Atypical Presentation of a Midline Nasal Dermoid with Intracranial Extension.

Although rarer than their lateral orbital counterparts, dermoid cysts are part of any differential diagnosis of a midline nasal mass in the pediatric population. Here we present a case of a nasal dermoid with intracranial extension that presented as a mass appearing at the nasal-cheek junction. This atypical presentation for a nasal dermoid highlights the need for clinicians to remain vigilant and consider midline dermoid cyst as a diagnosis despite an off-midline position on the face.

Bien qu'ils soient plus rares que les kystes orbitaux, les kystes dermoïdes font partie du diagnostic différentiel de masse nasale médiane dans la population pédiatrique. Les auteurs présentent un cas de kyste dermoïde comportant une extension intracrânienne qui a pris la forme d'une masse à la jonction du nez et de la joue. Cette manifestation atypique de kyste dermoïde nasal fait ressortir la nécessité que les cliniciens demeurent vigilants et envisagent ce diagnostic malgré une position décalée de la médiane sur le visage.

The Implementation of International Electives for Plastic Surgery Residents: Current State and Future Directions.

INTRODUCTION: Interest in international surgical missions has been rising exponentially, with the plastic surgery community being a leader in this endeavor. The role of residents in such missions remains a topic of debate. This systematic review aims to consolidate the literature relevant to the inclusion of plastic surgery residents on international surgical missions to devise an algorithm to facilitate resident participation. MATERIALS AND METHODS: A comprehensive search of PubMed, Medline, and EMBASE was performed to identify studies relevant to plastic surgery resident involvement in the context of surgical missions. Relevant conclusions were retrieved from each study and compiled according to category. RESULTS: Of 418 initial studies, 26 were retained for the qualitative synthesis. These were grouped into 3 categories: surveys (n=12), reflections (n=7), and reviews (n=7). The survey studies addressed the perceived value, educational impact, and long-term effect on participating residents. Three reflection studies were from the perspective of residents and 4 from staff, while all recounted the many benefits gained for participating residents. Review studies addressed the issue of accreditation and the ethics surrounding resident involvement. CONCLUSION: This systematic review highlights the overwhelming support from residents and staff, the highly regarded educational value, and the positive global health effects associated with plastic surgery resident participation in international surgical missions. The authors hope this will encourage and facilitate the implementation of formal opportunities for residents within residency training programs.

Local Versus General Anesthesia in Pediatric Otoplasty: A Cost and Efficiency Analysis.

OBJECTIVE: Quantify the cost benefits of otoplasty under local as opposed to general anaesthesia. DESIGN: A cost analysis of all components of otoplasty surgery under local anaesthesia (LA) in a minor operating room (OR) and general anaesthesia in a main OR was performed. SETTING: Our institution, compared to provincial/federal data, with costs converted into 2022 Canadian dollars. PATIENTS, PARTICIPANTS: Patients undergoing otoplasty under LA in the last year. INTERVENTIONS: An efficiency analysis was performed by means of an opportunity cost, and the cost of failure was added to the overall LA costs. MAIN OUTCOME MEASURE: Expenses for infrastructure, surgical and anaesthetic material, salaries, and personnel costs were derived from the literature, our hospital OR catalog and federal/provincial salary data, respectively. The cost of failure to tolerate local anaesthesia for such cases was also tabulated. RESULTS: The true cost of LA otoplasty was computed as the absolute cost ($611.73) added to the cost of failure ($10.80), resulting in a total of $622.53/procedure. The true cost of GA otoplasty was calculated as the absolute cost ($2033.05) added to the opportunity cost ($1108.94), representing 3141.99$/procedure. The total savings when performing LA otoplasty to GA otoplasty are thus 2519.44$/case, with 1 GA otoplasty costing 5.05 LA otoplasties. CONCLUSION: Otoplasty under local anaesthesia offers significant cost savings when compared with the same procedure under general anaesthesia. Economic considerations must be given particular attention given the elective nature of this procedure, which is often publicly funded.

Determination of Novel, Cranium-Based Relationships for Construct Placement in Microtia Reconstruction for Hemifacial Microsomia Patients.

OBJECTIVE: Determine if the ideal location of the construct in microtia reconstruction for hemifacial microsomia (HFM) can be more accurately derived from measurements on the cranium. DESIGN: High-resolution computerized tomography (CT) images were analyzed through craniometric linear relationships. SETTING: Our tertiary care institution from 2000 to 2021. PATIENTS/PARTICIPANTS: Patients diagnosed with HFM and microtia, who had high-resolution craniofacial CT scans, yielding 36 patients accounting for 44 CT scans. MAIN OUTCOME MEASURE(S): First, the integrity of the posterior cranial vault among HFM patients was determined. If proven to be unaffected, it could be used as a reference in the placement of the construct. Second, the position of the ear in relation to the cranium was assessed in healthy age-matched controls. Third, if proven to be useful, the concordance of these cranium-based relationships could be validated among our HFM cohort. RESULTS: The posterior cranial vault is unaffected in HFM (P > .001). Further, craniometric relationships between the tragus and the Foramen Magnum, as well as between the tragus and the posterior cranium, have been shown to be highly similar and equally precise in predicting tragus position in healthy controls (P > .001). These relationships held true across all age groups (P > .001), and importantly among HFM patients, where the mean absolute difference in predicted tragus position never surpassed 1.5 mm. CONCLUSIONS: Relationships between the tragus and the cranium may be used as an alternative to distorted facial anatomy or surgeon's experience to assist in pre-operative planning of construct placement in microtia reconstruction for HFM patients.

Surgical Microtia Reconstruction in Hemifacial Microsomia Patients: Current State and Future Directions.

Background: Hemifacial microsomia (HFM) is one of the most common congenital craniofacial disorders. Among many other features, microtia is present in the large majority of these patients. However, mainly due to the unilateral hypoplastic anatomy, microtia reconstruction among this patient population remains a reconstructive challenge for plastic surgeons. Given that no clear standards exist, an evidence-based synthesis of the literature was devised. Methods: A systematic search of Pubmed, Medline, and Embase was carried out, in accordance with the PRISMA guidelines. Studies discussing surgical microtia reconstruction for HFM patients were retained. Qualitative data regarding study design, challenges addressed, specific recommendations, and their respective strengths/limitations were extracted from each. Retrieved recommendations were consolidated and assigned a level of evidence grade. Results: Although only 11 studies were included in this review, these provided 22 main recommendations regarding the eight HFM-specific challenges identified, which were of either grade C (n = 5) or D (n = 17). Included studies addressed construct location (n = 7), the low hairline (n = 6), soft tissue construct coverage (n = 6), earlobe reconstruction (n = 6), construct projection (n = 5), anomalies of the relevant neurovascular systems (n = 2), retroauricular construct coverage (n = 2), and sizing of the construct (n = 2). Conclusions: Given the many persisting reconstructive challenges regarding surgical microtia reconstruction for HFM patients, the authors present a comprehensive and evidence-based consolidation of recommendations specific to these challenges. The authors hope this systematic review can appropriately guide plastic surgeons and will ultimately improve care for this patient population.

Current Advances in Hypertrophic Scar and Keloid Management.

Hypertrophic scars and keloids are caused by excessive tissue response to dermal injury due to local fibroblast proliferation and collagen overproduction. This response occurs because of pathologic wound healing due to dysregulation in the inflammatory, proliferative, and/or remodeling phase. Patients with hypertrophic scars or keloids report reduced quality of life, physical status, and psychological health. Hypertrophic scars or keloids will develop in 30 to 90% of individuals, and despite their prevalence, treatment remains a challenge. Of the treatments currently available for hypertrophic scars and keloids few have been adequately supported by studies with appropriate experimental design. Here, we aim to review the available literature to provide up-to-date information on the etiology, epidemiology, histology, pathophysiology, prevention, and management options available for the treatment of hypertrophic scars and keloids and highlight areas where further research is required.

Closed Digital Artery Injury in Children: A Case Report and Review of the Literature.

Closed digital artery injury is a very rare phenomenon, even more so in children, with only 5 cases reported in the literature. We report a case of closed digital arterial interruption in a child after crush injury to the left hand. We further discuss possible etiologies and describe adequate management as found in the pertinent literature. Digital arterial injury should be suspected even in closed hand trauma because a delay in recognition may lead to devastating consequences.

Pediatric burn contractures in low- and lower middle-income countries: A systematic review of causes and factors affecting outcome.

In low- and lower middle-income countries (LMICs), timely access to primary care following thermal injury is challenging. Children with deep burns often fail to receive specialized burn care until months or years post-injury, thus suffering impairments from hypertrophic scarring or joint and soft tissue contractures. We aimed to examine the correlation between limited access to care following burn injury and long-term disability in children in LMICs and to identify specific factors affecting the occurrence of late burn complications. A systematic literature search was conducted to retrieve articles on pediatric burns in LMICs using Medline, Embase, the Cochrane Library, LILACS, Global Health, African Index Medicus, and others. Articles were assessed by two reviewers and reported in accordance with PRISMA guidelines. Of 2896 articles initially identified, 103 underwent full-text review and 14 met inclusion criteria. A total of 991 children who developed long-term burn sequelae were included. Time from injury to consultation ranged from a few months to 17 years. Factors associated with late complications included total body surface area burned, burn depth, low socio-economic status, limited infrastructure, perceived inability to pay, lack of awareness of surgical treatment, low level of maternal education, and time elapsed between burn injury and reconstructive surgery.

Resorbable Implants for Mandibular Fracture Fixation: A Systematic Review and Meta-Analysis.

Mandibular fractures in adults commonly require rigid fixation to ensure proper occlusion while minimizing infection risks. Numerous centers have assessed the efficacy of resorbable materials as a potential alternative to metallic plates. The purpose of the current systematic review and meta-analysis is to shed light on overall outcomes for resorbable implants and to compare these results to those for metallic counterparts. METHODS: A systematic review of clinical studies reporting outcomes for resorbable plates for mandible fractures was carried out. The reported outcomes were hardware failure/exposure, infection, wound dehiscence, reoperation, malocclusion, and nonunion. The results were pooled descriptively and stratified according to fracture and implant type. A subset meta-analysis of prospective studies comparing metallic and resorbable implants was also carried out. RESULTS: Eighteen studies were included for a total of 455 patients managed with resorbable implants (mean follow-up, 8.95 months) with an overall complication rate of 19.8 % (n = 90/455). Infection (n = 31/455, 6.8%) and wound dehiscence (n = 28/455, 6.2%) were the most common complications. Nonunion occurred in 1.1% (n = 5/455) of patients. Seven studies were included in a meta-analysis, and the rates of adverse events in the resorbable and metallic groups were 18.0% (n = 32/178) and 18.3% (n = 33/180), respectively, with no statistically significant difference between both cohorts (95% CI 0.58, 1.82, P = 0.93). CONCLUSIONS: This study suggests that there are no statistical differences in outcomes for patients with mandible fractures managed with resorbable or metallic implants. In the absence of meta-analyses or large randomized controlled trials, the current study provides surgeons with an evidence-based reference to guide decision-making.

Spontaneous Osteogenesis of a Traumatic Mandibular Defect in the Pediatric Population.

Spontaneous osteogenesis of traumatic mandibular defects in the pediatric population remains a relatively rare phenomenon with only 2 patients reported in the literature. In the adult population, a low threshold exists for bone graft placement in the presence of small mandibular gaps, with no role for spontaneous osteogenesis in significant mandibular defects. The approach to traumatic mandibular defects in the pediatric population is not clearly described in the literature and the risks and benefits associated with donor site morbidity of bone graft harvest must be tempered by the possibility for potential spontaneous osteogenesis. The present study reports 1 such patient in whom a significant mandibular defect healed by means of rigid fixation of the defect and spontaneous osteogenesis, with no functional or esthetic sequelae at long-term follow-up. A review of the pertinent literature was performed, and the authors' approach is discussed. The authors propose that traumatic mandibular defects of < 3 cm in patients under the age of 10 years should be considered for treatment with rigid internal fixation alone and spontaneous osteogenesis.

Scaphoid Cysts: Literature Review of Etiology, Treatment, and Prognosis.

Background: Cystic lesions of the carpal bones are rare entities that are infrequently reported in the literature. Scaphoid intraosseous cystic lesions represent a rare subset of carpal bone cysts. This review aims to summarize the available evidence on the evaluation and treatment of scaphoid cystic lesions to help guide clinical management. Methods: Systematic electronic searches were performed using PubMed, Ovid, and Embase databases. Studies included were graded for their risk of bias. Pooled descriptive statistics were performed on incidence, etiology, physical exam findings, treatment, and follow-up. Results: A total of 38 patients representing 41 scaphoid cystic lesions were pooled from 27 articles. Patients presented with wrist pain without fracture (n = 27), pathological fracture (n = 9), swelling only (n = 1), or were asymptomatic (n = 4). Cystic lesions of the scaphoid were initially revealed on imaging with radiographs alone (n = 22), radiographs in combination with computed tomography (CT) (n = 10) or magnetic resonance imaging (n = 6), CT alone (n = 1), or using all 3 modalities (n = 2). Intraosseous ganglia were identified most frequently (n = 31), followed by "bone cyst-like pathological change" (n = 3), unicameral bone cysts (n = 2), aneurysmal bone cysts (n = 2), primary hydatid cysts (n = 2), and cystic like changes post fall (n = 1). Treatment modalities included curettage and bone graft (n = 39) or below-elbow cast (n = 2). On follow-up (average of 21.3 months; n = 40), all patients improved clinically after treatment and were found to have full wrist range of motion without pain (n = 31), slightly reduced grip strength (n = 3), limited range of motion (n = 2), or persistent mild discomfort (n = 2). Conclusions: Scaphoid cystic lesions are most commonly intraosseous ganglia, but can include other etiologies as well. The main presenting symptom is radial wrist pain that usually resolves after treatment. The presence of intracarpal cystic lesions should be considered in the differential diagnosis of wrist pain.

Cartilage exposure following autologous microtia reconstruction: An algorithmic treatment approach✰.

BACKGROUND: Successful reconstruction of microtia involves fabrication of a cartilaginous framework and provision of thin, durable, soft tissue cover. Vascular compromise of this skin envelope can lead to exposure of the underlying cartilage, resulting in cartilage resorption and distortion of the final form of the ear construct. We describe our algorithm for management of this complication. METHODS: All patients who underwent autologous ear reconstruction by a single surgeon (NWB) from April 2006 to September 2012 were retrospectively reviewed to identify any that developed exposure of the underlying cartilage framework. Details related to timing, location, size and management of the cartilage exposure were collected. RESULTS: From a total of 230 autologous auricular reconstructions (median age at first stage, 11.4 years), 15 exposures of the cartilage framework were identified. All exposures occurred following the first stage of reconstruction (mean of post-operative day 29, range, 7-86 days). Large areas of exposure (> 10 mm2) required surgical management, with debridement and coverage with either a cutaneous or fascial flap, depending on the location. Areas < 10 mm2 were managed conservatively. All exposures were successfully treated with no adverse effects on the final aesthetic outcome. CONCLUSION: Cartilage exposure following autologous microtia reconstruction can be a devastating complication if not addressed in a prompt and effective manner. The management strategy we propose provides a concise algorithm to guide the treatment of cartilage exposure. LEVEL OF EVIDENCE: Therapeutic, grade III.

Resorbable Material for Pediatric Orbital Floor Reconstruction.

INTRODUCTION: The use of resorbable materials is becoming more popular for pediatric orbital floor reconstruction. The purpose of this systematic review is to evaluate the effectiveness and safety of the various materials used in pediatric orbital floor reconstruction. METHODS: A systematic literature search was performed to identify all relevant articles reporting complications following pediatric orbital floor reconstruction. The search included published articles in three electronic databases-Ovid MEDLINE, EMBASE, and PubMed starting from database establishment to July 2017. Primary endpoints were enophthalmos, diplopia, and infection. Resorbable material was compared to autologous grafts and nonresorbable material. RESULTS: A total of 14 studies containing 248 patients were included in this review. Fifty-four (21.8%) patients had reconstruction performed with autologous grafts, 72 (29.0%) patients with resorbable material, and 122 (49.2%) patients with nonresorbable material. Resorbable materials had the lowest rate of postoperative enophthalmos (3/52; 5.8%) and the highest rate of postoperative diplopia (19/72; 26.4%). In contrast, nonresorbable materials had the lowest rate of postoperative diplopia (5/122; 4.1%), the highest rate of postoperative enophthalmos (14/102; 13.7%). Autologous reconstruction was associated with an 11.1% (4/36) rate of postoperative enophthalmos and a 22.2% (12/54) rate of postoperative diplopia. Nine cases (8.8%) of postoperative infection were documented with nonresorbable materials. No cases of infection were reported with autologous grafts or resorbable materials. CONCLUSION: Newer resorbable implants are safe and have a similar complication profile as traditional autologous grafts in pediatric orbital floor reconstruction.

Orbital Subcutaneous Emphysema in a Child.

The authors present a rare case of nontraumatic medial orbital wall fracture in an 11-year-old girl. Fractures of the orbital wall secondary to nose blowing have not been previously described in the pediatric population. The patient reported a history of chronic forceful nose blowing, followed by periorbital swelling after an episode of vigorous nose blowing. Erroneous diagnoses of sinusitis and periorbital cellulitis lead to unnecessary antibiotic treatment. The authors hypothesize that repeated and aggressive nose blowing is analogous to stress fractures, leading to weakening and eventual fracture of the medial orbital wall.

Cellular phone collateral damage: A review of burns associated with lithium battery powered mobile devices.

AIM: The spontaneous destruction of lithium battery powered cellphones has raised concern about the safety of these devices. We present a case report and review of the literature of burn injuries sustained in association with cellular phone usage. METHODS: A Medline search was performed to identify articles describing cellular phone associated thermal injuries using key search words including "burn," "burn injury," "cellular phone," "cellphone," "thermal injury," and "telephone." Articles were reviewed for etiology, location, severity and treatment. We also present a case of a burn to the upper thigh resulting from cellular phone battery malfunction. RESULTS: Six case reports were identified detailing burn injuries obtained from cellphone use. Half of these cases occurred from battery malfunction with second degree being the most common severity. All cases were managed conservatively except one case, which required excision and primary closure. CONCLUSION: Lithium powered cellular phones are susceptible to overheating and destruction from inadequate heat dissipation during thermal runaway. This process can be initiated by local short-circuiting from direct contact with a low resistance conductor such as keys or coins. We reinforce the importance of safe cell phone battery practices including avoiding overcharging and direct skin exposure to minimize thermal injury risk.

The management of midline frontonasal dermoids: a review of 55 cases at a tertiary referral center and a protocol for treatment.

BACKGROUND: The incidence of midline frontonasal dermoid cysts is one in 20,000 to one in 40,000. These lesions may have intracranial extension. This is explained by the anatomy and embryology of nasofrontal development. Skin involvement may also be extensive. Incomplete excision frequently leads to recurrence. The authors report their experience and pathway for management of midline dermoids. METHODS: Databases were searched to identify patients who had undergone surgery for removal of a dermoid cyst. Preoperative imaging and indications for surgery were reviewed. Cases were grouped according to surgical approach, and outcomes and complications were identified. RESULTS: Fifty-five patients were treated. Magnetic resonance imaging or computed tomography was used to delineate the anatomy, and surgical excision was expedited if there was a history of infection, especially if imaging suggested intracranial extension. Twelve patients were treated endoscopically (one was converted to open). Eleven required transcranial approaches for intracranial extension (20 percent). Of these, one lesion breached the dura. The remaining 32 patients had dermoids excised with an open approach (direct, bicoronal, or rhinoplasty). There were no recurrences in the open group and there was one recurrence in the transcranial group. This was treated by reexcision. CONCLUSION: Midline dermoid cysts are relatively uncommon. However, knowledge of the pathogenesis of these lesions together with the authors' experience over 15 years has allowed them to develop a protocol-driven approach, with a low incidence of complications. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Principles of chest wall resection and reconstruction.

Despite significant improvements in surgical technique and perioperative care, the management of patients requiring chest wall resection and reconstruction is an ongoing challenge for thoracic surgeons. A successful approach includes a thorough assessment of the patient and the lesion, an adequate biopsy to confirm tissue diagnosis, and a well-established treatment plan. In the case of a primary tumor of the chest wall, the extent of the resection should not be limited by the size of the resulting defect. Following resection, chest wall reconstruction mandates an appreciation for restoration of functional and structural components. An algorithmic approach to chest wall reconstruction begins with the assessment of the nature of the defect, taking into consideration factors such as infection, tumor location, previous radiation therapy, and surgical intervention. The latter factors bear influence on the type of tissue required as well as whether reconstruction can be performed in a single stage or whether it is better delayed. Finally, patient factors including lifestyle and work, as well as prognosis, are considered to determine the best reconstructive option.

Esophageal stricture and metaplasia following abdominoplasty.

Numerous complications have been reported following abdominoplasty. In this report, the case of a 48-year-old woman who developed an esophageal stricture, and subsequently Barrett's esophagus, secondary to increased intra-abdominal pressure following abdominoplasty is presented.

Utility of routine exercise treadmill testing early after percutaneous coronary intervention.

BACKGROUND: There have been few prospective studies examining the utility of routine exercise treadmill testing (ETT) early after percutaneous coronary intervention (PCI). The objective of this study was to examine the impact of a routine ETT strategy early after PCI on follow-up cardiac events and procedures. METHODS: We examined 136 patients who underwent routine ETT at 6 weeks post-PCI in the ADORE trial. The ETT was classified as positive, indeterminate, or negative. The Duke Treadmill Score (DTS) was calculated for all patients. Follow-up occurred at 9 months. RESULTS: ETT results at 6 weeks were: 32 (23.5%) positive, 24 (17.6%) indeterminate and 80 (58.8%) negative. At 9 months, the composite event rate was 21.9% in those with a positive ETT, 20.8% in those with an indeterminate ETT and 12.5% in those with a negative ETT (p = 0.25 positive vs. negative ETT). The sensitivity of early ETT for predicting clinical events was 41.2%, the specificity was 73.3%, the positive predictive value was 21.9% and the negative predictive value was 87.5%. At 9 months, the cardiac procedure rate was 18.8% in those with a positive test, 13.0% in those with an indeterminate test, and 6.3% in those with a negative test (p = 0.07 positive vs. negative ETT). In a multivariate logistic regression model, coronary stenting during PCI and a >/= 85% MPHR achieved were found to be inversely associated with clinical events. However, the DTS did not independently predict clinical events. CONCLUSION: Although the statistical power of the study was limited by the small number of clinical events (particularly MI and death), the results of this study support the ACC/AHA guidelines that exercise treadmill testing should not be used routinely after PCI.

Composite tissue allotransplantation of the face: Decision analysis model.

BACKGROUND: Facial composite tissue allotransplantation is a potential reconstructive option for severe facial disfigurement. The purpose of the present investigation was to use decision analysis modelling to ascertain the expected quality-adjusted life years (QALYs) gained with face transplantation (versus remaining in a disfigured state) in an effort to assist surgeons with the decision of whether to adopt this procedure. STUDY DESIGN: The probabilities of potential complications associated with facial allotransplantation were identified by a comprehensive review of kidney and hand transplant literature. A decision analysis tree illustrating possible health states for face allotransplantation was then constructed. Utilities were obtained from 30 participants, using the standard gamble and time trade-off measures. The utilities were then translated into QALYs, and the expected QALYs gained with transplantation were computed. RESULTS: Severe facial deformity was associated with an average of 7.34 QALYs. Allotransplantation of the face imparted an expected gain in QALYs of between 16.2 and 27.3 years. CONCLUSIONS: The current debate within the medical community surrounding facial composite tissue allotransplantation has centred on the issue of inducing a state of immunocompromise in a physically healthy individual for a non-life-saving procedure. However, the latter must be weighed against the potential social and psychological benefits that transplantation would confer. As demonstrated by a gain of 26.9 QALYs, participants' valuation of quality of life is notably greater for face transplantation with its side effects of immunosuppression than for a state of uncompromised physical health with severe facial disfigurement.