Superficial temporal artery perforator flaps for reconstruction of intraoral defects.

BACKGROUND: Intraoral defects after tumor resection are often reconstructed with free tissue transfer. However, in patients who are not good candidates for free tissue transfer, regional flaps based on the superficial temporal artery can be utilized. The authors present our technique to reconstruct intraoral defects with the superficial temporal artery perforator (STAP) flap and early outcomes. METHODS: Five patients underwent STAP flaps for defects including the hard palate, buccal sulcus, floor of mouth, and retromolar trigone between 2017 and 2019. The mean defect size was 5.6 × 3.4 cm2 (3 × 3 cm2 - 7 × 4 cm2 ). The mean age was 74 (57-88) and all patients had recurrent cancer. External Doppler, indocyanine green laser angiography, and FLIR thermal imaging were used intra-operatively to identify the best perforators and plan for flap design. RESULTS: The mean flap size was 7.6 × 3.5 cm2 (6 × 3 cm2 - 10 × 5 cm2 ). Four flaps were based off of the posterior branch of the STA, while the fifth was based off of the anterior branch. Two donor sites were closed primarily, and three required skin grafts. One patient experienced partial flap necrosis. There were no complete flap losses and no donor site complications. Average follow up was 14.6 months (9-20 months). All patients maintained preoperative level of speech, mastication, and oral continence. CONCLUSIONS: The STAP flap can be based on the anterior or posterior branch of the superficial temporal artery and is a useful regional flap for intraoral defects after tumor resection.

Management of Frontal Bone Fractures.

BACKGROUND: The purpose of this study was to examine a level 1 trauma center's 12-year experience treating frontal sinus fractures with regards to patient demographics, management strategies, and treatment outcomes. METHODS: An institutional review board-approved retrospective review of all facial fractures at a level 1 trauma center was performed for the years 2000 to 2012. Patient demographics, location of fractures, concomitant injuries, use of antibiotics, surgical management strategies and outcomes were collected for all frontal sinus fractures. A significance value of 5% was used. RESULTS: There were 291 frontal sinus fractures treated at our institution. The mean age of patients was 34.4 years with a male predominance (90%). The most common mechanisms of injury were assault in 82 (28.2%) and motor vehicle accidents in 80 (27.5%). Anterior table fractures were seen in 261 patients (89.7%) and posterior table fractures were seen in 181 (62.2%). Treatment included ORIF with sinus preservation in 18 (6.2%), ORIF with sinus obliteration in 20 (6.9%), and cranialization in 18 (6.2%). Antibiotics were started on admission in 152 patients (52.2%). Fatality occurred in 9.3% of patients and complications included meningitis (1%), frontal sinusitis (1%), early wound infection (0.3%), and mucopyelocele (0.3%). CONCLUSIONS: Frontal sinus fractures in our center are most often caused by interpersonal violence. Anterior table fractures were more common than posterior table fractures and ORIF with sinus obliteration was the most common surgical intervention. Most frontal sinus fractures at our institution (82%) were treated conservatively with no surgical intervention and we observed a low rate of long term complications.

Chest Masculinization Technique and Outcomes in 72 Double-incision Chest-contouring Procedures with Free Nipple Grafting.

Chest masculinization for gender affirmation is the removal of breast tissue and excess skin, often with repositioning of the nipple areola complexes to achieve a male-appearing chest. A double-incision technique with free nipple grafting (FNG) is the preferred method for trans men with large, ptotic breasts. The authors present the outcomes of 72 consecutive chest masculinization cases using this technique. METHODS: A retrospective chart review was performed between 2015 and 2020 on all patients who underwent chest masculinization surgery for gender dysphoria by the senior author (JDK). Patients who underwent masculinization by concentric circle or liposuction-only techniques were excluded. Potential risk factors for complications were analyzed with Chi-square and logistic regression techniques. P < 0.05 was considered significant. RESULTS: Seventy-two patients underwent bilateral mastectomy with free nipple grafting. There were 6 major complications resulting in return to operating room, re-admission, or need for interventional procedure. These included 4 hematomas, 1 infection, and 1 hospital admission for shortness of breath and pain.Minor complications treated conservatively included 3 seromas, 1 instance of delayed wound healing, 1 case of superficial thrombophlebitis, and 4 hypertrophic scars. Eleven patients experienced nipple areolar complex complications. Four patients underwent revision surgery. Nicotine use was associated with a higher rate of hematoma (χ2: 9.95, P = 0.007). Later operative date, a surrogate for experience, was associated with decreased return to the operating room (Odds ratio: 0.99, P = 0.025). CONCLUSION: Double-incision chest contouring with free nipple grafting provides good chest contour for transgender men,with low complication rates.

Pathological Evaluation of Breast Specimens in Transgender Chest Masculinization: Incidental Findings and Effect of Prior Chest Binding and Androgen Therapy in 74 Consecutive Patients.

Background: The rate of masculinizing chest surgery for gender affirmation continues to increase. With a paucity of literature on pathological evaluation of breast specimens in this patient population, there is a need for these data and for protocols on the handling of these specimens. Methods: A retrospective chart review was performed between 2015 and 2020 on all patients who underwent chest masculinization surgery for gender dysphoria by the senior author (J.D.K.). Inclusion criteria were any patient with sex assigned female at birth who underwent removal of breast and/or nipple areolar complex tissue for gender affirmation. Patient demographics were recorded. Bilateral breast tissue was sent for routine pathology in all cases and findings were recorded. A p-value of <0.05 was considered significant. Results: Seventy-four consecutive patients and 148 breast specimen reports were identified from a database and included in the study. The mean age was 26 years (15-49). Thirty-nine patients had a known history of chest wall binding and 60 patients had undergone preoperative androgen therapy. There was no invasive or in situ carcinoma found in any breast tissue specimens. Thirty-four patients had a benign lesion in one or both breast specimens. Atypical lobular hyperplasia was found in one patient's specimen. A history of chest wall binding was not correlated with any benign lesions (p=0.79) or stromal fibrosis (p=0.94). A history of testosterone use was not correlated with any benign lesions (p=0.35) or stromal fibrosis (p=0.20). Conclusions: The prevalence (1.4%) of significant breast pathology and of benign findings (46%) in our study closely correlates with the rates in the literature. We found no correlation between significant breast pathology or benign lesions and a history of chest wall binding or preoperative androgen therapy. We recommend all breast specimens removed during chest masculinization surgery be sent for pathological evaluation.

Mentorship Through Research: A Novel Approach to Increasing Resident and Medical Student Research Competency Through an Institutional Database.

BACKGROUND: We describe a novel research database development project to increase resident and medical student scholarly ability and mentorship skills. We collected data on 3147 facial fractures treated at our institution over a 12-year period. This data was used to publish novel research on multiple types of facial fractures and outcomes. METHODS: We learned about key database aspects that led to its high level of research quality and output volume through over 6 years of database development and expanded research output. A retrospective review was completed to compile the total research produced during this time period. RESULTS: Research resulted in 20 manuscripts, 17 podium presentations, and 11 posters. 16 medical students, 5 residents and 3 faculty members were authors on at least one project. The average number of published manuscripts was 5.17 overall and 2.9, 7.0, and 14.0 for medical students, residents, and faculty, respectively. Four residents matched into fellowship, 7 medical students matched into residency, and one faculty member was promoted academically. CONCLUSIONS: A database focused on a common and under-researched pathology can result in a high volume of novel research output. Additional program benefits include increased scholarly and mentorship ability in engaged residents and medical students.

Indocyanine Green Laser Angiography in the Setting of Tumescence.

Objective: Indocyanine green laser angiography utilizes fluorescent dye to assess tissue perfusion in real time. While various studies have recommended against the concurrent use of indocyanine green angiography with vasoconstrictors, few studies have described the intraoperative effect of tumescent wetting solutions on indocyanine green angiography and its subsequent impact on scan interpretation and clinical decision-making. Methods: A retrospective medical record review was performed for cases in which indocyanine green angiography was utilized to assess an area where epinephrine-based tumescent solution had been used. Results: The authors report 2 cases that utilized epinephrine-based tumescent solution along with intraoperative indocyanine green angiography assessment of the region. The first case was a bilateral reduction mammoplasty, whereas the second case was a nipple-sparing mastectomy with immediate tissue expander reconstruction. In both cases, intraoperative angiography predicted poor tissue perfusion while clinical examination showed good perfusion. Clinical examination was followed in both cases, with no additional tissue being removed. Neither case resulted in tissue necrosis despite angiography results. Conclusions: While indocyanine green angiography is a powerful tool in tissue perfusion assessment, there are some situations in which clinical examination must be used to determine tissue viability.

Migration of a Needle From the Chest Wall Into the Right Ventricle in a 10-Year-Old Child.

Cardiac foreign bodies are rare in children and the nature or timing of the injury may be hard to ascertain. We report a case of a 10-year-old boy who presented with a 28-mm solid core needle in the left chest wall that advanced into his right ventricle, possibly from soft tissue manipulation. Computed tomography, intraoperative fluoroscopy, and echocardiography were necessary to locate the needle and successfully remove it surgically.