Neural sheath tumors of the brachial plexus: a multidisciplinary team-based approach.

Peripheral tumors of the brachial plexus, although rare, provide an opportunity for the plastic surgeon to coordinate a multidisciplinary team and achieve excellent outcomes. Most of the case series are reported from the neurosurgical literature. We report on the experience of the Kaiser Permanente Brachial Plexus Clinic over a recent 2-year period. A retrospective review was conducted to examine the medical records, radiographic images, operative reports, and pathologic findings of 13 consecutive patients with peripheral nerve sheath tumors of brachial plexus origin. Of the 10 patients requiring surgical exploration, 90% had significant improvement or resolution of pain, with sensory and motor recovery showing mixed results. Average follow-up consisted of 2 years with occupational therapy beginning shortly after operative intervention. Our results are similar to or better than those published in the literature. The plastic surgeon with subspecialty training can safely and successfully treat tumors of the brachial plexus by implementing a multidisciplinary approach.

Trends in the surgical treatment of cubital tunnel syndrome: an analysis of the national survey of ambulatory surgery database.

PURPOSE: To ascertain trends in the surgical treatment of ulnar nerve compression at the elbow within the United States. METHODS: We analyzed the National Survey of Ambulatory Surgery to study trends in the treatment of cubital tunnel syndrome from 1994 to 2006. The National Survey of Ambulatory Surgery provides a comprehensive overview of ambulatory surgical procedures performed in the United States. Patients identified in the database with surgically treated cubital tunnel syndrome were verified by members of our research staff and compiled into these 3 groups: decompression, transposition, and other. The data were then statistically analyzed for trends in treatment, utilization, and demographics. RESULTS: A total of 52,133 surgical procedures were recorded in the National Survey of Ambulatory Surgery for the treatment of ulnar nerve compression in 2006. This represents an increase from 26,283 in 1994 and 35,406 in 1996. In the 11 years from 1996 to 2006, the total surgical procedures on the ulnar nerve increased by 47%. Transposition went from 49% of all cubital tunnel procedures in the 1990s to 38% in 2006. In 2006, women were much more likely to have a simple decompression (70%) than a transposition or other technique. Decompression had a mean surgical time of 48 minutes, and transposition had a mean surgical time of 59 minutes. CONCLUSIONS: The percentage of transpositions used in the treatment of cubital syndrome has decreased to 37% in the last survey. Possible reasons include expanded indications or changing surgical preferences. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic II.

Endoscopic delivery of calcium phosphate cement for secondary craniofacial reconstruction.

Contour defects are common following primary craniofacial procedures including cranial vault remodeling, fronto-orbital and midface advancements, and complex posttraumatic reconstructions. When onlayed as fast-setting pastes, calcium phosphate cements (CPCs) have been used to effectively correct contour defects in open secondary reconstruction procedures. Here, we describe an endoscopic procedure using an injectable CPC and compare surgical outcomes with the open technique. A retrospective review was conducted for 36 consecutive patients aged 3.0-28.9 years (mean, 10.1 years) who underwent secondary craniofacial reconstruction over a 3-year period. Patients were stratified into endoscopic or open groups depending on the surgical approach utilized. Mean operative time was significantly shorter (P < 0.001) for the endoscopic group (64 minutes) than for the open group (131 minutes). Similarly, hospital stay was significantly shorter (P = 0.005) in the endoscopic group than in the open group. There was also a significant difference with respect to cost (P < 0.001), with the endoscopic approach resulting in a per-patient cost savings of $2208.05. In conclusion, endoscopic delivery of CPC appears to be a safe, efficacious, and cost-effective method of performing secondary craniofacial reconstruction, with the additional benefits of decreased operative time and shorter postoperative hospital stay when compared with an open procedure.

Multifocal lipoblastoma of the face.

Lipoblastoma is a rare benign neoplasm found exclusively in the pediatric population that can occur anywhere in the body, most commonly seen in the extremities but also found in the face. We report an 8-month-old female subject who presented with multifocal soft tissue masses of the face. The diagnosis of lipoblastoma was made in 2 separate locations after surgical resection. Subsequent surgery was performed at the cheek site in an attempt to remove further mass, resulting in discovery of 2 other discrete tumors found to be lipoblastomas. Although the literature reports recurrence rates ranging from 14% to 27%, to our knowledge, aside from a case of Proteus syndrome, there are no known reports of multiple lipoblastomas in the literature. Presentation of the case, review of pertinent literature, and consideration of congenital infiltrative lipomatosis of the face follow.

Neonatal and infant mandibular distraction as an alternative to tracheostomy in severe obstructive sleep apnea.

CONTEXT: Surgical management for severe obstructive sleep apnea has been tracheostomy, which has significant morbidity. OBJECTIVE: To determine the efficacy of internal mandibular distraction in treating severe obstructive sleep apnea in infants and neonates. DESIGN: Retrospective review of medical records of 29 patients who underwent internal mandibular distraction for obstructive sleep apnea secondary to micrognathia. SETTING: Nonprofit, academic, pediatric medical center. PATIENTS: A total of 29 infants with obstructive sleep apnea were studied. Nine were included in the respiratory failure group requiring intubation prior to distraction surgery. The other 20 were included in the respiratory distress group and underwent preoperative polysomnography that assessed the severity of obstructive sleep apnea as measured by the apnea-hypopnea index. One patient expired following surgery; the remaining 28 underwent postoperative polysomnography determining their postoperative apnea-hypopnea index. INTERVENTIONS: Bilateral mandibular distraction with internal microdistractors. MAIN OUTCOME MEASURE: Improvement in the apnea-hypopnea index or extubation. RESULTS: The nine respiratory failure patients avoided tracheostomy and were successfully extubated postdistraction. Eight in this group had postoperative polysomnographies showing a mean apnea-hypopnea index of 3.13 (range, 0 to 13.9). All 20 patients in the respiratory distress group underwent polysomnography and showed improved apnea-hypopnea indices (p < .001). The mean pre-op apnea-hypopnea index was 39.7 (range, 4.5 to 177), and the mean post-op apnea-hypopnea index was 5.8 (range, 0 to 34). Average improvement in the apnea-hypopnea index was 33.9. The mean follow-up period was 18.7 months (1.6 to 45.2 months). CONCLUSIONS: Infants with micrognathia and obstructive sleep apnea may avoid tracheostomy and its inherent risks and complications by undergoing internal mandibular distraction, which is a viable alternative to tracheostomy.

In situ fronto-orbital advancement with medial orbital osteotomies for trigonocephaly-associated hypotelorism.

In treating trigonocephaly, the value of direct surgical correction of orbital hypotelorism is controversial. In many cases of hypotelorism, the distance between the orbits increases over time after traditional fronto-orbital advancement. Still, more severe hypotelorism is not fully corrected and may benefit from a more definitive surgical intervention. We describe an in situ fronto-orbital advancement that improves severe hypotelorism and simplifies the surgical treatment of trigonocephaly. The key modification to traditional fronto-orbital advancement is an in situ medial orbital osteotomy that extends along the medial orbit, posterior to the medial canthus, and then across the inferior orbital rim into the piriform aperture. The procedure is indicated only in patients with more severe hypotelorism on physical examination. Rather than creating a freely removable bandeau during the operation, the bone segment composed of the supraorbital bar and superior orbits remains attached at the medial canthi. A midline osteotomy allows the respective orbital segments to be independently mobilized with the medial canthi left attached, and the space between them widened with gentle lateral traction and placement of an interpositional bone graft. Concomitantly, the lateral orbits and lateral supraorbital bar are contoured, advanced, and fixed with resorbable plates and screws. Representative results are shown. In situ fronto-orbital advancement with medial orbital osteotomies is a safe, efficient, and relatively simple technique that results in immediate improvement of hypotelorism and may be a worthwhile maneuver to consider in selected cases.

Nasofrontal heterotopic ossification following lymphangioma resection.

Heterotopic ossification (HO) is the formation of mature lamellar bone in soft tissues. Heterotopic ossification can occur locally following surgical trauma, most commonly after total hip arthroplasty. Periosteal stripping, organizing hematoma, and extensive soft tissue dissection have been associated with subsequent HO. Craniomaxillofacial HO is rare and almost always associated with injury to the muscles of mastication. We present a report of biopsy-established HO of the cranium. An 18-month-old boy presented with a soft, compressible mass in the forehead midline, which did not extend intracranially on computed tomography scan. Surgical exploration revealed a poorly marginated lymphangioma infiltrating the periosteum of the nasofrontal region. This was debulked to restore nasofrontal contour. Two months postoperatively, after minor accidental trauma, the patient developed a subperiosteal hematoma that was evacuated in the clinic. Eight months postoperatively, the patient returned with a visible nasofrontal prominence overlying a firm immobile mass. Computed tomography scan revealed a 3-cm horn-like osseous structure extending inferiorly from the frontal bone across the nasofrontal junction. The bony mass was resected via a coronal approach and confirmed as HO with hematopoietically active marrow.

Subpectoral Implant Repositioning With Partial Capsule Preservation: Treating the Long-Term Complications of Subglandular Breast Augmentation.

BACKGROUND: Patients with long-term complications associated with subglandular breast augmentation are being seen in increasing numbers in the Southern California community. Late deformities include a characteristic "slide-down" deformity as well as capsular contracture, implant wrinkling, and nipple-areola complex enlargement. Repositioning the implant to a subpectoral pocket is a recognized revisionary technique to treat this problem; however, technical details of how this is accomplished are lacking in the literature. OBJECTIVES: To review our technique for treating long-term complications associated with subglandular implants using subpectoral repositioning with partial capsule preservation and mastopexy, without the need for an acellular dermal matrix (ADM) or mesh. METHODS: A retrospective review of all patients undergoing subpectoral repositioning over the course of 6 years was performed. Patient data and long-term outcomes were assessed. A technique is presented utilizing a partial capsulectomy that preserves a portion of the capsule as an ADM/mesh equivalent, ensuring adequate implant coverage and preventing window shading of the pectoralis major muscle. RESULTS: Twenty-four patients with subglandular implants and slide-down deformity as well as other associated complications including capsular contracture, implant wrinkling, and enlarged areolas underwent revision surgery with a subpectoral site change. Often, patients presented many years after their initial augmentation (mean 18 years, range 4-38 years). The average patient follow-up was 3.1 years (range 1.0-6.8 years). Two patients required minor revisions with local anesthetic, while another 2 revisions required general anesthesia. CONCLUSIONS: Long-term deformities associated with subglandular breast augmentation can reliably be corrected by subpectoral repositioning, mastopexy, and utilization of residual breast capsule in the place of an ADM or mesh.

Capsulorrhaphy for revisionary breast surgery.

BACKGROUND: Despite more than 3 million breast implant surgeries performed to date, the common sequela of implant malposition is a problem to which little attention has been paid in the literature. It can be treated predictably and relatively simply with capsulorrhaphy and mirror-image capsulotomy. Additionally, capsulorrhaphy can be used to reduce the size of the implant pocket when changing to a smaller implant. METHODS: Several capsulorrhaphy techniques have emerged that allow a more precise result with less effort. In almost all cases of implant malposition, a mirror-image capsulotomy was performed to decrease the tension on the capsulorrhaphy repair. Silicone gel-filled implants were placed in all cases. RESULTS: Seventy-five patients underwent capsulorrhaphy for implant malposition or implant size reduction between May 2002 and March 2006. Of these patients, just under half (49%) had an accompanying mastopexy. Excision of capsular tissue and prolonged taping of the breasts were found not to be necessary. Average follow-up was 21 months; no complications were reported. CONCLUSIONS: The current technique of capsulorrhaphy and mirror-image capsulotomy has demonstrated satisfactory improvement in implant malposition, without the need for excision of capsular tissue or prolonged taping. Patients did report that their postoperative discomfort was greater than anticipated.

Trends in the incidence and treatment of necrotizing soft tissue infections: an analysis of the National Hospital Discharge Survey.

Necrotizing soft tissue infections are a rare but potentially fatal condition of the soft tissues caused by virulent, toxin-producing bacteria. In the United States, there is an estimated annual incidence of 0.04 cases per 1000 annually, but previous estimates of the Centers for Disease Control and Prevention had the incidence at 500 to 1500 cases yearly. Early reports of mortality were variable with rates ranging from 46 to 76% but outcomes have been improving over time. The National Hospital Discharge Survey was analyzed to study current trends in the demographics, incidence, use, and mortality of patients diagnosed with necrotizing soft tissue infections. The authors analyzed the 1999, 2002, and 2007 National Hospital Discharge Survey by using a sampling weighting method. A total of 13,648 cases of necrotizing soft tissue infections were identified in 2007. This represents an increase from 12,153 cases in 2002 and 6612 cases in 1999. In the 9 years from 1999 to 2007 the gross incidence of necrotizing soft tissue infections more than doubled. Hospital stay was essentially unchanged within study years, at 16 days. Mean age increased from approximately 50 years in 1999 to 54 years in 2007. Further, mortality went from 10.45% in 1999 to 9.75% in the 2007 survey. The population-adjusted incidence rate increased 91% in the studied years. Rising use of immunosupression, exponential growth in the incidence of obesity, and type 2 diabetes could be a major contributing factor. The mortality rate is far below the rate in reports published from as early as 20 years ago, and at 9.75% compares with modern case series, but is a more accurate measure of mortality in this condition.

rhBMP-2 with a demineralized bone matrix scaffold versus autologous iliac crest bone graft for alveolar cleft reconstruction.

BACKGROUND: Secondary alveolar cleft reconstruction using autologous iliac crest bone graft is currently the standard treatment for alveolar clefts. Although effective, harvesting autologous bone may result in considerable donor-site morbidity, most commonly pain and the potential for long-term sensory disturbances. In an effort to decrease patient morbidity, a novel technique using recombinant human bone morphogenetic protein (rhBMP)-2 encased in a demineralized bone matrix scaffold was developed as an alternative to autografting for secondary alveolar cleft reconstruction. METHODS: A chart review was conducted for the 55 patients who underwent secondary alveolar cleft reconstruction over a 2-year period with a mean follow-up of 21 months. Of these, 36 patients received rhBMP-2/demineralized bone matrix scaffold (including 10 patients with previously failed repairs using iliac crest bone grafting) and 19 patients underwent iliac crest bone grafting. Postoperatively, bone stock was evaluated using occlusal radiographs rated according to the Bergland and Chelsea scales. RESULTS: Alveolar clefts repaired using rhBMP-2/demineralized bone matrix scaffold were 97.2 percent successful compared with 84.2 percent with iliac crest bone grafting. Radiographically, initial repairs with rhBMP-2/demineralized bone matrix scaffold were superior to iliac crest bone grafting according to both Bergland and Chelsea scales, and significantly more patients in the rhBMP-2/demineralized bone matrix scaffold group had coronal bridging. The postoperative intraoral infection rate following iliac crest bone grafting was significantly greater than for rhBMP-2/demineralized bone matrix scaffold. The cost of rhBMP-2/demineralized bone matrix scaffold products was offset by cost savings associated with a reduction in operative time averaging 102 minutes. CONCLUSIONS: rhBMP-2 encased in a demineralized bone matrix scaffold appears to be a viable alternative for secondary alveolar cleft repair. Patients are spared donor-site morbidity and achieve excellent results, decreasing operative time, and increasing operating room use. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

The variation in the absence of the palmaris longus in a multiethnic population of the United States: an epidemiological study.

The absence of the palmaris longus (PL) has been shown to vary based on body side, gender, and ethnicity. In prior studies, homogenous ethnic populations have been shown to have differences in rates of absence. However, no study thus far has analyzed the differences in palmaris longus prevalence in a multiethnic population. We prospectively collected data on 516 patients visiting the outpatient hand clinics at LAC+USC Medical Center and Keck Medical Center. Analysis of the data was then performed for variables including ethnicity, laterality, and gender. There were no differences in the absence of the PL based on laterality or gender. Ethnically, there was no difference between white (non-Hispanic) and white (Hispanic) patients, with prevalence of 14.9% and 13.1%, respectively. However, African American (4.5%) and Asian (2.9%) patients had significantly fewer absences of the PL than the Caucasian, Hispanic reference group (P = 0.005 and P = 0.008, resp.). African Americans and Asians have a decreased prevalence of an absent PL. The Caucasian population has a relatively greater prevalence of an absence of the PL. This epidemiological study demonstrates the anatomic variation in this tendon and may be taken into account when planning an operation using tendon grafts.

Hypertrophic scarring in cleft lip repair: a comparison of incidence among ethnic groups.

BACKGROUND: Although hypertrophic scar (HTS) formation following cleft lip repair is relatively common, published rates vary widely, from 1% to nearly 50%. The risk factors associated with HTS formation in cleft patients are not well characterized. The primary aim of this retrospective study of 180 cleft lip repairs is to evaluate the frequency of postoperative HTS among various ethnic groups following cleft lip repair. METHODS: A retrospective chart view of patients undergoing primary cleft lip repair over a 16-year period (1990-2005) by the senior surgeon was performed. The primary outcome was the presence of HTS at 1 year postoperatively. Bivariate analysis and multivariable logistic regression were used to evaluate potential risk factors for HTS, including ethnicity, type and laterality of cleft, and gender. RESULTS: One hundred and eighty patients who underwent cleft lip repair were included in the study. The overall rate of postoperative HTS formation was 25%. Ethnicity alone was found to be an independent predictor of HTS formation. Caucasian patients had the lowest rate of HTS formation (11.8%) and were used as the reference group. HTS rates were significantly higher in the other ethnicities, 32.2% in Hispanic patients (odds ratio [OR]: 3.51; 95% confidence interval [CI]: 1.53-8.85), and 36.3% for Asian patients (OR 4.27; 95% CI: 1.36-13.70). Sex, cleft type, and cleft laterality were not associated with increased rates of HTS. CONCLUSIONS: Differences in ethnic makeup of respective patient populations may be a major factor influencing the wide variability of reported HTS rates. Consideration should be given to potential prophylactic treatments for HTS in susceptible ethnic populations.

Fluidic lens laparoscopic zoom camera for minimally invasive surgery.

This work reports a miniaturized laparoscopic zoom camera that can significantly improve vision for minimally invasive surgery (MIS), also known as laparoscopic surgery. The laparoscopic zoom camera contains bioinspired fluidic lenses that can change curvature and focal length in a manner similar to the crystalline lenses in human eyes. The traditional laparoscope is long, rigid, and made of fixed glass lenses with a fixed field of view. The constricted vision of a laparoscope is often an inconvenience and plays a role in many surgical injuries. To further advance MIS technology, we developed a new type of laparoscopic camera that has a total length of less than 17 mm, greater than 4x optical zoom, and 100 times higher sensitivity than today's laparoscope allowing it to work under illumination as low as 300 lux. All these unique features are enabled by the technology of bioinspired fluidic lenses having a dynamic range over 100 diopters and being convertible between a convex and concave shape.

Nonalcoholic fatty liver disease as a comorbidity of childhood obesity.

Childhood obesity is a worldwide health problem associated with an increase in the prevalence and severity of comorbid conditions including nonalcoholic fatty liver disease (NAFLD). The increasing number of children with NAFLD presents a major public health concern. This review focuses on the recent advancements in the understanding of the epidemiology, diagnosis, histology, pathogenesis and treatment of pediatric NAFLD and highlights ongoing challenges and unmet needs in the area.

The emergence of hematopoietic stem cells is initiated in the placental vasculature in the absence of circulation.

The mouse placenta was unveiled as an important reservoir for hematopoietic stem cells (HSCs), yet the origin of placental HSCs was unknown. By tracking developing HSCs by expression of Runx1-lacZ and CD41, we have found that HSCs emerge in large vessels in the placenta. Analysis of Ncx1(-/-) embryos, which lack a heartbeat, verified that HSC development is initiated in the placental vasculature independent of blood flow. However, fewer CD41+ hematopoietic cells were found in Ncx1(-/-) placentas than in controls, implying that some HSCs/progenitors colonize the placenta via circulation and/or HSC emergence is compromised without blood flow. Importantly, placentas from Ncx1(-/-) embryos possessed equal potential to generate myelo-erythroid and B and T lymphoid cells upon explant culture, verifying intact multilineage hematopoietic potential, characteristic of developing HSCs. These data suggest that, in addition to providing a niche for a large pool of HSCs prior to liver colonization, the placenta is a true site of HSC generation.