Defining the Aesthetic Range of Normal Symmetry for Lip and Nose Features in 5-Year-Old Children Using the Computer-Based Program SymNose.

OBJECTIVE: To provide a normal comparison group against which to judge symmetry results after cleft surgery and to introduce the thin lip correction (TLC) feature in SymNose. A lip-aspect ratio algorithm has been added to the latest version of SymNose to compensate for the higher degree of overlap in thicker lips when compared to thin lips. DESIGN: Retrospective analysis of symmetry in healthy participants, using the computer-based program SymNose on both anteroposterior (AP) and base view images. Photographs of 91 noncleft children were traced twice by 3 independent investigators experienced with SymNose. PARTICIPANTS: Five-year-old healthy participants from a local state school in Tavistock (West Devon, United Kingdom). MAIN OUTCOME MEASURE: Asymmetry expressed as the perimeter mismatch percentage for nose and lip features on AP view images and for nose features on base view images. RESULTS: The perimeter mismatch reference range for the nose (AP view) was 2.65% to 30.91%, for the lip 2.13% to 15.44%, for the nose (base view) 1.69% to 14.84%, for the nostrils 4.68% to 26.6%, and for the width-height ratio 1.15% to 1.80%. The perimeter mismatch percentage for the lip without TLC was significantly higher compared to the perimeter mismatch percentage with TLC (P < .001). CONCLUSION: This article provides a noncleft reference range for all perimeters drawn from SymNose against which to compare results after cleft surgery at 5 years of age. Furthermore, it shows the importance of correcting for variance in lip volume per child.

A systematic review of 2-strand versus multistrand core suture techniques and functional outcome after digital flexor tendon repair.

PURPOSE: To determine published evidence to evaluate the hypothesis that multistrand techniques result in a poorer outcome than 2-strand techniques for digital flexor tendon repairs. METHODS: A systematic review was undertaken to compare outcomes and rupture rates between 2-strand and multistrand core sutures in digital flexor zones 2 to 5. Outcome was measured by the American Society for Surgery of the Hand criteria, original or modified Strickland criteria, or Buck-Gramcko criteria. RESULTS: A total of 1,878 patients (2,585 digits; 3,749 tendons) were included from the selected studies. Thirty-three studies reported 2-strand repairs and 15 reported multistrand repairs. Of the total tendon injuries, 59% were flexor digitorum profundus, 38% were flexor digitorum superficialis, and 2% were flexor pollicis longus. The pooled rupture rate was 3.9 per 100 digits. No significant difference was detected between 2-strand and multistrand repairs for outcomes by all measures or rupture rate. CONCLUSIONS: Because of the wide variation in reporting of outcomes and study design on which this analysis was based, we cannot definitively confirm our hypothesis. We present the standards for outcomes as well as rupture rate for digital flexor tendon repair. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic III.

The Evolution and Interpretation of the Gustilo and Anderson Classification.

BACKGROUND: The Gustilo classification is the most established system for classifying open fractures. Despite this, the classification has changed in how it has been described and interpreted. We have traced how this classification has slowly evolved throughout the literature over the past 4 decades. METHODS: A systematic search of the literature was undertaken with the MEDLINE, Embase, and PubMed databases to source relevant articles that have evolved the interpretation of the Gustilo classification. The references from these articles were consecutively hand-searched to find other articles that describe the Gustilo classification. RESULTS: There was a total of 393 results from the Healthcare Databases Advanced Search (HDAS): 95 from MEDLINE, 49 from Embase, and 249 from PubMed. Fifty-six articles were initially selected; an additional 67 articles were retrieved through reference checking and further checking of relevant articles until no additional relevant articles could be found. CONCLUSIONS: The original Gustilo and Anderson classification initially was modified by Gustilo before subtle changes were made to the descriptors in the 1990s. Some authors have used the Gustilo classification to create alternative classifications, but these have not gained traction. Other contemporaneous literature has modified the Gustilo-IIIB subtypes to better stratify functional and reconstructive outcomes following vascular injury. The impact and longevity of such recent modifications are yet to be known.

Thermographic Assessment of a Vascular Malformation of the Hand: A New Imaging Modality.

Vascular malformations of the hand are rare. Angiography is the current Gold Standard imaging modality. Thermal imaging is an emerging noninvasive, noncontact technology that does not require intravenous contrast agents. We present the case of a patient with an arteriovenous malformation affecting the hand in which thermal imaging has been used as an adjunct to capture baseline images to allow monitoring of progression. We suggest that thermal imaging provides an adjunct that can be used in addition to clinical examination and/or angiography for the diagnosis and routine follow-up of conservatively managed arteriovenous malformations, to monitor progression or vascular steal, and also for recording recurrence after surgical excision for which there is known to be a significant incidence. With the benefit of being a noninvasive imaging modality that does not require intravenous contrast, or ionizing radiation exposure, office-based thermal imaging may become commonplace.

Detection of Perforators Using Smartphone Thermal Imaging.

Thermal imaging detects infrared radiation from an object, producing a thermogram that can be interpreted as a surrogate marker for cutaneous blood flow. To date, high-resolution cameras typically cost tens of thousands of dollars. The FLIR ONE is a smartphone-compatible miniature thermal imaging camera that currently retails at under $200. In a proof-of-concept study, patients and healthy volunteers were assessed with thermal imaging for (1) detecting and mapping perforators, (2) defining perforasomes, and (3) monitoring free flaps. Preoperative, intraoperative, and postoperative thermograms can assist in the planning, execution, and monitoring of free flaps, and the FLIR ONE provides a low-cost adjunct that could be applied to other areas of burns and plastic surgery.

Outcomes of Cleft Palate Repair in Patients with Pierre Robin Sequence: A Matched Case-Control Study.

BACKGROUND: Pierre Robin sequence results from a cascade of events that occur during embryologic development and frequently presents with cleft palate. Some studies have shown speech outcomes to be worse in patients with Pierre Robin sequence after cleft palate repair. METHODS: A cohort of Pierre Robin sequence patients who all required an airway intervention and nasogastric feeding in the neonatal period were identified and speech outcomes assessed at 5 years of age. A cleft- and sex-matched non-Pierre Robin sequence, cleft palate-only comparison group was also identified from the same institution and study period. RESULTS: A total of 24 patients with Pierre Robin sequence that required airway and nutritional support in the neonatal period were matched for age, sex, and cleft type to a group of 24 non-Pierre Robin sequence cleft patients. There was no significant difference in the incidence of oronasal fistula between the groups. Secondary surgery for velopharyngeal incompetence was significantly more (p = 0.017) in the Pierre Robin sequence group, who also had significantly greater nasality (p = 0.031) and cleft speech characteristic (p = 0.023) scores. CONCLUSIONS: The authors hypothesize that other factors may exist in Pierre Robin sequence that may lead to poor speech outcomes. The authors would suggest counseling parents of children with Pierre Robin sequence that have required a neonatal airway intervention, that speech development may be poorer than in other children with cleft palate, and that these children will have a significantly higher incidence of secondary speech surgery. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, II.

Facial Aesthetic Outcomes of Cleft Surgery: Assessment of Discrete Lip and Nose Images Compared with Digital Symmetry Analysis.

BACKGROUND: High-quality aesthetic outcomes are of paramount importance to children growing up after cleft lip and palate surgery. Establishing a validated and reliable assessment tool for cleft professionals and families will facilitate cleft units, surgeons, techniques, and protocols to be audited and compared with greater confidence. This study used exemplar images across a five-point aesthetic scale, identified in a pilot project, to score lips and noses as separate units and compared these human scores with computer-based SymNose symmetry scores. METHODS: Forty-five assessors (17 cleft surgeons nationally and 28 other cleft professionals from the UK South West Tri-centre units), scored 25 standardized photographs, uploaded randomly onto a Web-based platform, twice. Each photograph was shown in three forms: lip and nose together, and separately cropped images of nose only and lip only. The same images were analyzed using the SymNose software program. RESULTS: Scoring lips gave the best intrarater and interrater reliabilities. Nose scores were more variable. Lip scoring associated most closely with the whole-image score. SymNose ranking of the lip images related highly to the same ranking by humans (p = 0.001). The exemplar images maintained their established previous ranking. CONCLUSIONS: Images illustrating the aesthetic outcome grades are confirmed. The lip score is reliable and seems to dominate in the whole-image score. Noses are much harder to score reliably. It appears that SymNose can score lip images very effectively by symmetry. Further use of SymNose will be investigated, and families of children with cleft will trial the scoring system. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Fistula incidence after primary cleft palate repair: a systematic review of the literature.

BACKGROUND: The development of an oronasal fistula after primary cleft palate repair has a wide variation reported in the literature. The aim of this review is to identify the reported oronasal fistula incidence to provide a benchmark for surgical practice. METHODS: A systematic review was undertaken to investigate the incidence of fistula. Multiple meta-analyses were performed to pool proportions of reported fistulae, in each data set corresponding to the continent of origin of the study, type of cleft, and techniques of cleft palate repair used. RESULTS: A total of 9294 patients were included from 44 studies. The overall incidence of reported fistula was 8.6 percent (95 percent CI, 6.4 to 11.1 percent). There was no significant difference in the fistula incidence corresponding to the continent of origin of each study or the repair technique used. The incidence of fistula in cleft lip-cleft palate was 17.9 percent, which was significantly higher (p = 0.03) than in cases of cleft palate alone (5.4 percent). CONCLUSIONS: Palatal fistulae were more likely to occur in cases of combined cleft lip-cleft palate, compared with cleft palate alone. The authors would recommend the prospective examination and recording of all fistulae to a standardized classification scheme. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Are systemic antibiotics indicated in aesthetic breast surgery? A systematic review of the literature.

BACKGROUND: The use of systemic prophylactic antibiotics to reduce surgical-site infection in aesthetic breast surgery remains controversial. The aim of this review is to weigh the available evidence with respect to reducing surgical-site infection. METHODS: Two literature searches were performed to analyze the available data for studies involving either reduction or augmentation mammaplasty and the results of different antibiotics regimens. Outcome measures included surgical-site infection and capsular contracture. RESULTS: A total of 2971 patients (5891 breasts) were included. A meta-analysis of surgical-site infection incidence after aesthetic breast surgery revealed a significant reduction in infections overall with antibiotic prophylaxis compared with controls (p=0.02). This was most significant with a single preoperative antibiotic dose (p=0.02). In cases of reduction mammaplasty, when antibiotics are administered as a single preoperative dose, the risk of developing surgical-site infection is halved. With augmentation mammaplasty, there was no effect on infection rates with any antibiotic regimen. Data concerning the incidence of capsular contracture were insufficient for meta-analysis. CONCLUSIONS: For cases of reduction mammaplasty, the authors recommend a single intravenous perioperative dose of antibiotic with action against Staphylococcus species. For augmentation mammaplasty, there is no evidence to refute current guidelines, based on recommendations obtained from other forms of implant surgery. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, II.

Detection of perforators using thermal imaging.

BACKGROUND: Perforator flaps are commonly used in reconstructive surgery and require accurate vascular anatomy navigation. Several imaging methods help surgeons, including hand-held Doppler, color Doppler ultrasound, computed tomography, and magnetic resonance angiography. A growing literature supports the efficacy of thermal imaging in identifying perforators. This study assessed the efficacy of thermal imaging and perforator anatomy in four body regions. METHODS: Twenty volunteers had their abdomen, sacrum, and both anterolateral thighs assessed for cutaneous perforators using thermal imaging. Key surface landmarks were marked with black crosshairs centered on the umbilicus, superior natal cleft, and traditional anterolateral thigh flap markings. All thermal imaging-identified perforators were marked by red crosses, immediately checked with a hand-held Doppler device, and marked with blue circles if not confirmed. A color digital photograph taken of each region was analyzed. RESULTS: Thermal imaging identified a total of 757 "hotspots," of which 732 (97.0 percent) were confirmed by hand-held Doppler. In 40 anterolateral thighs, the mean number of perforators identified was 1.3 within 2.5 cm and 4.6 within 5 cm of traditional landmarks. In the abdomen, the mean number of perforators was 0.7 and 3.7 within 2.5 cm and 5 cm of the umbilicus, respectively. In the sacral region, there was a mean number of 0.3 and 2.3 perforators within 2.5 cm and 5 cm, respectively, of the superior natal cleft. CONCLUSIONS: Thermal imaging is a quick, easy method of assessing cutaneous perforators. It should be considered a useful adjunct, and further investigated, to determine its best role among the established perforator imaging methods. CLINICAL QUESTION/LEVEL OF EVIDENCE: Diagnostic, II.

Infiltration of epinephrine in reduction mammaplasty: a systematic review of the literature.

BACKGROUND: Evidence of the benefit of dilute epinephrine infiltration before reduction mammaplasty is provided by several controlled trials. Despite variation in operative technique and data collection, a reduction in intraoperative blood loss has been shown. The aim of this review of the literature is to weigh the available evidence with respect to reducing blood loss during surgery and other outcome measures such as postoperative drainage. METHODS: Two researchers independently selected articles for review, and data were extracted from each primary article and used for statistical and descriptive comparisons. RESULTS: A meta-analysis of operative blood loss showed a highly significant drop in operative blood loss in breasts infiltrated with epinephrine and a reduction in the need for blood transfusion. Operative time, postoperative drainage, and complications were not significantly affected by epinephrine infiltration. CONCLUSION: The authors' recommendation would be for the use of dilute epinephrine infiltration before reduction mammaplasty.

An analysis of 277 consecutive latissimus dorsi breast reconstructions: a focus on capsular contracture.

BACKGROUND: Breast reconstruction by means of a latissimus dorsi myocutaneous flap in combination with a prosthesis is a well-established technique. Previous published series have highlighted significant rates of local complications, including capsular contracture. METHODS: A retrospective analysis of latissimus dorsi myocutaneous flap reconstructions performed between 2000 and 2010 was undertaken. A standardized preoperative, perioperative, and postoperative clinical protocol was applied to all cases, which included the use of textured, cohesive-gel silicone implants. RESULTS: Two hundred seventy-seven procedures were performed in 243 patients, with one-third being immediate reconstructions. The mean age at reconstruction was 50.4 years. Mean follow-up was 47 months, and 3.6 percent of patients developed Baker grade III capsular contracture requiring capsulotomy. Chemotherapy provided a protective effect (p = 0.0197) against capsular contracture formation. Previous radiotherapy had no significant influence on symptomatic capsule formation. The rate of infection requiring implant removal was 1.1 percent, and 0.7 percent of mastectomy scars showed evidence of recurrent disease. CONCLUSION: The use of textured, cohesive-gel silicone implants, combined with a standardized surgical approach, can reduce complications in the short- and long-term postoperative period, independent of radiotherapy.

The effect of dextrin-rhEGF on the healing of full-thickness, excisional wounds in the (db/db) diabetic mouse.

Chronic wounds, such as ulceration of the lower limb, represent a significant clinical challenge in today's ageing society. With the aim of identifying improved therapeutics, we have previously described a bioresponsive, dextrin-recombinant human epidermal growth factor conjugate (dextrin-rhEGF), that (i) protects rhEGF against proteolytic degradation by human chronic wound fluid; and (ii) mediates rhEGF release by α-amylase, capable of stimulating increased proliferation/migration in normal dermal and chronic wound fibroblasts; and keratinocytes, in vitro. The aim of this study was to extend these findings, by investigating the effects of dextrin-rhEGF on wound healing in the (db/db) diabetic mouse, a widely used in vivo model of delayed wound healing. Standardised, full-thickness excisional wounds, created in the dorsal flank skin, were treated topically with succinoylated dextrin (50 µg/mL), rhEGF (10 µg/mL) or dextrin-rhEGF (1 or 10 µg/mL). Treatments were applied immediately after injury and subsequently on post-wounding, days 3 and 8. Wound healing was assessed macroscopically, in terms of initiation of neo-dermal tissue deposition and wound closure (including wound contraction and re-epithelialisation), over a 16 day period. Wound healing was assessed histologically, in terms of granulation tissue formation/maturity; cranio-caudal wound contraction and wound angiogenesis (CD31 immuno-staining), using tissues harvested at day 16. Blood samples were also analysed for α-amylase and rhEGF concentrations. In this established impaired wound healing model, the topically-applied dextrin-rhEGF significantly accelerated wound closure and neo-dermal tissue formation at the macroscopic level; and significantly increased granulation tissue deposition and angiogenesis at the histological level (p<0.05), relative to untreated, succinoylated dextrin and rhEGF alone controls. Overall, these findings support the further development of bioresponsive polymer conjugates, for tissue repair.