Posterior pharyngeal augmentation in the treatment of velopharyngeal insufficiency: a 40-year experience.

BACKGROUND: Velopharyngeal insufficiency (VPI) remains a common problem in the care of patients with cleft palate and other related conditions. It may be successfully corrected with augmentation of the posterior pharynx. The purpose of this study was to review the experience and results of posterior pharyngeal augmentation over a 40-year period at one cleft center in the United States. METHODS: All patients from 1968 to 2008 who underwent posterior pharyngeal augmentation for the treatment of VPI were reviewed retrospectively. Diagnosis, age at the time of operation, type of implant used, duration of follow-up, speech performance both pre- and postoperatively, and complications were analyzed. Speech performance preoperatively was assessed by video fluoroscopy and/or nasoendoscopy. Resonance was assessed by both the surgeon and speech pathologist using a 4 point grading scale. RESULTS: One hundred eleven patients underwent posterior pharyngeal augmentation. Thirteen patients required removal of the implant because of extrusion (n = 12) or postoperative sleep apnea (n = 1). Five patients with failed implants at the primary operation had successful replacement at a second operation, resulting in a retained implant success rate of 93%. Of the 103 patients who were successfully augmented, 15 were lost to follow-up, leaving 88 patients with full postoperative speech evaluations. Of the 88 patients evaluated, 64 exhibited normal or near normal speech (73%), 22 patients had mildly nasal speech (25%), and 2 patients (2%) were not improved. Highest extrusion rates were seen for smooth surface silicone and rolled gortex implants. CONCLUSION: Augmentation of the posterior pharyngeal wall is a safe and effective treatment for patients with VPI. Implants are well tolerated and speech is substantially improved.

Techniques for labia minora reduction: an algorithmic approach.

BACKGROUND: Aesthetic reduction of the labia minora has gained popularity, and a number of different techniques have been described. Each procedure has its own set of advantages and disadvantages. However, no algorithm has been defined for pairing the degree of deformity with the optimal surgical procedure. METHODS: Patients were stratified into one of four groups based on labial size. The surgeon chose one of three reduction techniques based on the degree of labial hypertrophy and the patient's aesthetic preferences for labial edge color and contour. Three reduction techniques were used including the edge excision technique, the inferior wedge resection technique, and deepithelialization reduction labioplasty. The success of aesthetic reduction was evaluated, as was symptomatic relief. RESULTS: The 12 procedures performed included five deepithelialization techniques, four edge excision techniques, and three inferior wedge resection techniques. As reported, 92% of the patients were "very satisfied" with their aesthetic and functional results. The complications were minimal, with three patients experiencing minor wound healing difficulties that resolved spontaneously. One patient who underwent the edge excision technique was "not satisfied" and complained of overreduction. CONCLUSION: The authors found all three techniques for labia minora reduction to be useful in different clinical situations. A novel algorithm is described for matching the optimal surgical technique for each patient based on her degree of hypertrophy and aesthetic goals.

Objective indications for early tracheostomy after blunt head trauma.

BACKGROUND: Early tracheostomy has been shown to be beneficial after trauma; however, there are few objective data to identify early in the recovery period which patients will ultimately require tracheostomy after blunt head trauma. METHODS: The charts of all patients admitted to the surgical intensive care unit intubated at a level 1 urban trauma center, over a 5-year period with a primary admission diagnosis of blunt head trauma were retrospectively reviewed. RESULTS: Sixty-four patients met inclusion and exclusion criteria and were divided into two groups: those extubated and those that required tracheostomy. By day 3 the Glasgow Coma Scores for the two groups were significantly different and on day 4 the Simplified Acute Physiology (SAPS) Scores were significantly different. CONCLUSIONS: Calculating objective scores such as GCS and SAPS can aid in identifying those patients who will ultimately require a tracheostomy for prolonged airway protection after blunt head trauma with high positive predictive value.

Minimally invasive lateral canthopexy (MILC).

Many techniques have been described for lateral canthopexy. Here, we describe a technical modification of lateral canthopexy that involves percutaneous placement of a canthopexy suture through the confluence of the lateral superior and inferior grey lines or lateral canthal angle. A total of 52 canthopexies in 26 patients have been performed with excellent results and few complications. Our lateral canthopexy modification is a minimally invasive technique that is simple to perform, with absolute assurance of capturing the lateral canthal tendon.

Spectral imaging for precise surgical intervention in Hirschsprung's disease.

We used advanced spectral imaging for intrasurgical decision making in a preclinical study, on a mouse model of Hirschsprung's Disease. Our imaging device sampled areas from normal and abnormal (aganglionic) colon in these animals. Spectral segmentation and classification of the resulting images showed a clear distinction between the normal and aganglionic regions, as confirmed by pathological analysis and use of mutant mice. We developed a simple algorithm that could distinguish normal from aganglionic colon with high spatial resolution and reproducibility, and the following statistics: sensitivity = 97%, specificity = 94%, positive predictive value = 92%, negative predictive value = 98%. These studies showed translational proof of concept that spectral imaging could be used during operations, in real time, to help surgeons precisely distinguish normal from abnormal tissue without requiring traditional biopsy.

Use of acellular cadaveric dermis and tissue expansion in postmastectomy breast reconstruction.

Tissue expander or permanent implant coverage in postmastectomy breast reconstruction is often challenging. Multiple authors have demonstrated the use of acellular cadaveric dermis (ACD) in nonexpansive, single-stage breast reconstruction. The literature also suggests that tissue expansion may be accomplished with ACD as well for stage reconstructions. In many cases tissue expansion is necessary to create a submuscular and subACD pocket to accommodate a subsequent permanent prosthesis. In this study we report the outcomes and complication rates of using ACD in staged breast reconstruction. We reviewed the charts of 41 patients (65 breasts) in whom ACD was used in staged reconstructions. We analysed the patients' charts and operative records to determine postoperative complication rates and results. Complication rates for wound infection, expander removal, haematoma, and seroma were: 3.1% (two of 65), 1.5% (one of 65), 1.5% (one of 65), and 4.6% (three of 65), respectively. The use of ACD in expansive postmastectomy breast reconstruction has an extremely low complication rate, results in good cosmetic outcome, and should be in the repertoire of plastic surgeons. Further follow up is needed to evaluate the long term outcomes of ACD use in postmastectomy breast reconstruction.