performed to avoid missed sentinel nodes.

Characteristics of the Superficial Circumflex Iliac Artery Perforator Flap in a Western Population and a Practice Approach for Free Flap Reconstruction.

BACKGROUND: There has been increasing interest in the superficial circumflex iliac artery perforator (SCIP) flap as a source of thin, pliable soft tissue combined with a favorable donor site. Despite several clinical series from Asia, barriers to adoption include reluctance to perform submillimeter "supermicrosurgery" and the effect of body habitus on flap feasibility. The purpose of this study is to distinguish vascular anatomic characteristics of the SCIP flap in a North American population. METHODS: Computed tomography angiography was examined in 84 flaps in healthy prospective renal donor patients from a radiographic database. Descriptive statistics as well as linear regression comparing variables to body mass index (BMI) were performed. RESULTS: Mean BMI was 27.1 ± 3.5 kg/m2, while the mean patient age was 47.8 ± 11.4 years. The superficial circumflex iliac artery (SCIA) originated from the common femoral artery in 92% cases, with remainder originating from the profunda femoris. The mean vessel diameter was 1.85 mm at source vessel origin. Distance from skin to source vessel averaged 30.7 mm. Suprascarpal subcutaneous thickness averaged 16.5 mm. The mean distance from Scarpa's fascia to vessel origin was 14.1 mm. Direct three-dimensional distance from vessel origin to pubic tubercle was 50.2 mm. A medial and lateral perforator split off of the SCIA was observed in 38 cases (45%). Significant differences were shown when comparing BMI to skin to source vessel distance (p < 0.001), suprascarpal subcutaneous fat thickness (p < 0.001), and fascial distance to vessel origin (p < 0.001). BMI did not significantly affect vessel diameter. CONCLUSION: Despite a significantly higher BMI than many previously published cohorts, the SCIP remains an excellent source of thin and pliable tissue. When dissected closer to the source vessel, a vessel caliber of nearly 2 mm can be achieved, which may obviate the need for "supermicrosurgery" in this population.

The Hand Surgeon Consultation Improves Patient Knowledge in a Hand Surgery Mission to Honduras.

BACKGROUND: The purpose of this study was to assess impact of the surgeon consultation and informed consent process on patient education in an international hand surgery mission compared with a US academic hand surgery practice. These two groups were selected to evaluate communication difficulties in a surgical mission setting compared with standard of care in a high-income country. METHODS: A multi-part survey was administered to patients presenting to a hand surgery mission during March 2012 and new patients of a university hand center in a 3-month period during 2011. Surveys were administered prior to and following surgeon consultation with one fellowship-trained hand surgeon. The survey assessed knowledge of basic hand anatomy, physiology, disease, individual diagnosis, and surgical risks. RESULTS: 71 patients participated in the study (university n=36, mission n=35). Pre-consultation quiz score averaged 58% in the university group versus 27% in the mission group. Post-consultation quiz scores averaged 62% in the university group versus 40% in the mission group. Only the mission group's quiz score increase was statistically significant. 93% of the university group reported learning about their condition and diagnosis, but only 40% demonstrated correct insight into their diagnosis. In the mission group, 73% reported learning about their condition and diagnosis while 53% demonstrated correct insight into their diagnosis. Although all consultations involved discussion of surgical risks, only 62% of the university group and 52% of the mission group recalled discussing surgical risks. CONCLUSIONS: The hand surgeon consultation was more effective in improving hand knowledge in the surgery mission group compared to in a university hand practice. This suggests that the surgeon consultation should be pursued despite communication barriers in surgical missions. However, the discrepancy between patient perception of knowledge gains and correct insight into diagnosis, and the deficit of patient retention of surgical risks need to be improved.

Cleft Palate Repair Using a Double Opposing Z-Plasty.

Cleft palate is a common congenital defect with several described surgical repairs. The most successful treatment modality remains a controversy. The goals of repair focus on achievement of normal speech and optimizing velopharyngeal function while minimizing both fistula formation and facial growth restriction. In this video, the authors demonstrate use of the double opposing Z-plasty technique in the repair of a Veau II type cleft palate. The video demonstrates the marking, incisions, dissection, and repair of the cleft. It also examines the use of von Langenbeck-type relaxing incisions and demonstrates a specific approach to the repair of this particular cleft. The authors believe that the Furlow double opposing Z-plasty with the von Langenbeck relaxing incision can provide the best postoperative outcome by combining the benefits of each individual operation. The Z-plasty technique works to correct the aberrant muscle of the soft palate while increasing the length of the palate. The authors believe that this results in better velopharyngeal function.

Cleft Le Fort I Osteotomy: A Video Presentation.

In this video, we present a single piece Le Fort I osteotomy with bone graft in a patient with a unilateral cleft lip and palate. Maxillary osteotomies in the cleft patient can be challenging because of the presence of scar, palatal or alveolar fistulae, compromised teeth, and vascularization of the segments. The video demonstrates our current approach and technique. The authors particularly want to highlight aspects of the approach, such as the incision, exposure, osteotomies, mobilization, splints, and plating. The associated manuscript discusses the depicted video as well as the blood supply to the maxilla, and postoperative patient care.

Resection of oligometastatic lung cancer to the pancreas may yield a survival benefit in select patients--a systematic review.

OBJECTIVES: To conduct a systematic review of the existing literature regarding surgical therapy for oligometastatic lung cancer to the pancreas. METHODS: Data was collected on patients with singular pancreatic metastases from lung cancer from papers published between January 1970 and June 2014. This was performed following the Preferred Reporting Items for Systematic reviews and Meta-analysis (PRISMA) guidelines. Kaplan-Meier and Cox Regression analyses were then used to determine and compare survival. RESULTS: There were 27 papers that fulfilled the search criteria, from which data on 32 patients was collected. Non-small cell lung cancer (NSCLC) was the most prevalent type of primary lung malignancy, and metachronous presentations of metastases were most common. Lesions were most frequently located in the pancreatic head and consequently the most common curative intent metastasectomy was pancreaticoduodenectomy. There was a statistically significant survival benefit for patients whose metastasis were discovered incidentally by surveillance CT as opposed to those whose metastasis were discovered during a work up for new somatic complaints (p = 0.024). The overall median survival for patients undergoing curative intent resection was 29 months, with 2-year and 5-year survivals of 65% and 21% respectively. Palliative surgery or medical only management was associated with a median survival of 8 months and 2-year and 5-year survivals of 25% and 8% respectively. CONCLUSIONS: Curative intent resection of isolated pancreatic metastasis from lung cancer may be beneficial in a select group of patients.

Characteristics of patients with injury secondary to smoking on home oxygen therapy transferred intubated to a burn center.

BACKGROUND: The aim of this study was to compare outcomes of patients who sustained burn and ostensible inhalation injuries while on home oxygen therapy with those suffering equivalent injuries via other mechanisms. STUDY DESIGN: Between December 2002 and January 2006, 109 burn patients were transferred to our center intubated. Their charts were retrospectively reviewed. Patients who sustained injuries while on home oxygen therapy were age and total body surface area matched to patients with inhalation and burn injuries secondary to other mechanisms. RESULTS: Fourteen of 109 patients were injured while smoking on home oxygen therapy (15.26%). All 14 had COPD. Mean age was 63 years (range 53 to 77 years) and average total body surface area burned was 4% (range 0% to 10%). Charges for the 14 hospitalizations totaled $1,097,860 ($8,003 to $284,835; mean $78,418 per admission). Average time to extubation was 5.7 ± 10.2 days and average length of stay was 11.4 ± 15.2 days. No significant differences in the average time to extubation, length of stay, cost of hospitalization, or clinical signs of inhalation injury (ie, soot and edema in the pharynx) were noted between our series and the control group. CONCLUSIONS: Injury secondary to smoking on home oxygen therapy is a perennial problem, and guidelines for prescribing home oxygen therapy for smokers should be reassessed. Despite underlying lung disease, patients in our series did as well as patients without COPD who sustained similar injuries.