The Use and Outcomes of 3D Printing in Pediatric Craniofacial Surgery: A Systematic Review.

Three-dimensional (3D) printing has demonstrated efficacy in multiple surgical specialties. As accessibility improves, its use in specific fields deserves further attention. We conducted a systematic review of the implementation and outcomes of 3D printing in pediatric craniofacial surgery, as none has been performed. A systematic review was conducted according to Cochrane and PRISMA guidelines. PubMed, Embase, Cochrane library, and Clinicaltrials.gov were queried with combinations of the terms: "3D printing," "craniofacial," "surgery," and "pediatric." Original human studies containing patients <18 years old implementing 3D printing to aid in craniofacial surgery were included. Study selection, grading, and data extraction were performed independently by multiple authors. After screening 120 articles, 7 (3 case series and 4 case reports) were included, published from 2017 to 2022. All studies addressed patients with different disease processes including craniosynostosis, cleft lip/palate, and mandibular hypoplasia. 3D printing was used to create mock surgical models in 2 studies, intraoperative cutting guides/molds (CGs) in 6 studies, and cranioplasty implants in 2 studies. Two case series determined the accuracy of the CGs was acceptable within historical comparison, while 4 articles included subjective statements on improved accuracy. Five studies noted reduced operating time, 2 noted reduced intraoperative blood loss, and 1 felt the use of 3D printed materials was responsible for shorter hospitalization duration. No adverse events were reported. Despite the limitations of the current literature, all studies concluded that the use of 3D printing in pediatric craniofacial surgery was beneficial. Definitive conclusions cannot be made until further controlled research is performed.

Successful Shoulder Disarticulation under Local Anesthesia in the COVID-19 Era.

The use of the wide-awake local anesthesia no tourniquet, a tumescent local anesthetic technique in recent years, emerged as a powerful tool primarily in hand surgery. It has been adopted in many low- and middle-income countries where it was applied to an increasingly broad group of procedures. We report the case of an older patient with an arm liposarcoma for which surgery under general or regional anesthesia was deemed unsafe, but was successfully managed with a curative right shoulder disarticulation using tumescent local anesthesia.

An Innovative Solution to Complex Inguinal Defect: Deepithelialized SIEA Flap With Mini Abdominoplasty.

Introduction: We describe a novel technique of contralateral pedicled deepithelialized superficial inferior epigastric artery flaps, followed by abdominal advancement coverage, as an alternative treatment of radiated complicated inguinal or lower abdominal defects, avoiding the donor-site defect typically seen with other methods of coverage. Methods: Two male patients with histories of liposarcoma after excision and radiation to one side of lower abdomen/inguinal area presented with complicated wounds that were reconstructed with this technique. Results: Successful obliteration of dead space and wound closure were achieved with the combination of a superficial inferior epigastric artery flap with an abdominal advancement flap. In each case, patients went on to heal uneventfully without need for any secondary procedures. Discussion: The use of a superficial inferior epigastric artery flap for lower abdomen/groin defect closure is an option as an alternative to rectus abdominis myocutaneous flap and anterolateral thigh flaps and should be considered in patients with vascular anatomy conducive for this muscle-sparing procedure. Conclusions: A second layer-overlay coverage with an abdominal advancement flap creates a more durable repair in the complicated radiated wound and a well-concealed abdominoplasty scar.

A Simple Mandibular Distraction Protocol to Avoid Tracheostomy in Patients With Pierre Robin Sequence.

OBJECTIVE: Recent treatment goals for Pierre Robin sequence (PRS) focus on avoiding tracheostomy through modalities such as mandibular distraction osteogenesis (MDO). We primarily evaluated the efficacy of our straightforward MDO treatment protocol for resolution of PRS-associated airway obstruction while secondarily analyzing patient characteristics associated with success or failure of MDO. DESIGN: A retrospective chart review before and after treatment. SETTING: Tertiary institutional center and private practice setting. PATIENTS: All patients were diagnosed with PRS and treated with MDO, according to the MDO treatment protocol, by a single surgeon with the same operative technique from 1999 to 2013. A sample size of n = 38 met the inclusion criteria. Data assessed included tracheostomy status (pre-MDO, post-MDO, or none), microlaryngoscopy and bronchoscopy (MLB) findings, multipositional airway study results, clinical resolution of airway obstruction following MDO, and patient characteristics. MAIN OUTCOME MEASURE: Resolution of airway obstruction with avoidance of a tracheostomy. RESULTS: Prior to referral for MDO, five patients required urgent tracheostomy. Of patients without a pre-MDO tracheostomy (n = 33), two patients required tracheostomy post-MDO, while 94% avoided tracheostomy with clinical resolution of airway obstruction (n = 31). On secondary analysis, anatomic abnormalities diagnosed by MLB were associated with a higher rate of tracheostomy (P = .037), confirming the utility of preoperative evaluation with MLB; otherwise, no patient characteristics demonstrated significance in patient selection. Follow-up ranged from 6 months to 10 years (mean = 6.45 years, median = 7.61 years). CONCLUSIONS: Our treatment protocol demonstrates MDO is highly effective for resolving severe airway obstruction related to PRS. Based on secondary analysis, our simplified protocol does not require amendment.

Outcomes of mild to moderate upper eyelid ptosis correction using Müller's muscle-conjunctival resection.

BACKGROUND: Müller's muscle-conjunctival resection is used to correct mild to moderate ptosis commonly encountered in the rejuvenation patient population. The authors examined its efficacy and analyzed variables that potentially affect outcomes. METHODS: Patients who underwent ptosis correction using Müller's muscle-conjunctival resection with greater than 10-month follow-up were included. Amount of ptosis reduction, eyelid symmetry, effects of concomitant facial aesthetic operations, and adverse outcomes were analyzed. Patients were grouped into medium- (<24 months after surgery) and long-term follow-up (>24 months) cohorts to determine whether outcomes changed over time. RESULTS: Forty patients with a mean follow-up of 28 months combined for a total of 70 resection operations. Resection significantly reduced ptosis by a mean of 1.48 ± 0.88 mm (p < 0.001), corresponding to 0.19 mm of eyelid elevation for every 1.0 mm of Müller's muscle resected. The procedure successfully corrected 84 percent of eyelids to within 0.5 mm and 94 percent to within 1.0 mm of normal eyelid position. On patients with asymmetric ptosis, it significantly improved eyelid symmetry to within 1.0 mm from 85 percent of patients before surgery to 95 percent after surgery, and to within 0.5 mm from 53 percent before surgery to 75 percent of patients after surgery (p = 0.036). Furthermore, the mean correction of ptosis was not significantly different between medium- (1.58 ± 0.93 mm) and long-term (1.32 ± 0.93 mm) follow-up patients (p = 0.258). CONCLUSIONS: Müller's muscle-conjunctival resection is an effective long-term solution to mild to moderate eyelid ptosis and asymmetry, and can be effectively performed concomitantly with other aesthetic facial procedures. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Voxel size and measures of individual resorption cavities in three-dimensional images of cancellous bone.

Cavities formed by osteoclasts on the surface of cancellous bone during bone remodeling (resorption cavities) are believed to act as stress risers and impair cancellous bone strength and stiffness. Although resorption cavities are readily detected as eroded surfaces in histology sections, identification of resorption cavities in three-dimensional images of cancellous bone has been rare. Here we use sub-micrometer resolution images of rat lumbar vertebral cancellous bone obtained through serial milling (n=5) to determine how measures of the number and surface area of resorption cavities are influenced by image resolution. Three-dimensional images of a 1 mm cube of cancellous bone were collected at 0.7x0.7x5.0 microm/voxel using fluorescence based serial milling and uniformly coarsened to four other resolutions ranging from 1.4x1.4x5.0 to 11.2x11.2x10 microm/voxel. Cavities were identified in the three-dimensional image as an indentation on the cancellous bone surface and were confirmed as eroded surfaces by viewing two-dimensional cross-sections (mimicking histology techniques). The number of cavities observed in the 0.7x0.7x5.0 microm/voxel images (22.0+/-1.43, mean+/-SD) was not significantly different from that in the 1.4x1.4x5.0 microm/voxel images (19.2+/-2.59) and an average of 79% of the cavities observed at both of these resolutions were coincident. However, at lower resolutions, cavity detection was confounded by low sensitivity (<20%) and high false positive rates (>40%). Our results demonstrate that when image voxel size exceeds 1.4x1.4x5.0 microm/voxel identification of resorption cavities by bone surface morphology is highly inaccurate. Experimental and computational studies of resorption cavities in three-dimensional images of cancellous bone may therefore require images to be collected at resolutions of 1.4 microm/pixel in-plane or better to ensure consistent identification of resorption cavities.