An Algorithm for the Management of Concomitant Maxillofacial, Laryngeal, and Cervical Spine Trauma.

Concomitant maxillofacial, laryngeal and cervical spine injuries may occur after high-energy accidents. Although this presentation is uncommon, the multiple injuries may compromise airway, breathing, circulation, and neurologic function. We identified 8 adult trauma patients admitted to the National University Hospital with the concomitant injuries. We reviewed the patient data and existing literature to identify the important factors that must be considered for management. Seven resulted from high velocity accidents, whereas 1 was assaulted. An algorithm that prioritizes in-tandem diagnosis and acute management of the adult trauma patient with maxillofacial, laryngeal, and cervical spine trauma was developed. The first priority is to assess airway, breathing, and circulation with cervical spine immobilization. Early diagnosis of patients with severe laryngeal injury, confirmation by video endoscopy, and establishing a surgical airway prevents airway obstruction or even a laryngotracheal dissociation. Urgent computed tomography scans of the head and neck are essential for definitive diagnosis and surgical planning for the 3 injuries. Prudent sequencing of surgery is important to avoid complications and to achieve better functional outcomes.

Rare Cause of Facial Palsy: Case Report of Tick Paralysis by Ixodes Holocyclus Imported by a Patient Travelling into Singapore from Australia.

BACKGROUND: Ticks are blood-sucking arachnids that feed on all classes of vertebrates, including humans. Ixodes holocyclus, also known as the Australian Paralysis Tick, is capable of causing a myriad of clinical issues in humans and companion animals, including the transmission of infectious agents, toxin-mediated paralysis, allergic and inflammatory reactions, and mammalian meat allergies in humans. The Australian Paralysis Tick is endemic to Australia, and only two other exported cases have been reported in the literature. CASE REPORT: We report the third exported case of tick paralysis caused by I. holocyclus, which was imported on a patient into Singapore. We also discuss the clinical course of the patient, the salient points of management, and the proper removal of this tick species. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: With increasing air travel, emergency physicians need to be aware of and to identify imported cases of tick paralysis to institute proper management and advice to the patient. We also describe the tick identification features and proper method of removal of this tick species.

Pneumocephalus Following Air Travel in a Patient With Preexisting Facial Fractures and Dural Tears.

Changes in cabin pressure can potentially cause expansion of any preexisting intracranial air resulting in tension pneumocephalus. The authors describe a 28-year-old man, who was involved in a motor vehicle accident complicated by multiple facial fractures and a dural tear while on his way to the airport. Instead of seeking medical attention after the accident, he proceeded with a 2-hour commercial flight. He did not suffer from any neurologic deterioration inflight, but upon presentation to our center, a computed tomography scan was done which revealed extensive pneumocephalus, for which he required intensive monitoring and subsequent surgery. Controversy still exists regarding whether it is safe to travel by air in patients with intracranial air. It is hoped that this patient will add to the discussion regarding the safety for air travel in patients with traumatic pneumocephalus.

Prophylactic Intraoperative Nasolacrimal Duct Intubation in Surgical Treatment of Facial Fractures-Is There a Role?

Nasolacrimal duct (NLD) damage is associated in the majority of type II and III naso-orbito-ethmoid (NOE) fractures. 1 Our study aims to investigate the efficacy and safety of prophylactic NLD intubation in the setting of facial fractures, by comparing incidence of postoperative epiphora and wound infection. A retrospective matched control study was conducted on all patients with surgically treated facial fractures from 2008 to 2013 ( n = 280) (IRB ref number: DSRB 2013/01198). Patients with the following fracture types were included: NOE ( n = 16), frontal sinus ( n = 2), Le Fort II/III ( n = 8), and > 1 type ( n = 48). All patients in this study were included with the intention to treat. The study group comprised patients who were intubated, while the control group patients were not intubated. Each group had 37 patients matched for age, gender, fracture type, and injury type. A single oculoplastic surgeon skilled in lacrimal surgery performed the procedure for all intubated patients. Patients with more severe and complex facial fractures were intubated with bicanalicular Crawford stents. Postoperative epiphora and infective complications (both facial wound and dacryocystitis) were assessed at 1, 3, 6, and 12 months. There was no significant difference in incidence of either postoperative epiphora ( p = 0.152) or wound infection ( p = 0.556) comparing both groups. Reduced incidence of postoperative epiphora in the study group is statistically not significant and does not support the need for prophylactic intubation. If radiographic evidence of NLD disruption or regurgitation seen on syringing on the NLD intraoperatively is present, intubation is safe and efficacious only if performed by an expert.

Breast reconstruction rate and profile in a Singapore patient population: a National University Hospital experience.

INTRODUCTION: Breast reconstruction is an integral part of breast cancer management with the aim of restoring a breast to its natural form. There is increasing awareness among women that it is a safe procedure and its benefits extend beyond aesthetics. Our aim was to establish the rate of breast reconstruction and provide an overview of the patients who underwent breast reconstruction at National University Hospital (NUH), Singapore. METHODS: We evaluated factors that impact a patient's decision to proceed with breast reconstruction, such as ethnicity, age, time and type of implant. We retrospectively reviewed the medical records of women who had breast cancer and underwent breast surgery at NUH between 2001 and 2010. RESULTS: The breast reconstruction rate in this study was 24.3%. There were 241 patients who underwent breast reconstruction surgeries (including delayed and immediate procedures) among 993 patients for whom mastectomies were done for breast cancer. Chinese patients were the largest ethnic group who underwent breast reconstruction after mastectomy (74.3%). Within a single ethnic patient group, Malay women had the largest proportion of women undergoing breast reconstruction (60.0%). The youngest woman in whom cancer was detected in our study was aged 20 years. Malay women showed the greatest preference for autologous tissue breast reconstruction (92.3%). The median age at cancer diagnosis of our cohort was 46 years. CONCLUSION: We noted increases in the age of patients undergoing breast reconstruction and the proportion of breast reconstruction cases over the ten-year study period.

Sirtuin 5 is Anti-apoptotic and Anti-oxidative in Cultured SH-EP Neuroblastoma Cells.

As a nicotinamide adenine dinucleotide (NAD+)-dependent deacetylase, demalonylase, and desuccinylase, sirtuin 5 (SIRT5) in host cells has been reportedly observed in the mitochondria, in the cytosol/cytoplasm or in the nucleus. Various functional roles of SIRT5 have also been described in cellular metabolism, energy production, detoxification, oxidative stress, and apoptosis, but some of the reported results are seemingly inconsistent or even contradictory to one another. Using immunocytochemistry, molecular biology, gene transfection, and flow cytometry, we investigated the expression, subcellular distribution, and possible functional roles of SIRT5 in regulating apoptosis and oxidative stress of cultured SH-EP neuroblastoma cells. Both endogenous and transfected exogenous SIRT5 were observed in mitochondria of host SH-EP cells. Overexpression of SIRT5 markedly protected SH-EP cells from apoptosis induced by staurosporine or by incubation in Hank's balanced salt solution. SIRT5 also lowered the level of oxidative stress and countered the toxicity of hydrogen peroxide to SH-EP cells. It was suggested that the anti-apoptotic role of SIRT5 was mediated, at least in part, by its anti-oxidative effect in SH-EP neuroblastoma cells although the involved molecular mechanisms remain to be elucidated in details.

Cervicofacial, retropharyngeal and mediastinal emphysema: a complication of orbital fracture.

Retropharyngeal and mediastinal emphysema is associated with traumatic aerodigestive tract injury, and may be associated with potentially severe and even life-threatening complications. Retropharyngeal emphysema or pneumomediastinum, in the absence of severe trauma to the visceral organs, is rare following facial fractures. We report a case of extensive subcutaneous emphysema extending to the retropharyngeal space and mediastinum following an orbitozygomatic fracture.

Retained broken implants in the craniomaxillofacial skeleton.

Facial fracture patients are seen in a Level 1 trauma hospital. In our institution, we manage many patients with facial fractures and carry out more than 150 surgical procedures every year. Open reduction and internal fixation is our management of choice. All surgical procedures involve drilling of bone and implant insertion to keep the fractured bones in an anatomically reduced position to aid healing. Occasionally, drill bits used to create the pilot hole break and are embedded in the bone. We present a situation in which such an incident occurred and review the literature on retained broken implants and devices.

The deep inferior epigastric perforator and pedicled transverse rectus abdominis myocutaneous flap in breast reconstruction: a comparative study.

BACKGROUND: Our objective was to compare the complication rates of two common breast reconstruction techniques performed at our hospital and the cost-effectiveness for each test group. METHODS: All patients who underwent deep inferior epigastric perforator (DIEP) flap and transverse rectus abdominis myocutaneous (TRAM) flap by the same surgeon were selected and matched according to age and mastectomy with or without axillary clearance. Patients from each resultant group were selected, with the patients matched chronologically. The remainder were matched for by co-morbidities. Sixteen patients who underwent immediate breast reconstruction with pedicled TRAM flaps and 16 patients with DIEP flaps from 1999 to 2006 were accrued. The average total hospitalisation cost, length of hospitalisation, and complications in the 2 year duration after surgery for each group were compared. RESULTS: Complications arising from both the pedicled TRAM flaps and DIEP flaps included fat necrosis (TRAM, 3/16; DIEP, 4/16) and other minor complications (TRAM, 3/16; DIEP, 1/16). The mean hospital stay was 7.13 days (range, 4 to 12 days) for the pedicled TRAM group and 7.56 (range, 5 to 10 days) for the DIEP group. Neither the difference in complication rates nor in hospital stay duration were statistically significant. The total hospitalisation cost for the DIEP group was significantly higher than that of the pedicled TRAM group (P<0.001). CONCLUSIONS: Based on our study, the pedicled TRAM flap remains a cost-effective technique in breast reconstruction when compared to the newer, more expensive and tedious DIEP flap.

Innovative intraoperative titanium mesh preparation for safer implantation.

Titanium meshes have been extensively used in craniomaxillofacial surgery. The benefits of these titanium implants include being inert, stable, and radiopaque and having good drainage properties. The titanium mesh is cut to shape and bent before implantation, which may give rise to the cut edges being jagged and sharp. This can lead to soft tissue being caught or lacerated by these sharp ends. A change in technique to cut and shape the implant may reduce this problem. The implant should be cut right at the end of the bars flush with the remaining parts of the implant. We present a new and simple method for smoothing these troublesome edges. We use the diathermy scratch pad or tip cleaner, a tool used frequently in every major surgery. This scratch pad can be used as a rasp to smoothen the edges of the titanium mesh once it is cut into shape.

Stabilization of mobile mandibular segments in mandibular reconstruction: use of spanning reconstruction plate.

The fibular free flap is the gold standard for mandibular reconstruction. Accurate 3-dimensional contouring and precise alignment of the fibula is critical for reestablishing native occlusion and facial symmetry. Following segmental mandibulectomy, the remaining mandibular fragments become freely mobile. Various stabilization methods including external fixation, intermaxillary fixation, and preplating with reconstruction plate have been used. We describe a modification to the preplating technique. After wide resection of buccal squamous cell carcinoma, our patient had an 11-cm mandibular defect from the angle of the left mandible to the right midparasymphyseal region. A single 2.0-mm Unilock® (Synthes, Singapore) plate was used to span the defect. This was placed on the vestibular aspect of the superior border of the mandibular remnants before resection. Segmental mandibulectomy was then performed with the plate removed. The spanning plate was then reattached to provide rigid fixation. The fibular bone was contoured with a single osteotomy and reattached. The conventional technique involves molding of the plate at the inferior border of the mandible. This is time-consuming and not possible in patients with distorted mandibular contour. It is also difficult to fit the osteotomized fibula to the contoured plate. In comparison, the superiorly positioned spanning plate achieve rigid fixation of the mandible while leaving the defect completely free and unhampered by hardware, allowing space for planning osteotomies and easier fixation of the neomandible. Using this modified technique, we are able to recreate the original mandibular profile with ease.

Expansion and hepatocytic differentiation of liver progenitor cells in vivo using a vascularized tissue engineering chamber in mice.

Current cell-based treatment alternatives to organ transplantation for liver failure remain unsatisfactory. Hepatocytes have a strong tendency to dedifferentiate and apoptose when isolated and maintained in culture. In contrast, liver progenitor cells (LPCs) are robust, easy to culture and have been shown to replace damaged hepatocytes in liver disease. In this study we investigate whether isolated LPCs can survive and differentiate toward mature hepatocytes in vivo when implanted into a heterotopic mouse tissue engineering chamber model. Healthy Balb/c mice and those put on a choline-deficient ethionin-supplemented diet to induce chronic liver disease were implanted with a tissue engineering chamber based on the epigastric flow through pedicle model, containing either 1 × 10(6) LPCs suspended in Matrigel, or LPC-spheroids produced by preculture for 1 week in Matrigel. Four weeks after implantation the chamber contents were harvested. In all four groups, progenitor cells persisted in large numbers to 4 weeks and demonstrated evidence of considerable proliferation judged by Ki67-positive cells. Periodic acid Schiff staining demonstrated differentiation of some cells into mature hepatocytes. Constructs grown from LPC-spheroids demonstrated considerably greater LPC survival than those from LPCs that were grown as monolayers and implanted as dissociated cells. The combined use of LPC spheroids and the vascularized chamber model could be the basis for a viable alternative to current treatments for chronic liver failure.

The deep inferior epigastric perforator flap for breast reconstruction: Is this the ideal flap for Asian women?

INTRODUCTION: This study aims to evaluate the outcome and safety of the deep inferior epigastric perforator (DIEP) flap for breast reconstruction in a group of Southeast Asian women treated in our unit and to identify risk factors for breast reconstruction using the DIEP flap in this population. MATERIALS AND METHODS: This is a prospective study on 50 consecutive DIEP flap breast reconstructions by a single surgeon in an academic institution between July 1999 and July 2006. Data on patient demographics, diagnosis, procedure type, adjuvant and neoadjuvant treatments, risk factors and complications were prospectively collected and registered in a clinical database. Outcome variables include total flap loss, partial flap loss, fat necrosis and minor complications related to the donor site or flap. Known risk factors are analysed to determine if they affect outcome in terms of complication rate in this group of patients. RESULTS: Total flap loss, partial flap loss and fat necrosis complication rates were 6%, 4% and 10%, respectively. Flap complication rates were comparable to those quoted by previous studies done worldwide. Obesity (BMI >27) is a statistically significant factor associated with development of DIEP flap complications in our population. CONCLUSION: Breast reconstruction with DIEP flap is a safe and reliable method when used in Southeast Asian women, offering optimal results with less donor -site morbidity. Obesity increases the incidence of flap complication in this group of patients.

Patent blue dye in lymphaticovenular anastomosis.

INTRODUCTION: Lymphaticovenular anastomosis (LVA) has been described as a treatment of chronic lymphoedema. This microsurgical technique is new and technically difficult. The small caliber and thin wall lymphatic vessels are difficult to identify and easily destroyed during the dissection. MATERIALS AND METHODS: We describe a technique of performing lymphaticovenular anastomosis with patent blue dye enhancement. Our patient is a 50-year-old lady who suffers from chronic lymphoedema of the upper limb after mastectomy and axillary clearance for breast cancer 8 years ago. RESULTS: Patent blue dye is injected subdermally and is taken up readily by the draining lymphatic channels. This allows for easy identification of their course. The visualisation of the lumen of the lymphatic vessel facilitates microsurgical anastomosis. The patency of the anastomosis is also demonstrated by the dynamic pumping action of the lymphatic within the vessels. CONCLUSION: Patent blue dye staining during lymphaticovenular anastomosis is a simple, effective and safe method for mapping suitable subdermal lymphatics, allowing for speedier dissection of the lymphatic vessels intraoperatively. This technique also helps in the confirmation of the success of the lymphaticovenular anastomosis.