The Effects of Adjunctive Pain Medications on Postoperative Inpatient Opioid Use in Abdominally Based Microsurgical Breast Reconstruction.

BACKGROUND: The purposes of this study were to quantify the amount of opioid medication used postoperatively in the hospital setting after abdominally based microsurgical breast reconstruction, to determine factors that are associated with increased opioid use, and to identify other adjunctive medications that may contribute to decreased opioid use. METHODS: An electronic medical record data pull was performed at the University of Pennsylvania from November 2016 to October 2018. Cases were identified using Current Procedural Terminology code 19364. Only traditional recovery after surgery protocol patients were included. Patient comorbidities, surgical details, and pain scores were captured. Postoperative medications including non-patient-controlled analgesia opioid use and adjunctive nonopioid pain medications were recorded. Non-patient-controlled analgesia total opioid use was calculated and converted to oral morphine milligram equivalents (mme). Statistical analysis was performed using t test analyses and linear regression. RESULTS: A total of 328 patients satisfied our inclusion criteria. Five hundred forty free flaps were performed (212 bilateral vs 116 unilateral, 239 immediate vs 89 delayed). Bilateral patients used on average 115.2 mme (95% confidence interval [CI], 103.4-127.0 mme) compared with 89.0 mme in unilateral patients (95% CI, 70.0-108.0 mme; P = 0.015). Patients with abdominal mesh placement (n = 249) required 113.0 mme (95% CI, 100.5-125.5 mme) compared with 83.8 mme (95% CI, 68.8-98.7 mme) for patients without mesh (n = 79; P = 0.016). Each additional hour of surgery increased postoperative mme by 9.4 (P < 0.01). Patients with a nonzero preoperative pain score required 100.3 mme (95% CI, 90.2-110.4 mme) compared with 141.1 mme (95% CI, 102.7-179.7 mme) for patients with preoperative pain score greater than 0/10 (P < 0.01). Patients with postoperative index pain score ≤5/10 required 89.2 mme (95% CI, 78.6-99.8 mme) compared with 141.1 mme (95% CI, 119.9-162.2 mme) for patients with postoperative index pain score >5/10 (P < 0.01). After regression analysis, a dose of intravenous acetaminophen 1000 mg was found to decrease postoperative mme by 11.7 (P = 0.024). A dose of oral ibuprofen 600 mg was found to decrease postoperative mme by 8.3 (P < 0.01). CONCLUSIONS: Bilateral reconstruction and longer surgery resulted in increased postoperative mme. Patients with no preoperative pain required less opioids than did patients with preexisting pain. Patients with good initial postoperative pain control required less opioids than did patients with poor initial postoperative pain control. Intravenous acetaminophen and oral ibuprofen were found to significantly decrease postoperative mme.

International Adoptees With Cleft Lip and/or Palate: Lessons Learned From a Growing Population.

BACKGROUND: International adoptees with cleft lip and palate (CLP) are a growing population in the United States. They represent a clinical challenge, presenting at various ages and stages of cleft repair. METHODS: A retrospective review of patients seen at the CLP Program at the Children's Hospital of Philadelphia (CHOP) between 1998 and 2012 with a history of international adoption was performed. Demographics, surgical histories, and long-term speech outcomes were reviewed. RESULTS: Seventy-four female and 77 male patients were evaluated. Patients were adopted at an average age of 2.3 years (range, 0.4-8.6 years); 80.8% (n = 122) of patients were adopted from China. The rate of international cleft adoption increased by approximately 1.5 patients per year (r = 0.7739, P < 0.001); 13.2% (n = 19) of all subjects with cleft palates had oronasal fistulas (ONFs) that required repair. The ONF rates for primary palatoplasties at CHOP were significantly lower compared to both preadoption repairs (P = 0.002) and postadoption repairs at outside hospitals (P = 0.01); 14.8% (n = 21) of all patients had secondary surgeries for velopharyngeal incompetence (VPI). Rates of secondary surgery for VPI were also significantly lower for primary palatoplasties at CHOP compared to both preadoption repairs (P = 0.0018) and postadoption repairs at outside hospitals (P = 0.0033). CONCLUSIONS: International adoptees with CLP are a growing population and are clinically challenging with high ONF rates and high secondary surgery rates for VPI. We recommend expedited repair of unoperated cleft palates in adoptees older than 18 months. Adopted patients with CLP should be rigorously evaluated for the need for speech therapy and secondary surgeries to correct for VPI.

An Assessment of 30-Day Complications in Primary Cleft Lip Repair: A Review of the 2012 ACS NSQIP Pediatric.

OBJECTIVE: The aim of this study is to identify risk factors associated with complications and readmissions following cleft lip repair using the multicenter American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) Pediatric. DESIGN: Patients undergoing CPT codes 40700, 40701, and 40702 were extracted from the ACS NSQIP Pediatric. Fisher exact, χ(2), and rank-sum tests were used to evaluate risk factors. RESULTS: Of the 525 patients included, 4.2% had complications, with respiratory complications being the most common. Risk factors included congenital malformations (P = .001), ventilator dependence (P = .002), oxygen support (P = .016), tracheostomy (P = .005), esophageal/gastric/intestinal disease (P = .007), impaired cognitive status (P = .034), acquired central nervous system abnormality (P = .040), nutritional support (P = .001), major and severe cardiac risk factors (P = .011 and P = .005), and an American Society of Anesthesiologists score of 3 (P = .002). In addition, complications were associated with undergoing a one-stage bilateral repair (P = .045) or concomitant ear, nose, and throat procedure (P = .045). The readmission rates for ambulatory patients and inpatients were 2.6% and 4.9% (P = .556), with an overall readmission rate of 4.6%. Ambulatory patients were older (P = .005) and had shorter operative times (P < .001). CONCLUSIONS: Perioperative complications are low following cleft lip repair, with respiratory complications being the most common. Readmission rates of 4.6% are higher than expected, and insight into predictors of complications will allow surgeons to identify patients who could benefit from additional resources.

An Assessment of 30-Day Complications in Primary Cleft Palate Repair: A Review of the 2012 ACS NSQIP Pediatric.

OBJECTIVE: This study uses the American College of Surgeons Pediatric National Surgical Quality Improvement Program (ACS NSQIP Pediatric), a multicenter database, to identify risk factors for complications after cleft palate repair. DESIGN: Patients undergoing Current Procedural Terminology (CPT) codes 42200 and 42205 were extracted from the 2012 ACS NSQIP Pediatric. Patients older than 36 months or those who had undergone an additional surgery that altered the risk were excluded. Outcome variables were combined to create a complication variable. Fisher's exact, Pearson chi-square, and Wilcoxon rank-sum tests were used for analysis. RESULTS: Eligibility criteria were met by 751 patients. Of these, 192 (25.6%) had unilateral clefts, 146 (19.4%) bilateral, and 413 (55.0%) were unspecified. The average age at time of surgery for those without and with complications was 421.1 ± 184.8 and 433.6 ± 168.0 days, respectively (P = .76). Of the 21 (2.8%) patients with complications, respiratory complications were the most common. Risk factors associated with complications included American Society of Anesthesiologists classification of 3 (P = .003), nutritional support (P = .013), esophageal/gastric/intestinal disease (P = .016), oxygen support (P = .003), structural pulmonary/airway abnormality (P = .011), and impaired cognitive status (P = .009). Patients undergoing concurrent laryngoscopy (P = .048) or other surgeries (P = .047) were also found to be associated with increased complications. The 30-day fistula rate was 0.5%, and the readmission rate was 1.9%. CONCLUSION: Perioperative complications for primary palatoplasty were 2.8% according to the ACS NSQIP Pediatric. Preoperative patient-related factors as well as concurrent surgeries may affect 30-day complication rates. These results help target those at greater risk for complications and allow for appropriate interventions to mitigate risks.

Striving for Normalcy after Lower Extremity Reconstruction with Free Tissue: The Role of Secondary Esthetic Refinements.

BACKGROUND: Many patients with successful lower extremity salvage have postoperative functional and esthetic concerns. Such concerns range from contour irregularity preventing proper shoe-fitting to esthetic concerns involving color, contour, and texture match. The purpose of this study is to determine the overall incidence as well as factors associated with an increased likelihood of undergoing secondary, esthetic refinements of lower extremity free flaps and to review current revision techniques. METHODS: All patients undergoing lower extremity soft tissue coverage for limb salvage procedures between January 2007 and June 2013 at a single institution were included in the analysis. Patients who underwent secondary refinements for lower extremity free flaps were compared with patients not undergoing secondary procedures. RESULTS: During the study period, 152 patients underwent reconstruction and were eligible for inclusion. Of these, 32 (21.1%) patients underwent secondary, esthetic revisions. Few differences in patient or case characteristics were noted, although revision patients trended toward being younger, having lower body mass index, with defects secondary to acute trauma located below the ankle. The most common revision was complex soft tissue rearrangement or surgical flap debulking/direct excision (87.5% of patients), followed by scar revision (12.5%), suction-assisted lipectomy (3.1%), laser scar revision (3.1%), and tissue expansion with local tissue rearrangement (3.1%). CONCLUSION: A significant portion of patients desire secondary revisions following the initial procedure. This is especially true of younger patients with below ankle reconstruction. In many patients, an esthetic consideration should not be of secondary concern, but should be part of the ultimate reconstructive algorithm for lower extremity limb salvage.

Cranial base deviation in hemifacial microsomia by craniometric analysis.

Although facial asymmetry in hemifacial microsomia (HFM) is well documented in the literature, no studies have concentrated on the morphology of the cranial base. This study aimed to evaluate the endocranial morphology in patients with HFM. Consecutive patients with unilateral HFM treated at a craniofacial center from 2000 to 2012 were included. The patients were grouped according to severity on the basis of the Kaban-Pruzansky classification: mild (0-1), moderate (2a), and severe (2b-3). Skull base angulation and transverse craniometric measures were recorded and then compared with those of age-matched controls. A total of 30 patients (14 males, 16 females) averaging 7.5 years of age (range, 1.1-15.7 y) were included. Four patients were classified as mild; 12, as moderate; and 14, as severe. The mean cranial base angle was found to be between 179 and 181 degrees with no significant difference between the severity groups (P = 0.57). The mean cranial base angle did not differ significantly in the patients compared with the controls(179.6 vs 180.0; P = 0.51) No significant differences between the affected and unaffected sides in the patients were found in distances from the midline to hypoglossal canal, internal acoustic meatus, lateral carotid canal, medial carotid canal, foramen ovale, and rotundum. There were no significant differences in transverse measurements between the severity classes using the same landmarks (P = 0.46, P = 0.30, P = 0.40, P = 0.25, P = 0.57, and P = 0.76, respectively). The cranial base axis is not deviated in the patients with HFM compared with the age-matched controls, and there exists little difference in endocranial morphologic measurements with increasing severity of HFM. These data are interesting, given the role of the cranial base in facial growth and the varying hypotheses regarding the mechanism of disease in HFM.

Surgical Site Infections after Free Flap Breast Reconstruction: An Analysis of 2,899 Patients from the ACS-NSQIP Datasets.

BACKGROUND: Surgical site infections (SSIs) are a costly complication, resulting in lower patient satisfaction and higher health care expenditures. Incidence varies widely in the literature by surgery type, yet few studies focus exclusively on autologous breast reconstruction, an increasingly common surgery. The aim of this study is to identify risk factors for SSIs in free flap breast reconstruction using the National Surgical Quality Improvement Program Database (NSQIP). METHODS: Patients undergoing breast reconstruction with any flap type were identified by Current Procedural Terminology codes in the NSQIP database. Patients with superficial or deep SSIs within 30 days of surgery were compared with controls by univariate analysis and multivariate logistic regression across various characteristics. RESULTS: Overall, 2,899 patients undergoing autologous reconstruction were identified. Of these, 143 (4.9%) patients developed SSIs. Those who developed wound complications were more likely smokers (18.2 vs. 8.4%, p < 0.001) and diabetics (9.8 vs. 3.4%, p < 0.001) with hypertension (38.2 vs. 25.4%, p < 0.001) and pulmonary (4.5 vs. 1.3%, p = 0.01) history. SSIs occurred in patients with higher American Society of Anesthesiologists (p = 0.003) and the World Health Organization obesity (p < 0.001) classes. On multivariate regression, SSIs were significantly associated with smoking (odds ratio [OR] = 3.59, p < 0.001) and hypertension (OR = 1.86, p = 0.03). CONCLUSIONS: This study demonstrates that patients who are active smokers or have hypertension are at the highest risk for SSIs. Preoperative identification and tailored postoperative management of these patients may decrease the incidence of this complication.

Maxillary involvement in hemifacial microsomia: an objective three-dimensional analysis of the craniofacial skeleton.

The aim of our study is to better understand the maxillary involvement in relation to the mandibular deformation in hemifacial microsomia (HFM). To do so, consecutive patients with HFM treated at The Children's Hospital of Philadelphia from 2000 to 2012 were included in our study. Both two-dimensional and three-dimensional analyses of the bony and sinus structures of the midface and mandible were performed using three-dimensional segmentation software. Patients were stratified into groups based on the Kaban-Pruzansky classification--mild (0-1), moderate (2A), and severe (2B-3)--as well as rank ordering based on overall severity. Analyses involved paired t-tests within severity groups, 1-way analysis of variance when assessing across groups (ipsilateral/contralateral ratio), and regression to assess for trends. Thirty patients were included (4 mild, 12 moderate, and 14 severe). The mandibular volume ratio differed across all patient groups (P < 0.001) and trended with rank order (P < 0.001). No significant difference in maxillary bony volume ratio was found across all patient groups (P = 0.16). In patients with severe disease, the maxillary bone volume was found to be significantly decreased on the ipsilateral side as compared with the contralateral side (P = 0.0123). There was no difference in maxillary sinus volume between ipsilateral and contralateral sides within any patient groups or in comparing across groups (P = 0.10). No significant trend was found in the volume ratio of mandible and maxilla (P = 0.41). To conclude, the maxillary sinus seems to show no difference in volume when comparing between laterality and severity groupings. These findings suggest that there may be alternative influences other than the vascular insult acting as the driving force behind the mandibular deformity and the additional classic clinical findings of HFM.

Treatment of large calvarial defects with bone transport osteogenesis: a preclinical sheep model.

BACKGROUND: Bone transport osteogenesis (BTO), distraction of a free portion of bone across a defect, offers an autologous solution to large cranial defects that may allow treatment without permanent hardware implantation. This study establishes a sheep model to evaluate the feasibility and distraction kinetics of BTO. METHODS: Subtotal cranial defects (3.5 × 3.5 cm) were created in 10 young adult sheep and a transport segment (3.5 × 2 cm) traversed the defect at varying distraction rates (0, 0.5, 1.0, and 1.5 mm/day) using semi-buried cranial distractors. After a 6-week consolidation period, sheep were euthanized and the resultant bone was analyzed by CT, histology, and mechanical testing. RESULTS: Gross examination, histology, and 3D CT revealed that control animals had fibrous nonunion whereas distraction animals had ossified defects with fibrous nonunion at the distal docking site. There was one premature consolidation in the 0.5 mm/day group. The volume of bony regenerate in the 0.5, 1.0, and 1.5 mm/day distraction rate groups was statistically indistinct (P = 0.16). The mean flexural moduli (MPa) of non-decalcified samples from the control cranium, transport segment, and bone regenerate were found to be 4.50 ± 4.9, 6.17 ± 2.1, and 4.14 ± 4.8, respectively (P = 0.24). CONCLUSIONS: This experiment provides proof of concept for BTO for large calvarial defects in a sheep model. Distraction at a rate of 0.5 mm per day may place individuals at higher risk for premature consolidation, but distraction rates did not have significant effects on regenerate quantity or quality. Future work will include the use of curvilinear distraction devices for 3-dimensional contour.

Free tissue transfer for complex reconstruction of the lower extremity: experience of a young microsurgeon.

To examine the limb salvage experience of a young microsurgeon to determine risk factors for complications and demonstrate lessons learned through cases in practice. We performed a retrospective review of lower extremity (LE) reconstruction between 2007 and 2012 performed by the senior author. This analysis focused on medical comorbidities, mechanisms, indications, and perioperative complications. A total of 61 free tissue transfers were performed with a 95% LE salvage rate. The most common donor site was the anterolateral thigh (ALT) (n = 39). Infection (n = 25) and trauma (n = 25) were the most common indications for intervention. A total of 18 complications were reported, with 8 defined as major complications. Total flap loss occurred in three patients. Through increased utilization of the ALT and adherence to lessons learned over time, improvements in outcomes can occur, giving patients the best possible chance at limb salvage.

Free flap lower extremity reconstruction in the obese population: does weight matter?

The obesity epidemic continues to grow, and we have observed greater numbers of obese individuals among patients seeking lower extremity reconstruction at our institution. These patients may present a greater reconstructive challenge, thus we sought to identify risk factors and differences in outcomes among patients undergoing lower extremity reconstruction.In this study we have performed a retrospective cohort analysis of patients undergoing lower extremity reconstruction with free tissue transfer at our institution from 2005 to 2012. Patients were classified using the World Health Organization criteria for obesity. Records were reviewed for patient characteristics, mechanism of injury, indications for reconstruction, and surgical technique, with a focus on intraoperative and early postoperative complications and outcomes.A total of 43 out of the 119 patients undergoing lower extremity reconstruction were obese (body mass index ≥ 30). Mechanism of injury, wound location, and the indications for reconstruction were similar in both cohorts. No significant differences were found in operative characteristics and techniques, including the type of flap utilized, operative time, or thrombotic events. No significant differences were seen in complication rates overall, however, obese patients more frequently needed second flaps (11.6 vs. 0%, p=0.005).This study concludes that successful lower extremity reconstruction can be performed in the obese population, with few differences in complication rates and outcomes relative to healthy weight patients.

A population-level analysis of bilateral breast reduction: does age affect early complications?

BACKGROUND: As the American population ages, a growing number of women may suffer from symptomatic macromastia in their later years. OBJECTIVES: The authors analyzed population data from the 2005-2010 American College of Surgeons National Surgical Quality Improvement Program database to investigate effects of age on 30-day surgical outcomes for reduction mammaplasty with the hope of improving patient care, counseling, and risk stratification. METHODS: Overall, 3537 patients were included in the analysis. Outcome variables included 30-day postoperative major surgical, medical, and wound complications. Patients were initially stratified into 2 groups: <60 years and ≥60 years. The World Health Organization defines age >60 years as elderly. The authors then performed a subgroup analysis, further stratifying the younger cohort into <50 years and 50-60 years of age. Univariate analysis was performed to assess the dependency of preoperative factors on surgical outcomes (P < .05). RESULTS: Of the 3547 patients, 3050 were <60 years of age (39.7 ± 11.8 years) and 487 were ≥60 years of age (65.1 ± 4.7 years). A total of 182 thirty-day postoperative surgical complications were documented. Stratifying patients into 2 age groups did not reveal an association between age and any surgical complication (P = .26). CONCLUSIONS: This population-level analysis of reduction mammaplasty indicated that, with proper patient selection, the procedure can be performed safely on older patients.

Reconstruction after Mohs Surgery for Digit Melanoma: Description of Techniques and Postoperative Limb Function.

Introduction: Mohs surgery and reconstruction has enabled tissue-preserving resection of cutaneous malignancies. The goal of our case series evaluation is to present reconstructive techniques and functional outcomes in patients undergoing digit-sparing treatment for primary melanoma. Materials and Methods: A chart review was performed to identify consecutive patients undergoing Mohs surgery and reconstruction for melanoma of the digits. Quality of life (QOL) survey was performed to assess function after the procedure. Results: Thirty-two patients (13 hand, 19 foot, Age: 65.03 +/-17.78 years) who were undergoing Mohs surgery were identified. No recurrence was identified with an average follow-up of 16.1 months (1-95 months). The average defect size was 5.79 +/-4.54 cm2. Reconstruction was performed 0-4 days after resection. The most common techniques included full-thickness skin graft (FTSG) (N = 7), collagen matrix + FTSG (N = 4), and volar advancement flap (N = 7). The reconstructive technique choice appears correlated with defect size (p = 0.0125). Neuro-QOL upper extremity survey results showed a difference that approached statistical significance between patients who underwent digit-sparing treatment (n = 7) versus direct to amputation controls (n = 5) (p = 0.072). No survey differences between digit-sparing treatment (n = 10) and amputation (n = 8) were identified in the lower extremity (p = 0.61). Conclusion: Our results show digit-sparing treatment can confirm clear surgical margins and a trend toward improvement in upper extremity function compared with immediate amputation.

Analysis of the long-term growth of the mandible in Apert syndrome.

Apert syndrome carries a characteristic phenotype of midface hypoplasia, syndactyly, craniosynostosis, and developmental delay. These patients frequently require a large number of surgical procedures to produce a functional and aesthetically pleasing correction of their facial deformities. Although most of the focus for surgical planning is allocated to the cranial vault and the midface, controversy exists as to whether the mandible is intrinsically abnormal in this population.A retrospective chart review was performed to identify patients with Apert syndrome cared for at The Children's Hospital of Philadelphia. Patients with available craniofacial computed tomographic scans after skeletal maturity were examined using cephalometric and three-dimensional volumetric techniques. A comparison was made to age- and demographically matched controls, and statistical significance was determined using the Student t test (P < 0.05).Thirty-eight patients, in total, were identified, 9 of which had available three-dimensional computed tomographic scans. Most patients underwent frontal-orbital advancement in their infancy and at least 1 midface procedure later in life. Three-dimensional volumetric analysis identified a decreased maxillary volume (P = 0.03) in the population with Apert syndrome but found no difference in the mandibular volume (P = 0.59). Cephalometric analysis demonstrated that the patients with Apert syndrome have normal ramal height but a statistically significant decreased mandibular length.The mandible with Apert syndrome seems to be intrinsically normal on the basis of our three-dimensional analysis, and differences in appreciated mandibular length are likely related to the interrelationship with the maxilla. Patients can therefore be instructed that improving the midface position may likely also reduce the compensatory mandibular deformity.

A retrospective review of outcomes and flap selection in free tissue transfers for complex lower extremity reconstruction.

PURPOSE: Complex lower extremity wounds present a significant challenge to the reconstructive surgeon. We report a consecutive experience of free tissue transfers for lower extremity reconstruction with a focus on outcomes and flap selection. METHODS: A retrospective review of all free tissue transfers for lower extremity reconstruction between 2006 and 2011 was performed. Minor complications were defined as nonoperative complications (infection, seroma, hematoma, wound breakdown, and partial loss). Major complication required a surgical intervention (total flap loss, thrombosis, nonunion, amputation, and hematoma). RESULTS: A total of 119 free flaps were performed in 114 patients. Reconstructed defects were most commonly derived from acute traumatic (N = 40) or chronic traumatic (N = 34) wounds, oncologic (N = 14), or diabetic (N = 8). Flap loss occurred at a rate of 5.9% and the overall lower extremity salvage rate was 93%. Complications were significantly higher for free tissue transfers to the region of the distal tibia (p = 0.04). Major complications were significantly higher in patients with chronic obstructive pulmonary disease (p = 0.02) and in patients who experienced intraoperative technical difficulties (p = 0.014). Flap loss was significantly higher when the rectus abdominis flap was used (p = 0.02) and when a delayed venous thrombotic event occurred (p = 0.001). CONCLUSION: Patient comorbidities and defect location can be associated with higher rates of complications; flap selection and delayed venous thrombotic events appear to be associated with flap failure.Level of Evidence Prognostic/risk category, level III.

The orphan G protein-coupled receptor, Gpr161, encodes the vacuolated lens locus and controls neurulation and lens development.

The vacuolated lens (vl) mouse mutant causes congenital cataracts and neural tube defects (NTDs), with the NTDs being caused by abnormal neural fold apposition and fusion. Our positional cloning of vl indicates these phenotypes result from a deletion mutation in an uncharacterized orphan G protein-coupled receptor (GPCR), Gpr161. Gpr161 displays restricted expression to the lateral neural folds, developing lens, retina, limb, and CNS. Characterization of the vl mutation indicates that C-terminal tail of Gpr161 is truncated, leading to multiple effects on the protein, including reduced receptor-mediated endocytosis. We have also mapped three modifier quantitative trait loci (QTL) that affect the incidence of either the vl cataract or NTD phenotypes. Bioinformatic, sequence, genetic, and functional data have determined that Foxe3, a key regulator of lens development, is a gene responsible for the vl cataract-modifying phenotype. These studies have extended our understanding of the vl locus in three significant ways. One, the cloning of the vl locus has identified a previously uncharacterized GPCR-ligand pathway necessary for neural fold fusion and lens development, providing insight into the molecular regulation of these developmental processes. Two, our QTL analysis has established vl as a mouse model for studying the multigenic basis of NTDs and cataracts. Three, we have identified Foxe3 as a genetic modifier that interacts with Gpr161 to regulate lens development.

Subungual Schwannoma, a Rare Entity: A Case Report and Literature Review.

We present a case of a 26-year-old right hand dominant male landscaper with a slow growing right ring finger subungual mass. MRI confirmed a 0.9 × 1.5 × 0.9 cm well circumscribed subungual mass believed to be consistent with a glomus tumor, although size and symptoms were not consistent with that diagnosis. The mass was completely excised and diagnosis of schwannoma was confirmed by H&E histology. A literature search was performed utilizing the term "subungual schwannoma." Four case reports were found describing this diagnosis in the hand as well as a single case report describing it in the foot. In summary, this is a 26-year-old male who presents with a schwannoma in the unusual subungual location. Although rare, based on our case and the existing literature, subungual schwannomas should be included in the differential diagnosis of a slow growing subungual mass, particularly if symptoms and exam are inconsistent with more common etiologies.

Flap Reconstruction of the Hand.

LEARNING OBJECTIVES: After studying this article, the participant should: 1. Be familiar with local, regional, and free flaps for reconstruction of the hand. 2. Be able to identify potential sources of tissue for vascularized coverage using an algorithmic approach to provide stable and functional reconstruction of the hand. 3. Recognize the controversies and complications unique to flap reconstruction of the hand. SUMMARY: The goal of this continuing medical education module is to provide the practicing reconstructive surgeon with a framework in which to think about reconstruction of the hand. The hand has unique functional and aesthetic characteristics that must be considered when choosing the optimal methods for reconstruction. There are a number of reliable local and regional flaps that can be used to treat the hand requiring soft-tissue coverage and/or vascularized bone graft. The "reconstructive ladder," originally described by Mathes and Nahai, is based on the principle of using the simplest approach that adequately restores form and ideally optimizes function. In cases where the simplest techniques prove to be inadequate, local and regional flaps and, ultimately, microsurgical tissue transfer should be considered.

Strabismus in Unicoronal Craniosynostosis: Effect of Orbital Dysmorphology and Fronto-Orbital Advancement and Remodeling.

BACKGROUND: The purpose of this study was to determine what craniometric changes occur to both orbits of unicoronal craniosynostosis patients undergoing fronto-orbital advancement and remodeling, and which of these changes are associated with new onset of postoperative strabismus. METHODS: A retrospective analysis was performed of the preoperative and postoperative orbits of 24 unicoronal craniosynostosis patients and the orbits of 24 control subjects, totaling 144 orbits. Eight parameters were evaluated using multivariate logistic regression analysis. One of the parameters was modified orbital index, an indicator of severity of harlequin deformity. RESULTS: Significant differences in orbital dimensions and angles were present bilaterally in unicoronal craniosynostosis orbits when compared to controls. Fronto-orbital advancement and remodeling increased the ipsilateral unicoronal craniosynostosis orbital volume from 13,184 ± 2003 mm to 16,220 ± 2323 mm (p < 0.001). Ipsilateral horizontal cone angles were increased from 48 ± 5 degrees to 54 ± 7 degrees (p = 0.004). Ipsilateral vertical cone angles were decreased from 73 ± 8 degrees to 66 ± 10 degrees (p = 0.003). Ipsilateral modified orbital index improved from 0.83 ± 0.06 to 0.88 ± 0.06 (p = 0.003). Three of the 19 unicoronal craniosynostosis patients developed transient postoperative strabismus. Logistic regression analysis displayed a strong significant association between new-onset strabismus and a change in modified orbital index with a coefficient of 30.84 ± 14.51 (p < 0.05). CONCLUSIONS: The orbital dysmorphology in unicoronal craniosynostosis is bilateral in nature, and it is not wholly treated with conventional fronto-orbital advancement and remodeling. The severity of ipsilateral orbital dysmorphology is correlated with the incidence of postoperative strabismus following conventional fronto-orbital advancement and remodeling. Future research is needed to develop strategies to mitigate the risk of development of strabismus in this group of patients. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

Mortality after inpatient open ventral hernia repair: developing a risk stratification tool based on 55,760 operations.

BACKGROUND: The medical complexity of hernia patients imparts higher risk for complications, and mortality is a distinct reality. No study has stratified patients based on preoperative risk for open ventral hernia repair (VHR) specifically. We utilized the American College of Surgeons National Surgical Quality Improvement Program to create a mortality risk stratification model following VHR. METHODS: Patients undergoing open VHR were identified from American College of Surgeons National Surgical Quality Improvement Program databases. Baseline variables correlated with mortality risk were entered into stepwise regression and bootstrap analysis. ß-Coefficients were used to weigh each factor, yielding the risk assessment tool. RESULTS: A total of 55,760 patients were included with a mortality of 1.34%. Predictors of mortality included the following: functional status (odds ratio [OR] = 2.87), liver disease (OR = 3.61), malnutrition (OR = 1.43), age greater than 65 years (OR = 2.39), American Society of Anesthesiologists 4 or higher (OR = 2.90), systemic inflammation (OR = 1.99), and contamination (OR = 2.15). Patients were risk stratified into low risk (mortality .33%), moderate risk (mortality 1.86%), high risk (mortality 8.76%), and extreme risk groups (mortality 34.2%). Unplanned reoperations and medical complications increased across risk groups. The model demonstrated high discriminatory ability with a C-statistic value of .86. CONCLUSIONS: This study provides an accurate model to predict mortality risk specific to open VHR. The strongest predictors were American Society of Anesthesiologists, liver disease, functional status, and older age. This tool may inform clinical decision making to reduce complications.