Management of pediatric maxillary fractures.

BACKGROUND: Maxillary trauma in pediatric patients is a challenge to health care professionals. The successful treatment and extended care of pediatric maxillary fractures requires multiple considerations. METHODS: This review of the current literature investigates all components of management to provide optimal outcome. Specifically, pediatric management distinctions are discussed for both facial reconstruction and rehabilitation. The current etiology, incidence, classification of injury, and methods to diagnose and treat these patients is outlined. CONCLUSIONS: Pediatric maxillofacial fractures remain a challenging problem. The management of this patient population includes comprehensive knowledge of pediatric maxillofacial growth and development, available reduction techniques, biocompatible materials, and duration of the selected therapy.

Recurrent and persistent carpal tunnel syndrome: "Triple-therapy approach".

BACKGROUND: Various procedures have been described for patients undergoing a revision carpal tunnel release. These can include repeat open decompression with external or internal neurolysis, tenosynovectomy, endoscopic release, various flap techniques, saphenous vein wrapping and use of prosthetic implants. This study reports a case series of 30 consecutive patients who underwent revision carpal tunnel release at single institution from 2012 to 2018. Our surgical plan in all the patients involved a combination of these three techniques (triple therapy approach): neurolysis (external or internal) and tenosynovectomy, collagen matrix conduit wrap (NeuraWrap; Integra LifeSciences or Axoguard Nerve Protector, AxoGen Inc), and hypothenar fat flap. MATERIALS AND METHODS: A total of 30 patient records were identified. The index surgery was performed by a variety of surgeons at varied private institutions as well as the VA hospital. However, all of the revision interventions in this series were performed by the senior author (Z.J.P.). Demographic data (age, sex, hand dominance, comorbidities, alcohol, and smoking history) were collected. Preoperative and postoperative symptoms were recorded for all patients, including: subjective outcomes, need for additional surgery and complications. Mean VAS preoperatively and postoperatively were compared using a paired t-test. All statistical analyses were performed with SPSS 20 (IBM, Chicago, IL). RESULTS: Patient reported measures of resolution of symptoms and VAS scores documented at 3 months. Of the 30 patients who underwent surgery for persistent or recurrent carpal tunnel syndrome, symptoms resolved completely in 25 patients. 2 patients were lost to follow up. 3 patients showed no improvement. The mean preoperative VAS score was 4.37 and declined to 1.23 after surgery (P < .0001). CONCLUSION: Our study demonstrates that a combination of neurolysis and tenosynovectomy along with a nerve wrap and hypothenar fat flap should be considered in patients presenting with recurrent or persistent carpal tunnel syndrome.

Case report of a definitive autologous reconstruction in a patient requiring immediate postoperative anticoagulation and reduced operative time.

INTRODUCTION: The available options for post-mastectomy reconstruction in a patient requiring abbreviated operative times and immediate and sustained post-operative anticoagulation are limited. PRESENTATION OF CASE: A 50year old woman with a history of multiple deep venous thromboses (DVTs) and pulmonary embolisms (PEs) requested a bilateral prophylactic mastectomy and immediate reconstruction. She had a history of multiple breast biopsies demonstrating atypia and two sisters with premenopausal breast cancer. Her hematologist requested that her anticoagulation be held for the minimal amount of time and that her theater times be kept as short as possible. As such, we felt that she was not a candidate for traditional implant-based reconstruction nor autologous flap surgery. Instead, we made use of a recently described single-stage autologous modified Goldilocks procedure to complete her bilateral mastectomy and reconstruction in 150min. She was anticoagulated in the operating room and was restarted on her preoperative regimen twelve hours after surgery. She suffered no post-operative complications. DISCUSSION: There is minimal published literature discussing immediate post-mastectomy reconstruction in the anticoagulated patient. Most reconstructive surgeons find these patients unsuitable for traditional reconstructive techniques. In the current case, we utilized a recently described single-stage autologous technique which allowed us to avoid the bleeding complications associated with the muscular dissection required with implant and flap-based reconstructive surgery. The extirpation and reconstruction was completed in 150min which is significantly quicker than traditional reconstructions. CONCLUSION: The modified Goldilocks procedure is an excellent option in the patient who requires immediate postoperative anticoagulation and abbreviated operative times.

Total Single-Stage Autologous Breast Reconstruction with Free Nipple Grafts.

Outstanding results are difficult to achieve in postmastectomy reconstructions in obese ptotic patients. We describe an autologous single-stage reconstruction with free nipple grafts that is best suited for these difficult patients. This technique allows for delayed volume supplementation with implants or fat grafting but does not commit the patient to additional surgery. It avoids the common complications of immediate implant-based reconstructions. This technique is also an excellent option in patients with a known requirement for radiotherapy as it does not sacrifice a valuable autologous flap nor does it subject the patient to capsular contracture, infection, and extrusion. It also obviates the psychological trauma that many women suffer awaiting a reconstruction after radiotherapy. We believe it should be considered as a first-line reconstructive option.

Reconstruction of acquired defects of the vagina and perineum.

Successful reconstruction of vaginal and perineal defects requires close communication and cooperation between the extirpative and reconstructive surgeon. A variety of reconstructive options is available, dependent on the nature of the defect and extent of the ablative surgery. In all cases, obliteration of pelvic dead space and separation of intraabdominal contents from the perineum are important considerations to ensure uncomplicated perineal wound healing. The decision for vaginal reconstruction is also contingent upon the age, sexual function, and wishes of the patient. In this article, we review options for vaginal and perineal reconstruction in acquired defects.