Anatomical Nasal Lining Flaps for Closure of the Nasal Floor in Unilateral and Bilateral Cleft Lip Repairs Reduce Fistulas at the Alveolus.

BACKGROUND: Techniques vary for addressing the nasal floor during cleft lip repair in patients with a cleft lip and palate. Sometimes, no closure is performed, leaving a symptomatic alveolar fistula until the time of alveolar bone grafting. Often, medial and lateral skin flaps are used, but these are often thin and unreliable. Anatomical nasal lining flaps are used to improve closure with robust, well-vascularized flaps that anatomically close the nasal floor. METHODS: A retrospective chart review was performed to identify patients with a unilateral or bilateral cleft lip and palate who underwent primary cleft lip repair with nasal lining flaps or with medial and lateral flaps. The primary outcome was presence of a symptomatic and/or visible oronasal fistula. RESULTS: Sixty-four patients were included. Thirty-seven underwent closure with nasal lining flaps, whereas 27 underwent closure using Millard medial and lateral flaps. The rate of symptomatic/visible fistulas after cleft palate repair was 19 percent (seven of 37) for patients with nasal lining flaps and 44 percent (12 of 27) for patients with medial and lateral flaps (p = 0.0509, Fisher's exact test). The alveolar fistula rate was 3 percent (one of 37) for patients with nasal lining flaps and 30 percent (eight of 27) for patients with medial and lateral flaps (p = 0.0032, Fisher's exact test). CONCLUSIONS: Nasal lining flaps at the time of cleft lip repair effectively close the anterior nasal floor in patients with a unilateral or bilateral cleft lip and palate. Decreasing the presence of alveolar fistulas after cleft palate repair improves the quality of life for patients with cleft deformities. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Virtual Surgical Planning Decreases Operative Time for Isolated Single Suture and Multi-suture Craniosynostosis Repair.

BACKGROUND: Cranial vault reconstruction is a complex procedure due to the need for precise 3-dimensional outcomes. Traditionally, the process involves manual bending of calvarial bone and plates. With the advent of virtual surgical planning (VSP), this procedure can be streamlined. Despite the advantages documented in the literature, there have been no case-control studies comparing VSP to traditional open cranial vault reconstruction. METHODS: Data were retrospectively collected on patients who underwent craniosynostosis repair during a 7-year period. Information was collected on patient demographics, intraoperative and postoperative factors, and intraoperative surgical time. High-resolution computed tomography scans were used for preoperative planning with engineers when designing osteotomies, bone flaps, and final positioning guides. RESULTS: A total of 66 patients underwent open craniosynostosis reconstruction between 2010 and 2017. There were 35 control (non-VSP) and 28 VSP cases. No difference in age, gender ratios, or number of prior operations was found. Blood loss was similar between the 2 groups. The VSP group had more screws and an increased length of postoperative hospital stay. The length of the operation was shorter in the VSP group for single suture and for multiple suture operations. Operative time decreased as the attending surgeon increased familiarity with the technique. CONCLUSIONS: VSP is a valuable tool for craniosynostosis repair. We found VSP decreases surgical time and allows for improved preoperative planning. Although there have been studies on VSP, this is the first large case-control study to be performed on its use in cranial vault remodeling.

Management of Zygomatic Fractures: A National Survey.

INTRODUCTION: Repair of zygomatic fractures can be classified into the early closed reduction or the more recent open reduction and rigid internal fixation (ORIF) methods. Surgical training and literature advocate ORIF, but the actual frequency of the different techniques in clinical practice is unknown. The purpose of this study was to determine the current trends in the management of zygomatic fractures among US surgeons and elucidate their influences. METHODS: A 10-question survey was developed and distributed to over 16,000 practicing US facial trauma surgeons, including plastic surgeons (PS), oral and maxillofacial surgeons (OMFS), and otorhinolaryngologists (ENT). The survey queried training background, zygoma fracture treatment preferences, and rationale. Responses were tabulated and both univariate and bivariate statistical analyses completed. RESULTS: One thousand six hundred eleven (10%) total responses were received. Zygomatic fractures are treated most commonly by OMFS (61%), then PS (20%) and ENT (19%), with 71% of repairs being performed in private practice. Open reduction and rigid internal fixation is the most common treatment modality (81%), with most surgeons using 2 to 3 sites for exposure, reduction, and fixation with titanium miniplates (70%). Thirty-five percent of surgeons perform routine orbital floor exploration. Forty-three percent quoted training and 32% reported accuracy of repair as the primary reason for choosing ORIF. CONCLUSIONS: This is the largest reported survey on the repair of zygoma fractures. The response rate suggests dominance of OMFS in zygoma fracture care, an area pioneered by PS. Evolution of technique is also evident by predominance of ORIF with emphasis of multiple points of exposure, reduction, and fixation with rigid hardware.

Reverse posterior interosseous flap for defects of the dorsal ulnar wrist using previously burned and recently grafted skin.

BACKGROUND: In the severely burned patient, coverage of exposed bone in the dorsal ulnar wrist can be a difficult problem. This is especially challenging in patients with a high percentage total body surface area (TBSA) where donor flaps can be scarce. The use of previously burned and/or recently grafted skin as flaps is an option. It has been postulated that use of previously burned skin can result in higher rates of local or distant flap failures. The reverse posterior interosseous flap (PIF) is an axial flap, based on the retrograde posterior interosseous artery, to provide coverage of the hand. Here we describe utilization of the PIF, using previously burned and/or recently grafted skin for coverage of dorsal ulnar wrist defects. METHODS: This is a case series of three patients, with extensive burns (range 35-83%TBSA), where defects of the dorsal ulnar wrist necessitated coverage. Each patient underwent PIF(s) utilizing previously burned and/or grafted skin, all within three months after their initial burn event. RESULTS: Case 1: 28 year old male who suffered 35% TBSA via blast mechanism developed a chronic open wound over the dorsal ulnar wrist with exposed tendon. The patient successfully underwent a left PIF using previously grafted skin. Case 2: 23 year old male with 83% TBSA. Bilateral ulnar styloids were exposed. PIFs were performed bilaterally, using previously burned and recently grafted skin. Coverage was successful but received leech therapy post-operatively for venous congestion. Case 3: 37 year old male with 52% TBSA, with the most severe burns isolated to his bilateral upper extremities; the ulnar head was exposed. The posterior interroseous artery was explored and PIF was attempted, but there was no retrograde flow in the distal artery due to a deeper injury than previously recognized. The patient ultimately underwent a pedicled abdominal flap for coverage. CONCLUSIONS: Defects of the distal ulnar wrist after deep and extensive burns can be problematic. Use of the reverse PIF using previously burned skin, even those that has just been recently grafted is a viable option for this difficult patient population. However, it may not be possible in all patients. Vigilance and early intervention for post-operative venous congestion are important.

Dications of 3-phenyl-indenylidene dibenzo[a.d]cycloheptene: the role of charge in the antiaromaticity of cationic systems.

Dications of 9-(3-phenyl-1H-inden-1-ylidene)-5H-dibenzo[a,d]cycloheptene, 5(2+), were prepared by oxidation with SbF(5) in SO(2)ClF, and their magnetic behavior was compared to dications of 9-(3-phenyl-1H-inden-1-ylidene)-9H-fluorene, 2(2+). The good correlation between the experimental (1)H NMR shifts for the dications that were oxidized cleanly and the chemical shifts calculated by the GAIO method supported the use of the nucleus independent chemical shifts, NICS, to evaluate the antiaromaticity of the indenyl systems of 2(2+)/5(2+) and their unsubstituted parent compounds, 6(2+) and 7(2+), as well as the antiaromaticity of the fluorenyl system of 2(2+)/7(2+) and the aromaticity of the dibenzotropylium system of 5(2+)/6(2+). Antiaromaticity was shown to be directly related to the amount of charge in the antiaromatic systems, with the antiaromatic systems more responsive to changes in the calculated NBO charge than the aromatic systems. The antiaromaticity was also shown to be directly related to the amount of delocalization in the ring system. The aromaticity of the dibenzotropylium system was much less responsive to changes in the amount of charge in the tropylium system, because the aromatic system was much more completely delocalized. Thus, antiaromatic species are more sensitive probes of delocalization than aromatic ones.