Utility of Regional Maxillary Nerve Blocks in Improving Cleft Palate Postoperative Outcomes.

BACKGROUND: Palatoplasty procedures used to repair cleft palates are commonly associated with limiting postoperative pain. Regional anesthetic blocks have been utilized to improve pain outcomes and decrease opioid intake, yet additional data is needed to fully explore its utility in this setting. OBJECTIVE: To explore whether ultrasound-guided suprazygomatic maxillary blocks (SMB) improve postoperative pain, postoperative opioid use, time to oral feeding, and length of stay compared with a palatal field block in cleft palate repair. METHODS: In this retrospective chart review, 47 patients aged 9 to 25 months who underwent cleft palate repair between 2013 and 2020 were allocated into 2 groups: a control group where patients received only palatal local anesthetic in a field block fashion (N=29), and Maxillary block group who received ultrasound-guided SMB (N=18). Patients were matched by age and cleft Veau type. The primary outcomes were total postoperative morphine equivalent consumption, average pain scores, length of stay, and time to first oral feed. RESULTS: Comparing field block versus SMB groups, there was not a statistical difference in the overall dose of postoperative morphine equivalent opioid administration (11.71 vs. 13.36 mg; P =0.483), average pain scores (5.78 vs. 5.27; P =0.194), time to first oral feed [17.21 vs. 14.48 h; P =0.407, 95% CI: (-3.85, 9.32)] or length of stay ( P =0.292). CONCLUSION: The use of SMBs did not demonstrate a difference in the postoperative outcomes evaluated by this study. Further study is needed to define its utility in cleft palate repair.

Long-term Outcomes After Gender-Affirming Surgery: 40-Year Follow-up Study.

BACKGROUND: Gender dysphoria is a condition that often leads to significant patient morbidity and mortality. Although gender-affirming surgery (GAS) has been offered for more than half a century with clear significant short-term improvement in patient well-being, few studies have evaluated the long-term durability of these outcomes. METHODS: Chart review identified 97 patients who were seen for gender dysphoria at a tertiary care center from 1970 to 1990 with comprehensive preoperative evaluations. These evaluations were used to generate a matched follow-up survey regarding their GAS, appearance, and mental/social health for standardized outcome measures. Of 97 patients, 15 agreed to participate in the phone interview and survey. Preoperative and postoperative body congruency score, mental health status, surgical outcomes, and patient satisfaction were compared. RESULTS: Both transmasculine and transfeminine groups were more satisfied with their body postoperatively with significantly less dysphoria. Body congruency score for chest, body hair, and voice improved significantly in 40 years' postoperative settings, with average scores ranging from 84.2 to 96.2. Body congruency scores for genitals ranged from 67.5 to 79 with free flap phalloplasty showing highest scores. Long-term overall body congruency score was 89.6. Improved mental health outcomes persisted following surgery with significantly reduced suicidal ideation and reported resolution of any mental health comorbidity secondary to gender dysphoria. CONCLUSION: Gender-affirming surgery is a durable treatment that improves overall patient well-being. High patient satisfaction, improved dysphoria, and reduced mental health comorbidities persist decades after GAS without any reported patient regret.

Quantifying Burn Injury-Related Disability and Quality of Life in the Developing World: A Primer for Patient-Centered Resource Allocation.

BACKGROUND: Untreated or undertreated burns are commonly encountered by plastic surgeons on medical trips in India and represent a major cause of disability. We sought to utilize validated patient-reported outcomes instruments to identify the patient population with the greatest burn-related disability in order to appropriately allocate plastic surgery resources to those in greatest need. METHODS: The Quick Disability of the Arm, Shoulder, and Hand, RAND 36-Item Short Form Health Survey, and Burn-Specific Health Scale-Revised, Brief, and Adapted questionnaires were administered via an interpreter during a plastic surgery trip to Jharkhand, India, in January 2018. Demographics, comorbidities, and burn-specific history were recorded. RESULTS: Twenty-eight postburn patients were surveyed (mean age, 17.0 ± 9.2 years; male:female ratio, 1:2.5). Mean time from injury was 4.74 years. No patient had received formal, primary burn care. Mechanism of injury: flame (39%), oil (32%), scalding water (14%), and other (14%). Fifty-four percent were extremity burns; 25%, facial; and 18%, neck burns. The Burn-Specific Health Scale-Revised, Brief, and Adapted demonstrated that the most significantly impacted domains for all patients were body image and skin sensitivity, with more than 80% of patients complaining of issues with skin sensitivity. In addition, children (aged <18 years) had diminished body image domain scores. RAND SF-36 scores were lowest in the energy (73.1 ± 25.0) and general health (76.5 ± 13.8) domains, and females with extremity burns demonstrated statistically significant decreases in their physical limitation domain scores (85.9 ± 17.3, P < 0.05). Females with extremity burns also had statistically significant lower scores in the energy domain (64.09 ± 25.75) as compared with their male counterparts with extremity burns (100 ± 0, P = 0.045). In general, females scored lower than did males in multiple domains, and those results reached statistical significance in the energy (65.9 ± 24.6 vs 93.6 ± 10.9), emotional (77.2 ± 21.5 vs 95.4 ± 11.2), and general health domains (71.1 ± 11.9 vs 90.0 ± 7.5) with P < 0.05. Children demonstrated significantly diminished scores in the emotional (75.5 ± 24.6) and general health (79.1 ± 11.8) domains. CONCLUSION: These data demonstrate the significant impact on quality of life that untreated burns have in this population. Male and female children with extremity burns and adult women with extremity burns were most significantly affected in multiple domains. Consequently, children and adult women with extremity burns appear to be the patient cohort with the greatest opportunity to impact their quality of life. These data may be utilized to improve patient triage and resource allocation for future surgical trips but could also be of significant benefit to internal health agencies and ministries for the same purpose.

The Average Size and Position of the Umbilicus in Young Men and Women.

INTRODUCTION: Abdominoplasty was the third most common cosmetic surgical procedure in 2012. The umbilicus is transposed within the abdominal skin flap during this procedure. Few studies address the size and location of the umbilicus with precise measurements as well as those that do report on a heterogeneous population. The goal of our study was to determine the average size and position of the ideal umbilicus by limiting the study to young men and women of normal body habitus. METHODS: Subjects were recruited in a University of Virginia Institutional Review Board-approved study. Demographics of the subjects were recorded. Each subject's umbilicus was assessed for height, width, and position relative to existing landmarks. RESULTS: Eighty subjects met the inclusion criteria: 43 women and 37 men. Most of the subjects were white (72.5%). The mean ± SD BMI was 22.4 ± 2.5 kg/m. The mean ± SD height and width of the umbilicus was 2.1 ± 0.6 cm and 2.3 ± 0.7 cm, respectively. The umbilicus was located at a mean ± SD of -0.7 ± 1.3 cm in relation to the iliac crest (crest at zero). There were differences seen in the position between men and women. There were no statistical differences in measurements between the races. CONCLUSION: Our study serves as a guide for umbilical positioning with mean measurements for men and women, and categorized by sex and race.

Paradoxical Adipose Hyperplasia and Cellular Effects After Cryolipolysis: A Case Report.

Cryolipolysis is a noninvasive technique for the reduction of subcutaneous adipose tissue by controlled, localized cooling, causing adipocyte apoptosis, reportedly without affecting surrounding tissue. Although cryolipolysis has a low incidence of adverse side effects 33 cases of paradoxical adipose hyperplasia (PAH) have been reported and the precise pathogenesis of PAH is poorly understood. This present case study of PAH aims to characterize the pathological changes in the adipose tissue of PAH on a cellular level by using multiple different assays [hematoxy lin and eosin staining, LIVE/DEAD staining, BODIPY(®) 558/568 C12 (4,4-Difluoro-5-(2-Thienyl)-4-Bora-3a,4a-Diaza-s-Indacene-3-dodecanoic acid) staining]. to identify the underlying mechanism of PAH and reduce the prevalence of PAH in the future. Tissue with PAH had fewer viable cells, significantly decreased quantities of interstitial cells (p = 0.04), and fewer vessels per adipose tissue area when compared to the control tissue. Adipocytes from the PAH tissue were on average slightly smaller than the control adipocytes. Adipocytes of PAH tissue had irregularly contoured edges when compared to the smooth, round edges of the control tissue. These findings from a neutral third party are contrary to prior reports from the inventors of this technique regarding effects of cryolipolysis on both the microvasculature and interstitial cells in adipose tissue. Our use of different assays to compare cryolipolysis-treated PAH tissue with untreated adipose tissue in the same patient showed adipose tissue that developed PAH was hypocellular and hypovascular. Contrary to prior reports from the inventors, cryolipolysis may cause vessel loss, which could lead to ischemia and/or hypoxia that further contributes to adipocyte death. LEVEL OF EVIDENCE 5: Risk.

Transverse mucoperiosteal flap inset by rotation for cleft palate repair: technique and outcomes.

INTRODUCTION: Cleft palate is a relatively common deformity with various techniques described for its repair. Most techniques address the hard palate portion of the cleft with bilateral mucoperiosteal flaps transposed to the midline. This results in superimposed, linear closure layers directly over the cleft and may predispose the repair to oronasal fistula formation. This report details an alternative technique of flap rotation with an outcome analysis. METHODS: A retrospective chart analysis was performed of all patients having undergone primary palatoplasty for cleft palate. Demographics and cleft Veau type were recorded. Postoperative speech outcomes were assessed by standardized speech evaluation performed by 2 speech language pathologists. The presence and location of oronasal fistulae was assessed and recorded by the surgeon and speech language pathologists in follow-up evaluations. RESULTS: The study revealed an overall incidence of velopharyngeal insufficiency of 5.7% using this surgical technique. It also revealed a fistula rate of 8.6%. Secondary surgery has been successful in those patients in which it was indicated. Eleven (31%) patients were diagnosed with Robin sequence. CONCLUSIONS: This technique demonstrates excellent early outcomes in a difficult subset of cleft patients including a high proportion of those with Pierre Robin sequence. The technique addresses the inherent disadvantages to a linear closure over the bony cleft. The variability in its design provides the surgeon another option for correction of this deformity.

Treatment of postsurgical temporal hollowing with high-density porous polyethylene.

Temporal hollowing is most frequently an acquired defect and can be caused by a volumetric deficiency of bone, soft tissue, or both. Given high-density porous polyethylene's ease of use, customizability, long-term strength and resiliency, and successful application in other areas of the craniofacial skeleton, the authors have used it as the first-line material for reconstruction of temporal hollowing. Herein, we present 4 illustrative cases demonstrating this technique and further describe subtypes of the temporal defect with appropriate means of reconstruction. The cases were reviewed for comorbidities, intraoperative details, and the postoperative course. There were no complications, and all patients were pleased with their final result. High-density porous polyethylene is a safe, well-studied, and easily handled biomaterial that is useful for the treatment of temporal hollowing.

Achieving Clinical Success in Nonsedated Velopharyngeal MRI: Insights for Optimal Data Quality & Effective Patient Selection.

BACKGROUND: The ability of MRI for in vivo visualization of the velopharyngeal (VP) musculature makes it the only imaging modality for this purpose. This underscores a need for exploration into clinical translation of this imaging modality on craniofacial teams. The purpose of this study was to assess outcomes of a clinically feasible VP MRI protocol and describe the ideal patient population for utilization of this imaging protocol. METHODS: Sixty children (2-12 years) with velopharyngeal insufficiency (VPI) underwent a nonsedated, child-friendly MRI protocol. No exclusions based on syndromic conditions were made. Logistic regression assessed predictors of VP MRI success and multinomial logistic regression evaluated factors influencing quality of anatomic data. RESULTS: An 85% overall success rate was achieved, including children as young as two and those with syndromic diagnoses. Stratifying by age revealed a 97.5% success rate in children ages four and up. The regression model [χ2(5) = 37.443, p < 0.001] explained 81.4% of success rate variance, correctly classifying 93.3% of cases. Increased age significantly predicted success (p=0.046), while sex and syndromic conditions did not. Multinomial regression identified preparatory materials (p=0.011) and audio/video during the scan (p=0.024) as predictors for improved image quality. CONCLUSIONS: Implementation of VP MRI is feasible for a broad population of children with VPI, including those with concomitant syndromic diagnoses. Quality is improved by incorporating pre-scan preparation and audio/visual stimuli during scans. This underscores the potential of VP MRI as a valuable tool in clinical settings, especially for pre-surgical assessments.

The use of an acellular dermal matrix "sandwich" for the successful treatment of a persistent cranial cerebrospinal fluid fistula.

Cerebrospinal fluid (CSF) fistulae are problematic because of the high risk of meningitis and other infectious complications, as well as the potential for critically delaying chemotherapy in cases associated with malignancy. The plastic surgical literature suggests vascularized autologous tissue for the treatment of chronically draining CSF fistulae. Many of these patients, however, are debilitated, have multiple comorbidities, and may have a limited life expectancy, making the lengthy surgery and the associated donor-site morbidity of a regional or free tissue transfer procedure unattractive. There is a need for an alternative procedure that is a less morbid, yet equally effective solution for the obliteration of CSF fistulae. Herein we report the first use of acellular dermal matrix to successfully seal a persistent cranial CSF fistula.

Outcomes in threadlift for facial rejuvenation.

The search for less invasive surgical techniques to address the effects of facial aging led to the development of barbed polypropylene sutures for facial suspension. Theoretical advantages of these "threadlifts" included limited scarring, rapid recovery, relative safety, and reduced cost when compared with a standard rhytidectomy. The goal of this study was to evaluate the outcomes of patients undergoing threadlifts to determine the actual complication rates, the durability of results, and the rates of reoperative surgery. A single surgeon's initial 2-year experience with 72 patients undergoing threadlifts was retrospectively reviewed. Preoperative patient demographical and clinical data, operative information, and postoperative outcomes data were compiled and evaluated. A total of 72 thread lifts were performed by 1 surgeon over a 24-month period. Of these patients, 76% underwent threadlift alone, whereas concomitant procedures were performed in 24% of patients. Minor complications were common and usually self-limited. Forty-two percent of patients underwent a secondary procedure after primary threadlift, an average of 8.4 months after the original surgery. Thirty-one percent of patients required revisional surgery for cosmetic reasons an average of 8.7 months after their threadlift. Eleven percent of the patients ultimately required removal of palpable threads. Threadlift is a safe procedure associated with minor complications. Rates of revisional surgery for cosmesis are high after threadlift. Time to revisional surgery for cosmesis is short. Results achieved by threadlift are subtle and short-lived. Threadlift is not a minimally invasive replacement of surgical rhytidectomy. Patients should understand the limitations of this technique and its high rates of revisional surgery.

Plastic surgery at the University of Virginia: a 50-year retrospective.

The University of Virginia recently celebrated 50 years of plastic surgery history. Past and present chairmen were honored by the department and previous residents. Accomplishments by our department, faculty, and residents have come in areas of national leadership, education, research, and patient care. The tradition of excellence in plastic surgery continues by building upon the strong history of the department.

Special considerations in the management of pediatric upper extremity and hand burns.

Pediatric patients account for approximately one third of all burn patients in the United States, with upper extremity or hand involvement in most admitted burn patients. Specialized management and care of pediatric burn patients optimizes functional outcomes. Common mechanisms of injury are discussed. Acute and long-term care aspects of pediatric upper extremity and hand burns require unique considerations. Diagnosis, treatment, and management of upper extremity and hand burns are discussed in detail with respect to the pediatric population.

A Hundred Years Later, the Legacy of Milton Edgerton, MD, Prevails.

This Viewpoint honors the legacy of a plastic surgeon who was ahead of his time, both in surgical innovations and in the creation of a multidisciplinary clinic for transgender patients.

Resident Participation in International Surgical Missions is Predictive of Future Volunteerism in Practice.

BACKGROUND: Interest in global health and international mission trips among medical student and resident trainees is growing rapidly. How these electives and international mission experiences affect future practice is still being elucidated. No study has identified if participation in international surgical missions during residency is a predictor of participation in international surgical missions in practice after training completion. METHODS: All trainees of our plastic surgery residency program from 1990 to 2011, during the implementation of optional annual international surgical missions, were surveyed to determine if the graduate had gone on a mission as a resident and as a plastic surgeon. Data were compared between graduates who participated in missions as residents and graduates who did not, from 1990 to 2011 and 1990 to 2007. RESULTS: Of Plastic Surgery graduates from 1990 to 2011 who participated in international missions as residents, 60% participated in missions when in practice, versus 5.9% of graduates participating in missions in practice but not residency (P<0.0001). When excluding last 5 years, graduates participating in international missions in practice after doing so as residents increases to 85.7%, versus 7.41% who participate in practice but not residency P<0.002. CONCLUSIONS: Results reveal plastic surgeons who participate in international surgical missions as residents participate in international surgical missions in practice at higher rates than graduates who did not participate in missions during residency. International missions have significant intrinsic value both to trainee and international communities served, and this opportunity should be readily and easily accessible to all plastic surgery residents nationwide.

The "open-book" variation of component separation for repair of massive midline abdominal wall hernia.

The reconstruction of massive midline abdominal wall defects as a result of intra-abdominal catastrophes has long challenged the reconstructive surgeon. Previously, the lack of autogenous tissue often forced the surgeon to resort to synthetic materials, which may be complicated by adhesions, enterocutaneous fistulas, and infection. The introduction of the "components of anatomic separation" technique by Ramirez et al. in 1990 allowed for autogenous reconstruction using bipedicle rectus flaps. This technique was far superior to any previous option, but it had its limitations. The authors report a modification to the component separation technique which may allow larger defects to be closed as well as diminish the weakness left below the arcuate line found in some of the previously reported techniques. Ten patients are discussed for which this modified technique of component separation was employed. The follow-up ranges from 5 weeks to 53 months.

Vascular anomalies: hemangiomas.

Mulliken and Glowacki categorized vascular anomalies as either hemangiomas or malformations, with the former being the most common tumor of infancy. Despite distinct clinical, radiologic, and histologic findings, the two major types of vascular lesions are often confused. This complicates both patient care and interpretation of the medical literature. A thorough understanding of the presentation, natural history, treatment, and complications of vascular tumors (hemangiomas) and vascular malformations is essential to their proper management. A comprehensive review outlining the diagnosis and treatment of hemangiomas in presented.

Obstructive sleep apnea: Part II. Surgical approaches to sleep apnea.

Successful surgical management of obstructive sleep apnea (OSAS) requires a thorough understanding of the pathophysiology and anatomical contributions to this widely variable disease. Early efforts to surgically correct OSAS involved bypassing the upper airway; thus, indirectly improving the symptoms without directly addressing the pathophysiology. Surgical procedures to treat OSAS have evolved over the past several decades as further understanding of the disease continues to be elicited. The surgical techniques employed in the treatment of OSAS are quite varied. Many surgical subspecialties have contributed to the understanding of the complexities of OSAS. Recent surgical management involves site-specific alterations of the upper airway to more directly address the disease process. In addition, current literature suggests an algorithmic and phased approach to the treatment of OSAS. Future technology offers the hope of better diagnostic and therapeutic options for the surgical management of OSAS.

Lidocaine metabolism pathophysiology, drug interactions, and surgical implications.

A thorough understanding of the pathophysiology of lidocaine metabolism is an important prerequisite to minimizing the risk of morbidity and mortality associated with lipoplasty. Although the tumescent technique has greatly improved the safety of large-volume lipoplasty through decreased blood loss and reduced anesthetic needs, it has introduced the possibility for lidocaine toxicity. Because lidocaine is metabolized by the cytochrome P450 system, the potential for drug interactions is heightened. These drug interactions are implicated as a cause of lidocaine toxicity. A comprehensive review of the patient's preoperative, intraoperative, and postoperative medication profile is critical to perioperative patient safety.

Human adipocyte viability testing: a new assay.

BACKGROUND: Surgical experience and anecdotal data on the most effective method of harvesting, preparing, and injecting autologous fat grafts are inconsistent and conflicting. Because the limitation of fat grafting is its resorption, understanding how various handling techniques affect adipocyte survival is crucial to optimizing its long-term survival. OBJECTIVE: We sought to develop a method for assaying fat viability in its clinically used form and then to test several common techniques used in fat grafting for their effects on the viability of the fat. METHODS: We performed the well-established MTT [3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyl tetrasodium bromide] cell survival and proliferation assay on fat, but the colored enzyme-breakdown product could not be released into the supernatant for spectrophotometric analysis. An entirely new protocol was developed that allowed the MTT assay to quantitate the viability of free fat grafts. The assay was able to distinguish between different quantities of live fat and to quantify the decrease in viability when the fat is stored. We subjected the fat to various treatments, including insulin and Triton-X 100 detergent, (Sigma Aldrich, St. Louis, MO) centrifugation, extrusion through different types and sizes of needles, and freezing. RESULTS: With the exception of detergent, which decreased viability, all other treatments had no statistically significant effect on adipocyte survival. Freezing did not result in decreased cell viability. CONCLUSIONS: It is unlikely that variations in the clinical results of free fat grafting are the result of the handling techniques examined in this study.