Liposomal Bupivacaine Use During Orthognathic Surgery in Cleft Lip and Palate Patients.

INTRODUCTION: Effective pain management is crucial in cleft lip and palate (CLP) patients undergoing orthognathic surgery for earlier recovery and decreased opioid reliance. Liposomal bupivacaine (Exparel) is a local anesthetic that provides extended postoperative analgesia in adult patients; however, research on its use in adolescents is limited. This study explores the efficacy of liposomal bupivacaine for postoperative pain management in adolescent CLP patients undergoing orthognathic surgery. METHODS: The authors performed a retrospective chart review at their institution between July 2020 and December 2022 to identify patients who underwent LeFort I or mandibular osteotomy. Two cohorts were compared: patients who received liposomal bupivacaine and patients who received standard pain medications alone. Outcome measures included intraoperative pain medications, length of stay, breakthrough opioid use, time to first oral intake, volume of oral intake, and opioids prescribed at discharge. RESULTS: This study included 22 patients who underwent orthognathic surgery. The liposomal bupivacaine group (n=10) demonstrated earlier and greater oral intake during hospitalization compared with controls (n=12). The most significant difference was observed in total breakthrough opioid use, with an average of 8.60 morphine milligram equivalents for liposomal bupivacaine patients compared with 35.1 morphine milligram equivalents for controls (P=0.037). CONCLUSIONS: This study provides the first analysis of liposomal bupivacaine use in adolescent CLP patients undergoing orthognathic surgery, demonstrating a significant reduction in postoperative opioid consumption compared with controls. These results may guide future studies of liposomal bupivacaine within CLP patients, potentially as a component of enhanced recovery after surgery guidelines, as well as in cost-analysis studies.

Velopharyngeal Insufficiency Following Furlow Versus Straight Line Repair With Intravelar Veloplasty: A Single-institution Experience.

BACKGROUND: Measurements of postoperative velopharyngeal dysfunction (VPD) can be used to determine the efficacy of a palatoplasty operation. Hypernasality and audible nasal air emission are typical manifestations of VPD during speech. We aimed to longitudinally compare VPD outcomes in postpalatoplasty patients who underwent Furlow repair versus straight line repair with intravelar veloplasty (IVVP). Additionally, we examined the relationship between VPD outcomes and select pre-existing patient characteristics. METHODS: Retrospective chart review was performed to identify primary palatoplasty patients treated from April 2012 to March 2021. Variables collected included gender, syndromic status, primary language, Veau cleft type, type of speech assessment, age at time of surgery, degree of hypernasality, presence of audible nasal air emission, and overall adequacy of velopharyngeal function. Pearson χ2 test and multivariable t tests were used to analyze variables. Logistic regression was used to control for statistically significant variables. RESULTS: Of the 118 patients included, 38 received a Furlow procedure and 80 received a straight line with IVVP procedure. Audible nasal air emission was present in 57.3% of straight line with IVVP patients and 42.9% of Furlow patients, with no statistically significant difference between groups. Clinically significant hypernasality was present in 42.1% of straight line with IVVP patients and 22.9% of Furlow patients (P=0.05). Velopharyngeal function was classified as adequate in 63.5% of straight line with IVVP patients and 83.3% of Furlow patients (P=0.03). However, after stratifying by syndromic versus nonsyndromic status, there was no statistically significant difference between straight line with IVVP and Furlow patients for postoperative hypernasality and velopharyngeal function. CONCLUSIONS: This study suggests that there are no statistically significant differences between straight line with IVVP and Furlow palatoplasty techniques regarding speech outcomes including hypernasality, audible nasal air emission, and overall VP function. Furthermore, select patient characteristics such as gender, primary language, syndromic status, age at repair, and Veau cleft type do not significantly impact postoperative speech outcomes.

A Unique Case of Intrauterine Pressure Injury.

ABSTRACT: The authors present a review of the literature regarding pressure injuries (PIs) in neonates and a case of a newborn who developed a PI following a prolonged labor process and fetal malposition. A girl born at 35 weeks' gestation to a 34-year-old gravida 7 para 6 mother with a medical history of untreated gestational diabetes, preeclampsia, and COVID-19 was delivered via cesarean section after failure to progress through labor. The premature infant was found to have a 3.2 × 2.3-cm PI at the nape of the posterior neck. Premature infants have a histologically proven, age-dependent decreased thickness of their stratum corneum, epidermis, and dermis, which places them at increased risk of developing PIs that can be painful and lead to infection. In the present case, the neonate's congenital PI was successfully treated with medical-grade honey for approximately a month.

Referring patients with suspected lung cancer: a qualitative study with primary healthcare professionals in Ireland.

Lung cancer is the leading cause of cancer death globally. Most cases are diagnosed late. Primary healthcare professionals are often the first point of contact for symptoms of concern. This study explored primary healthcare professionals' experience of referring individuals with signs and symptoms suggestive of lung cancer along the appropriate healthcare pathway and explored strategies to help primary healthcare professionals detect lung cancer early. Focus groups and individual interviews were conducted with 36 general practitioners, community pharmacists, practice nurses, and public health nurses. Data were analysed thematically. Participants identified typical lung cancer signs and symptoms such as cough and coughing up blood (i.e., haemoptysis) as triggers for referral. Atypical/non-specific signs and symptoms such as back pain, pallor, and abnormal blood tests were perceived as difficult to interpret. Participants often refrained from using the word 'cancer' during conversations with patients. Ireland's Rapid Access Lung Clinics were perceived as underused, with some general practitioners referring patients to these clinics only when clear and definitive lung cancer signs and symptoms are noted. Lack of communication and the resulting disruption in continuity of care for patients with suspected lung cancer were highlighted as healthcare system flaws. Education on early referral can be in the form of communications from professional organizations, webinars, interdisciplinary meetings, education by lung specialists, and patient testimonials. Lung cancer referral checklists and algorithms should be simple, clear, and visually appealing, either developed as standalone tools or embedded into existing primary care software/programmes.

Rotavirus vaccination impact, Ireland, implications for vaccine confidence and screening.

BACKGROUND: Rotavirus vaccine efficacy is well established. However, it is important to consistently demonstrate the positive impact of vaccination programmes in order to optimize uptake rates and combat vaccine hesitancy. METHODS: Routine data were used to examine rotavirus vaccine effectiveness in Ireland, including changes in age-specific crude incidence rates (CIRs), hospitalizations and hospital length of stay. National intussusception incidence was interrogated. Vaccination status of vaccine-eligible cases of rotavirus infection was determined. RESULTS: Nationally, a reduction in the CIR of rotavirus infection of 77.2% [95% confidence interval (CI) 57.8-88.5%, P<0.001] was observed post-inclusion of the rotavirus vaccine in the primary immunization schedule. A decrease in hospitalizations of 85.5% (95% CI 79.3-90.2%, P<0.001), 86.5% (95% CI 82.9-89.4%, P<0.001) and 78.5% (95% CI 74.7-81.9%, P<0.001) was observed in children aged <1, <2 and <5 years, respectively. Most hospitalizations occurred in infants too young to have been vaccinated. There was no significant difference in median length of stay for children hospitalized with rotavirus infection. Decreased CIRs and hospitalization rates in unvaccinated children aged between 2 and 5 years suggest community immunity. Vaccine non-protection was 0.13%. No increase in the national CIR of intussusception was observed. CONCLUSIONS: Inclusion of the rotavirus vaccine in the Irish primary immunization schedule has resulted in a significant reduction in the burden of rotavirus infection. However, vaccine hesitancy remains a concern. With new vaccination programmes, risk of vaccine harms should be considered and mitigated in order to protect individuals and the integrity of the programme.

Gabapentin Enacarbil Extended-Release for Alcohol Use Disorder: A Randomized, Double-Blind, Placebo-Controlled, Multisite Trial Assessing Efficacy and Safety.

BACKGROUND: Several single-site alcohol treatment clinical trials have demonstrated efficacy for immediate-release (IR) gabapentin in reducing drinking outcomes among individuals with alcohol dependence. The purpose of this study was to conduct a large, multisite clinical trial of gabapentin enacarbil extended-release (GE-XR) (HORIZANT® ), a gabapentin prodrug formulation, to determine its safety and efficacy in treating alcohol use disorder (AUD). METHODS: Men and women (n = 346) who met DSM-5 criteria for at least moderate AUD were recruited across 10 U.S. clinical sites. Participants received double-blind GE-XR (600 mg twice a day) or placebo and a computerized behavioral intervention (Take Control) for 6 months. Efficacy analyses were prespecified for the last 4 weeks of the treatment period. RESULTS: The GE-XR and placebo groups did not differ significantly on the primary outcome measure, percentage of subjects with no heavy drinking days (28.3 vs. 21.5, respectively, p = 0.157). Similarly, no clinical benefit was found for other drinking measures (percent subjects abstinent, percent days abstinent, percent heavy drinking days, drinks per week, drinks per drinking day), alcohol craving, alcohol-related consequences, sleep problems, smoking, and depression/anxiety symptoms. Common side-effects were fatigue, dizziness, and somnolence. A population pharmacokinetics analysis revealed that patients had lower gabapentin exposure levels compared with those in other studies using a similar dose but for other indications. CONCLUSIONS: Overall, GE-XR at 600 mg twice a day did not reduce alcohol consumption or craving in individuals with AUD. It is possible that, unlike the IR formulation of gabapentin, which showed efficacy in smaller Phase 2 trials at a higher dose, GE-XR is not effective in treating AUD, at least not at doses approved by the U.S. Food and Drug Administration for treating other medical conditions.

Transplantation sites for porcine islets.

AIMS/HYPOTHESIS: Xenotransplantation has great potential to provide beta cell replacement and thereby provide a cure for large numbers of people with type 1 diabetes. Crucial to the success of xenotransplantation is establishment of the most viable sites for transplantation. METHODS: We compared porcine islet tissue transplanted into kidney, liver and spleen in pig recipients as assessed by blood glucose levels and IVGTT. RESULTS: Kidney was the superior site for porcine islet tissue transplantation, followed by liver then spleen. This was demonstrated by IVGTTs showing significant difference between the peak glucose levels: 22.8 ± 2.9 mmol/l for kidney compared with 26.8 ± 1.3 mmol/l for spleen and 24.7 ± 1.7 mmol/l for liver. CONCLUSIONS/INTERPRETATION: Kidney grafts are not as feasible in humans and liver results were relatively poorer than spleen. For islet transplantation to be viable and successful in the longer term, there remains a need for future investigation of alternative sites.

Ex vivo-expanded baboon CD39 + regulatory T cells prevent rejection of porcine islet xenografts in NOD-SCID IL-2rγ-/- mice reconstituted with baboon peripheral blood mononuclear cells.

BACKGROUND: A high immunosuppressive burden is required for long-term islet xenograft survival in non-human primates even using genetically modified donor pigs. AIMS: We aimed to investigate the capacity of baboon regulatory T cells (Treg) to suppress islet xenograft rejection, thereby developing a potential immunoregulatory or tolerance therapy that could be evaluated in NHP models of xenotransplantation. MATERIALS & METHODS: Baboon Treg expanded with stimulation by porcine peripheral blood mononuclear cells (PBMC) were characterized by cell phenotyping and suppressive activity assays in vitro. Their function in vivo was evaluated in neonatal porcine islet cell clusters (NICC) transplanted NOD-SCID IL-2rγ-/- (NSG) mice receiving baboon PBMC alone or with expanded autologous Treg. RESULTS: The majority of expanded Treg coexpressed Foxp3 and CD39 and were highly suppressive of the baboon anti-pig xenogeneic T cell response in vitro. Reconstitution of mice with baboon PBMC alone resulted in NICC xenograft rejection within 35 days. Cotransfer with baboon PBMC and Treg prolonged islet xenograft survival beyond 100 days, correlating with Treg engraftment, intragraft CD39 and Foxp3 gene expression, and reduced graft infiltrating effector T cells and reduced interferon-γ production. DISCUSSION & CONCLUSION: Our data supports the capacity of ex vivo expanded CD39+ baboon Treg to suppress islet xenograft rejection in primatized mice, suggesting it has potential as an adjunctive immunotherapy in preclinical NHP models of xenotransplantation.

Plastic surgeon closure is comparable to orthopedic closure when a perioperative optimization protocol is instituted for pediatric patients with neuromuscular scoliosis.

BACKGROUND CONTEXT: Since 2015, plastic multilayer closure (PMC) has been gaining attraction due to improved wound healing outcomes for medically complex patients. Plastic multilayer closure has been readily used for complex spine surgery closures in patients susceptible to wound healing issues (ie, dehiscence, surgical site infection [SSI]). However, PMC requires extensive soft tissue manipulation compared with standard orthopedic spine surgeon closure (SOC) and can result in extended operative times, increased transfusion rates, and more frequent returns to the operating room. PURPOSE: From 2016 to 2019, our institution implemented a perioperative protocol designed to decrease postoperative complication rates in NMS patients. A retrospective cohort study was performed to determine if PMC imparted advantages over SOC above and beyond that from the perioperative protocol. STUDY DESIGN/SETTING: Retrospective study at a single academic institution. PATIENT SAMPLE: Eighty-one pediatric patients with neuromuscular scoliosis undergoing spinal fixation surgery. OUTCOME MEASURES: Postoperative wound complications such as surgical site infection, hematoma, and superficial/deep dehiscence were the main outcome measures. Respiratory and neuromuscular complications along with duration of surgery were also recorded. METHODS: A retrospective review was conducted of NMS patients undergoing spinal fixation at a single academic pediatric hospital over 4 years. Cases were labeled as SOC (n=41) or PMC (n=40) based on the closure technique applied. Reported 90-day complications were evaluated as the primary outcome. RESULTS: Of the 81 reviewed patients, 45 reported complications, roughly equal between the study groups. While we found no statistically significant differences in rates of postoperative complications or SSIs, SOC cases were 30 minutes shorter on average with fewer returns to the operating room for additional surgery. CONCLUSIONS: With the implementation of our perioperative protocol for NMS patients, PMC did not result in fewer complications than SOC but the surgeries did take longer.

Staged breast reconstruction utilizing primary nipple repositioning surgery prior to nipple-sparing mastectomy.

Staged nipple-sparing mastectomy (NSM) following mastopexy or breast reduction has become increasingly utilized in patients with large or ptotic breasts. The safety and efficacy of this approach has been demonstrated in recent years. However, the optimal timing between stages has not been established. The authors provide their experience with this staged approach with emphasis on timing between stages. An institutional review board approved this retrospective study. Data of all patients at a single institution who underwent staged NSM following mastopexy or reduction mammaplasty for therapeutic or prophylactic oncologic surgical management from 2016 to 2020 were reviewed. Timing between stages as well as surgical, oncologic, aesthetic, and patient-reported outcomes were evaluated. Nineteen patients (38 breasts) underwent staged NSM following planned mastopexy/breast reduction. The mean time interval between stages was 25 weeks. No patients developed nipple areolar complex necrosis. Infection and hematoma were seen in one breast (2.6%) and seroma in two (5.3%) after NSM. Delayed wound healing was seen in eight breasts (21.1%) after first stage mastopexy/reduction and in 12 breasts (31.6%) after NSM. Skin flap necrosis was noted in two breasts (5.3%) after NSM. No patients developed oncological recurrence. Mean patient-reported post-operative satisfaction and well-being scores were 63 and 67 out of 100, respectively. The authors describe their experience with staged NSM following nipple repositioning procedures. Their results suggest that this procedure can be performed safely with cosmetically favorable results if surgeons wait an average of 25 weeks between first and second stage procedures.

Intragraft memory-like CD127hiCD4+Foxp3+ Tregs maintain transplant tolerance.

CD4+Foxp3+ regulatory T cells (Tregs) play an essential role in suppressing transplant rejection, but their role within the graft and heterogeneity in tolerance are poorly understood. Here, we compared phenotypic and transcriptomic characteristics of Treg populations within lymphoid organs and grafts in an islet xenotransplant model of tolerance. We showed Tregs were essential for tolerance induction and maintenance. Tregs demonstrated heterogeneity within the graft and lymphoid organs of tolerant mice. A subpopulation of CD127hi Tregs with memory features were found in lymphoid organs, presented in high proportions within long-surviving islet grafts, and had a transcriptomic and phenotypic profile similar to tissue Tregs. Importantly, these memory-like CD127hi Tregs were better able to prevent rejection by effector T cells, after adoptive transfer into secondary Rag-/- hosts, than naive Tregs or unselected Tregs from tolerant mice. Administration of IL-7 to the CD127hi Treg subset was associated with a strong activation of phosphorylation of STAT5. We proposed that memory-like CD127hi Tregs developed within the draining lymph node and underwent further genetic reprogramming within the graft toward a phenotype that had shared characteristics with other tissue or tumor Tregs. These findings suggested that engineering Tregs with these characteristics either in vivo or for adoptive transfer could enhance transplant tolerance.

Pediatric Microsurgery and Free-Tissue Transfer.

Advancements in microsurgery, along with increased microsurgical experience in pediatric patients, have made free-tissue transfer a reliable modality for pediatric bone and soft tissue reconstruction today. Free-tissue transfer is most commonly used in children for the coverage of large or complex defects resulting from traumatic, oncologic, or congenital etiologies. While flap success and complication rates between pediatric and adult populations are similar, special considerations must be taken into account within the pediatric population. In this article, we will describe common indications, technical nuances, and clinical considerations for the management of the pediatric free-tissue transfer patient.

Seminars in Plastic Surgery: Pediatric Ear Anomalies and Reconstruction.

Congenital ear anomalies affect 15 to 20% of neonates and can be categorized as either auricular deformations or malformations. Deformations involve a fully developed, albeit abnormally shaped, chondrocutaneous framework, which makes them amenable to correction with ear molding within the first few months of life. Malformations involve hypoplastic or fully absent auricular structures that require augmentation with alloplastic and/or autogenous reconstruction. The goal of this article is to outline the various auricular deformities and malformations, followed by a description of the latest clinical management options, both nonsurgical and surgical, by auricular anomaly.

Craniofacial Distraction Osteogenesis.

Distraction osteogenesis (DO) of the craniofacial skeleton has become an effective technique for the treatment of both nonsyndromic and syndromic conditions. The advent of craniofacial DO has allowed for earlier intervention in pediatric patients with less complication risk and morbidity compared to traditional techniques. In this review, we will discuss current application and technique for craniofacial DO by anatomical region and explore future applications in craniofacial surgery.

Robotic Plastic Surgery Education: Developing a Robotic Surgery Training Program Specific to Plastic Surgery Trainees.

Over the past two decades, the surgical community has increasingly embraced robotic-assisted surgery (RAS) due to its potential to enhance accuracy and decrease surgical morbidity. Plastic surgery as a field has been historically slow to incorporate RAS, with lack of adequate training posing as one of the most commonly cited barriers. To date, robot technology has been utilized for various reconstructive procedures including flap elevation and inset, pedicle dissection, and microvascular anastomosis. As RAS continues to integrate within plastic surgery procedures, the need for a structured RAS curriculum designed for plastic surgery trainees is rising. This article delineates the essential components of a plastic surgery-specific RAS curriculum and outlines current training models and assessment tools utilized across surgical subspecialties to date.

Robotics in Microsurgery and Supermicrosurgery.

Microsurgery has changed the ability to perform highly precise and technical surgeries through the utilization of high-powered microscopes and specialized instruments to manipulate and repair anatomical structures as small as a few millimeters. Since the first human trials of robotic-assisted microsurgery in 2006, the expansion of microsurgery to supermicrosurgery (luminal diameter less than 1 mm) has enabled successful repair of previously inaccessible structures. Surgical robotic systems can offer two distinct operative advantages: (1) minimal access surgery-by entering body cavities through ports, flap harvest can be redesigned to affect a minimally invasive approach for flaps such as the rectus abdominis muscle, the latissimus flap, and the deep inferior epigastric perforator flap; and (2) precision-by eliminating physiologic tremor, improving ergonomics, increasing accessibility to difficult spaces, and providing motion scaling, precision is significantly enhanced. Robotic-assisted microsurgery is a promising application of robotics for the plastic surgeon and has played an important role in flap harvest, head and neck reconstruction, nerve reconstruction, gender-affirming surgery, and lymphatic reconstruction-all the while minimizing surgical morbidity. This article aims to review the history, technology, and application of microsurgery and supermicrosurgery in plastic surgery.