RESUMEN
OBJECTIVE: To understand psychosocial functioning before and after gender-affirming facial feminization surgery (FFS) as well as identify predictors of postoperative psychosocial functioning. SUMMARY BACKGROUND DATA: Few investigations have rigorously explored the impact of gender-affirming FFS on psychosocial functioning in transgender and gender non-binary (TGNB) individuals. This knowledge gap hinders the identification of methods to optimize mental health quality-of-life outcomes after FFS and carries repercussions for access to care. METHODS: Adult TGNB participants awaiting gender-affirming FFS were prospectively enrolled and administered Patient-Reported Outcomes Measurement Information System (PROMIS) instruments assessing anxiety, anger, depression, global mental and physical health, positive affect, emotional support, social isolation, companionship, and meaning and purpose before and 3-6 months after FFS. Paired t-tests compared pre- and postoperative scores. Multivariable linear models identified predictors of postoperative psychosocial outcomes. RESULTS: Among the domains, psychosocial scores improved for anxiety, depression, global mental health, social isolation, and positive affect after FFS. When accounting for potential variables contributing to postoperative psychosocial scores including other gender-affirming surgeries, hormone therapy duration, and private versus public insurance type, we found that preoperative depression scores independently predicted the variance in all other postoperative scores with global mental health (ß=-0.52, 95%CI -0.58--0.31 P<0.001), anxiety (ß=0.40, 95% CI 0.21-0.51, P<0.001), and meaning and purpose (ß=-0.52, 95% CI -0.78--0.42 P<0.001) as the strongest models. CONCLUSIONS: This study suggests that gender-affirming FFS improves psychosocial functioning; however, such improvements are highly influenced by the baseline psychological functioning of each individual. These findings indicate that preoperative psychological functioning may be a potential avenue for improving outcomes after FFS via perioperative psychological interventions.
RESUMEN
This study aims to determine the utility of 3D photography for evaluating the severity of metopic craniosynostosis (MCS) using a validated, supervised machine learning (ML) algorithm.This single-center retrospective cohort study included patients who were evaluated at our tertiary care center for MCS from 2016 to 2020 and underwent both head CT and 3D photography within a 2-month period.The analysis method builds on our previously established ML algorithm for evaluating MCS severity using skull shape from CT scans. In this study, we regress the model to analyze 3D photographs and correlate the severity scores from both imaging modalities.14 patients met inclusion criteria, 64.3% male (n = 9). The mean age in years at 3D photography and CT imaging was 0.97 and 0.94, respectively. Ten patient images were obtained preoperatively, and 4 patients did not require surgery. The severity prediction of the ML algorithm correlates closely when comparing the 3D photographs to CT bone data (Spearman correlation coefficient [SCC] r = 0.75; Pearson correlation coefficient [PCC] r = 0.82).The results of this study show that 3D photography is a valid alternative to CT for evaluation of head shape in MCS. Its use will provide an objective, quantifiable means of assessing outcomes in a rigorous manner while decreasing radiation exposure in this patient population.
Asunto(s)
Craneosinostosis , Imagenología Tridimensional , Humanos , Masculino , Lactante , Femenino , Estudios Retrospectivos , Imagenología Tridimensional/métodos , Craneosinostosis/diagnóstico por imagen , Craneosinostosis/cirugía , FotograbarRESUMEN
BACKGROUND: Pierre Robin Sequence (PRS) is characterized by micrognathia, glossoptosis, and upper airway obstruction. Early recognition and appropriate perinatal management is crucial for optimizing outcomes. This study aimed to evaluate 20-week fetal ultrasounds to determine if specific mandibular measurements could predict PRS diagnosis and disease severity. METHODS: A retrospective case-control study of 48 patients with PRS and gender-matched controls was performed. Medical records were reviewed for respiratory and surgical interventions. Three parameters to assess micrognathia were measured on mid-sagittal profile ultrasound images: frontal nasal-mental angle (FNMA), facial-maxillary angle (FMA), and alveolar overjet. Student's t-test and univariate logistic regression was performed. P ≤ 0.05 was considered statistically significant. RESULTS: Patients with PRS demonstrated a significantly smaller mean FNMA compared to the control group, 129.3 ± 8.6° and 137.4 ± 3.2°, respectively (p < 0.0001), as well as significantly smaller mean FMA, 63.2 ± 9.2° and 74.8 ± 6.1°, respectively (p < 0.0001). The PRS group also demonstrated significantly larger mean alveolar overjet compared to the control group, 3.9 ± 1.4 mm and 2.1 ± 0.9 mm, respectively (p < 0.0001). The odds of respiratory intervention increased among cases when FMA was <68°. Additionally, there was a significant difference in median overjet between patients with PRS who did and did not require respiratory intervention. CONCLUSIONS: Mandibular features on the 20-week ultrasound can be measured to predict diagnosis and severity of PRS. This is an important first step to prepare for potential respiratory intervention at delivery to minimize perinatal hypoxia. Alveolar overjet, previously not described in prenatal ultrasound literature, is measurable and has utility in prenatal screening for PRS, as do FMA and FNMA.
Asunto(s)
Obstrucción de las Vías Aéreas , Micrognatismo , Síndrome de Pierre Robin , Femenino , Humanos , Embarazo , Estudios de Casos y Controles , Mandíbula/diagnóstico por imagen , Micrognatismo/diagnóstico por imagen , Síndrome de Pierre Robin/diagnóstico por imagen , Síndrome de Pierre Robin/cirugía , Estudios Retrospectivos , Ultrasonografía PrenatalRESUMEN
INTRODUCTION: The concept of "overcorrection" for trigonocephaly has been reported to achieve both anterior cranial fossa expansion and normalization of craniofacial form. The purpose of this study is to describe in detail a standardized technique to fronto-orbital advancement utilizing the concept of "overcorrection" and objectively evaluate intermediate results. METHODS: This retrospective study included patients with isolated metopic synostosis who underwent surgery via the proposed surgical technique and age and sex-matched unaffected controls. Craniofacial morphometric analysis was performed on pre-, immediate post-, and intermediate postoperative (>2 years) three-dimensional (3D)-rendered computed tomographic (CT) scans and photographs. Key CT-based measurements included interzygomaticofrontal suture distance (IZFS), endocranial bifrontal angle (ECA), and temporal expansion. 3D photogrammetry was performed using established measurements and associated Z-scores converted. A Paired t-test and analysis of variance were performed when appropriate. RESULTS: Forty-one patients were included. A comparison of pre- and immediate postoperative CT scans demonstrated statistically significant increases in all measurements. Subset analysis of 12 patients with intermediate follow-up (age: 39.6 ± 3.6 months) demonstrated significant differences from preoperative values except for IZFS, which decreased from immediate postoperative values and was smaller than age- and sex-matched controls. 3D photogrammetry demonstrated a mean Z-score above the norm for frontal breath. 3D photogrammetry is also positively correlated with CT-based measurements. CONCLUSIONS: This standardized "overcorrection" approach for trigonocephaly can provide the appropriate changes to maintain a normal ECA despite a reduction in bifrontal width over time. 3D photogrammetry positively correlated with CT-based measurements and may provide useful information when following patients clinically. Long-term follow-up assessment to determine the necessary degree of overcorrection at skeletal mature is needed.
Asunto(s)
Craneosinostosis , Imagenología Tridimensional , Procedimientos de Cirugía Plástica , Preescolar , Humanos , Craneosinostosis/diagnóstico por imagen , Craneosinostosis/cirugía , Estudios Retrospectivos , Tomografía Computarizada por Rayos X/métodosRESUMEN
The diagnosis of late-presentation sagittal suture craniosynostosis (SCS) can be challenging, especially in the setting of subtle physical exam findings. The clinical significance of clinocephaly-a retro-coronal concavity along the midvault-in this context remains unknown. The aim of this study is to evaluate the predictive value of clinocephaly in identifying late-presentation SCS.A retrospective chart review of all patients >1 year old presenting to the craniofacial clinic with a concern for SCS was performed. The presence or absence of SCS in the setting of clinocephaly was recorded following diagnostic imaging. Student's t test, Chi Square test, and multivariate logistic regression analysis were performed to determine predictors for SCS.75 patients met inclusion criteria. 32 patients (42.7%, 6% female) were diagnosed with SCS. No difference in age between patients with and without SCS was detected. Stratification of patients by age (1-2, 2-4, and >4 years) revealed a higher rate of SCS in younger patients (P = 0.04). The cephalic index (C.I.) of those with sagittal synostosis was significantly smaller but within the normal range, indicating a more scaphocephalic shape (P = 0.003). Logistic regression analysis revealed that C.I. was a strong predictor for SCS (P = 0.003). Of those with SCS, a mix of complete and partial fusion of the sagittal suture was appreciated.This study found that 42.7% of patients with clinocephaly had SCS. C.I. was the only predictor for SCS and unique suture fusion patterns were identified in those with SCS. This study suggests that clinocephaly should be considered a core component of the exam and work-up for SCS. Future studies aimed at evaluating the positive predictive value of this exam finding and identifying risk factors associated with late-presentation SCS are underway.
Asunto(s)
Relevancia Clínica , Craneosinostosis , Lactante , Humanos , Femenino , Preescolar , Masculino , Estudios Retrospectivos , Tomografía Computarizada por Rayos X , Craneosinostosis/diagnóstico por imagen , Craneosinostosis/cirugía , Suturas Craneales/diagnóstico por imagen , Suturas Craneales/cirugíaRESUMEN
BACKGROUND: Data breach costs in the United States are among the highest in the world, making robust cybersecurity an important bulwark of national defense. Healthcare is a popular target for cyber threats, and there is increasing emphasis on cybersecurity safeguards to protect sensitive patient data. OBJECTIVES: The objective of this national survey and scoping review is to (1) identify cybersecurity awareness, preparedness, and practices among plastic surgeons, and (2) to provide guidelines to mitigate the threat of cyberattacks. METHODS: A 16-question, anonymous online survey was developed and distributed to The Aesthetic Society registrants to ascertain plastic surgeons' cybersecurity practices. Utilizing PubMed, CINAHL, and Embase databases, eligible articles were identified as part of this scoping review. RESULTS: Of 89 individuals who began the survey, 69 completed it (77.5%). Sixty respondents agreed or strongly agreed that cybersecurity is an important issue in plastic surgery. The greatest perceived limitations for protection against cyberattacks were insufficient expertise (41.7%), followed by lack of funding and insufficient time to dedicate to this goal. Most respondents (78.7%) had cybersecurity policies incorporated into their practice. Those who agreed or strongly agreed they had technology to prevent data theft/breach were significantly more likely to be older than 54 years of age (P < .001). No articles identified in the literature specifically addressed cybersecurity in plastic surgery; however, 12 articles detailing cybersecurity in healthcare were identified and included. CONCLUSIONS: Despite possessing adequate technology and procedures in place to prevent cyberattacks, plastic surgeons perceive significant barriers to cybersecurity protection, including insufficient expertise and lack of dedicated funding. It is imperative that our field establishes standards and protocols to protect our patients.
Asunto(s)
Procedimientos de Cirugía Plástica , Cirujanos , Cirugía Plástica , Humanos , Estados Unidos , Encuestas y Cuestionarios , Seguridad ComputacionalRESUMEN
INTRODUCTION: Velopharyngeal insufficiency (VPI), a stigmatizing hallmark of palatal dysfunction, occurs in a wide spectrum of pediatric craniofacial conditions. The mainstays for surgical correction include palate repair and/or pharyngeal surgery. However, primary pharyngoplasty has a failure rate of 15% to 20%. Although revision pharyngoplasty may be necessary in those with persistent VPI, little is known regarding the indications for and outcomes after such procedures. The purpose of this study is to describe the authors' experience with indications for and outcomes after revision pharyngoplasty. METHODS: A single-center retrospective review was performed of all patients undergoing revision pharyngoplasty between 2002 and 2019. Demographic data and Pittsburgh Weighted Speech Scores, diagnoses, comorbidities, and complications were tabulated. Two-tailed Student t test was used, and a P value of 0.05 or less was considered statistically significant. RESULTS: Thirty-two patients (65.6% male) met inclusion criteria for this study. The most common diagnoses included cleft palate (68.8%), submucous cleft palate (SMCP, 18.8%), and congenital VPI (6.3%, likely occult SMCP). Most patients (84.4%) underwent palatoplasty before their initial pharyngoplasty. The primary indication for initial pharyngoplasty was VPI (mean age 7.1 ± 4.6 years). The most common indication for revision pharyngoplasty (mean age 11.2 ± 5.1 years) included persistent VPI (n = 22), followed by obstructive sleep apnea (OSA) (n = 11). Persistent VPI (n = 8) and OSA (n = 6) were the most common complications after secondary pharyngoplasty. Thirteen patients (40.6%) within the revision pharyngoplasty cohort required additional surgical intervention: 4 underwent tertiary pharyngoplasty, 4 underwent takedown for OSA (n = 3) or persistent VPI (n = 1), 3 underwent takedown and conversion Furlow for persistent VPI (n = 2), OSA (n = 2) and/or flap dehiscence (n = 1), and 2 underwent palatal lengthening with buccal myomucosal flaps for persistent VPI. Of the 4 patients who required a tertiary pharyngoplasty, the mean age at repair was 6.6 ± 1.1 years and their speech scores improved from 13.5 to 2.3 after tertiary pharyngoplasty (P = 0.11). The overall speech score after completion of all procedures improved significantly from 19 to 3.3. CONCLUSION: Patients who fail primary pharyngoplasty represent a challenging population. Of patients who underwent secondary pharyngoplasty, nearly half required a tertiary procedure to achieve acceptable speech scores or resolve complications.
Asunto(s)
Fisura del Paladar , Apnea Obstructiva del Sueño , Insuficiencia Velofaríngea , Adolescente , Niño , Preescolar , Fisura del Paladar/cirugía , Femenino , Humanos , Masculino , Faringe/cirugía , Estudios Retrospectivos , Resultado del Tratamiento , Insuficiencia Velofaríngea/etiología , Insuficiencia Velofaríngea/cirugíaRESUMEN
ABSTRACT: Complex nasal defects can necessitate nasal lining, bone and cartilage, and skin reconstruction. Defects requiring lining and structural support without the need for skin resurfacing are relatively uncommon. The following case report describes in detail a pericranial galeal-frontalis flap that is used to both reconstruct the nasal lining and provide adequate cartilage graft coverage. The pericranial galeal-frontalis flap provides yet another option for the reconstructive surgeon faced with complex defects of the nasal dorsum.
Asunto(s)
Neoplasias Nasales , Rinoplastia , Cartílago/cirugía , Humanos , Músculo Esquelético/cirugía , Nariz/cirugía , Neoplasias Nasales/cirugía , Colgajos Quirúrgicos/cirugíaRESUMEN
BACKGROUND: Optimizing operating room (OR) utilization is a critical component of health care system efficiency. The purpose of our study was to analyze the extent of OR cancellation and its effect on raw utilization of OR block time allotted to surgeons in the pediatric plastic surgery department. METHODS: The authors retrospectively reviewed the cases of 4 plastic surgeons at a tertiary pediatric hospital between 2018 and 2019. Data collected included patient demographics, type of surgery, time of cancellation, reason for cancellation, length of surgery, and minutes of block time allotted to each surgeon per year. Percent of cases canceled, scheduled times lost, and block times lost were calculated. RESULTS: Surgeons A, B, C, and D scheduled 170, 416, 305, and 474 cases, respectively. Overall, 7% of cases were canceled, 9.1% of scheduled time was lost, and a total of 5.1% of block time was lost due to cancellation. Patients of surgeon A and D were more likely to cancel due to reasons classified as ''other,'' including causes such as failure of nil per os or a family's last-minute decision to forego elective surgery (33.3% and 37.2%, respectively), whereas patients of surgeon B and C were more likely to cancel due to illness (67.9% and 36.4%, respectively). CONCLUSIONS: Cancellations negatively impact raw utilization times; if fewer cases are performed, allotted block times are redistributed. Communication with patients in the week prior to surgery may allow for earlier identification of likely cancellations. Future directions include exploring whether particular surgeon characteristics are linked to rate of cancellations.
Asunto(s)
Quirófanos , Cirugía Plástica , Citas y Horarios , Niño , Procedimientos Quirúrgicos Electivos , Humanos , Estudios RetrospectivosRESUMEN
PURPOSE: Persistent velopharyngeal insufficiency (VPI) following primary palatoplasty remains a difficult problem to treat. This study evaluates speech outcomes following revision palatoplasty with tissue augmentation using buccal myomucosal flaps (BMF) as an alternative to pharyngoplasty for patients with VPI. METHODS: A retrospective single-center review of revision palatoplasty with tissue augmentation at a tertiary pediatric hospital Cleft-Craniofacial Center between January 2017 and March 2021 was conducted. Patients with a history of previous palatoplasty, a diagnosis of persistent or recurrent VPI, and comprehensive pre- and postoperative speech evaluations who underwent revision palatoplasty with BMF were included. RESULTS: Twenty patients met inclusion criteria (35% female, 20% syndromic). Mean age at the time of revision palatoplasty with BMF was 9.7 years. Preoperatively, all patients had stigmatizing speech and received the recommendation for speech surgery; the mean Pittsburgh Weighted Speech Score (PWSS) was 14.3 ± 4.9. The mean postoperative PWSS at the most recent assessment was 4.2 ± 2.3, representing a statistically significant improvement from preoperative scores (P < .001). Mean follow-up time was 8.9 months. Following revision palatoplasty with BMF, only one patient has received the recommendation for further speech surgery. No complications were noted. CONCLUSION: In patients with VPI following primary palatoplasty, revision palatoplasty with tissue augmentation offers an alternative to pharyngoplasty. This approach preserves dynamic velopharyngeal function, improves speech outcomes, and should be considered an option when treating patients with post-primary palatoplasty VPI.
Asunto(s)
Fisura del Paladar , Insuficiencia Velofaríngea , Humanos , Femenino , Niño , Masculino , Insuficiencia Velofaríngea/etiología , Estudios Retrospectivos , Resultado del Tratamiento , Fisura del Paladar/cirugía , Fisura del Paladar/complicacionesRESUMEN
BACKGROUND: The role of computed tomography (CT) for diagnosis and surgical planning for craniosynostosis (CS) is well-established. The aim of this study was to quantify the cumulative medical radiation exposure from CT in patients with CS at a tertiary care children's hospital. METHODS: Medical records of patients who presented at < 2 years of age and underwent surgical intervention for CS were examined for demographic information. Effective radiation dose (ERD) in mSv was calculated for each head CT. Descriptive statistics and ANOVA were performed. Mean ± SD is reported; p < 0.05 was considered significant. RESULTS: Two hundred seventy-two patients met inclusion criteria: 241 nonsyndromic and 31 with syndromic diagnoses. For nonsyndromic patients, mean age at first head CT was 6.0 ± 4.9 months, mean number of CT scans obtained was 2.1 ± 1.1, and the mean total combined ERD was 9.1 ± 4.8 mSv. CT scans obtained at < 6 months of age had a significantly greater ERD than those obtained at > 6 months, 5.3 ± 1.9 versus 4.3 ± 1.4 mSv, respectively (p = 0.001). CONCLUSIONS: Patients with nonsyndromic CS undergo 2 CT scans on average related to their diagnosis, with a mean total ERD of 9.1 mSv; this is equivalent to 1.5 years of the average annual background radiation dose a person living in the USA will encounter from environmental radiation, medical exposures, and consumer products. A CT obtained at < 6 months is associated with a higher ERD; thus, we recommend delaying imaging from the initial presentation to the time of pre-operative planning when possible.
Asunto(s)
Craneosinostosis , Exposición a la Radiación , Craneosinostosis/diagnóstico por imagen , Craneosinostosis/cirugía , Cabeza , Humanos , Lactante , Dosis de Radiación , Tomografía Computarizada por Rayos XRESUMEN
PURPOSE: Safety-net hospitals (SNHs) are vital in the care of trauma populations, but little is known about the burden of facial trauma presenting to SNHs. The authors sought to characterize the presentation and treatment of facial fractures across SNHs and determine the association between SNH care and healthcare utilization in patients undergoing fracture repair. METHODS: Adult patients presenting with a facial fracture as their primary admitting diagnosis from the year 2012 to 2015 were identified in the National Inpatient Sample. The "safety-net burden" of each hospital was defined based on the proportion of Medicaid and self-pay discharges. Patient factors analyzed were sex, race, age, income level, insurance status, fracture location, and comorbidities. Hospital factors analyzed were safety-net burden, teaching status, geographic region, bed size, and ownership status. The main outcomes were length of stay (LOS), hospital costs, time to repair, and postoperative complications. RESULTS: Of 78,730 patients, 27,080 (34.4%) were treated at SNHs and 24,844 (31.6%) were treated at non-SNHs. Compared to non-SNHs, patients treated at SNHs were more likely to undergo operative repair at SNHs (65.8% versus 53.9%, Pâ<â0.001). Overall mean LOS was comparable between non-SNH and SNH (3.43 versus 3.38âdays, Pâ=â0.611), as was mean hospital cost ($15,487 versus $15,169, Pâ=â0.434). On multivariate linear regression, safety-net status was not a predictor of increased LOS, cost, or complications. However, safety-net status was significantly associated with lower odds of undergoing repair within 48âhours of admission (odds ratio 0.783, 95% confidence intervalâ=â0.680-0.900, Pâ=â0.001). CONCLUSIONS: Safety-net hospitals are able to treat facial trauma patients with greater injury burden and lower socioeconomic resources without increased healthcare utilization. Healthcare reform must address the financial challenges that endanger these institutions to ensure timely treatment of all patients.
Asunto(s)
Pacientes Internos , Proveedores de Redes de Seguridad , Adulto , Hospitales , Humanos , Tiempo de Internación , Medicaid , Estados Unidos/epidemiologíaRESUMEN
ABSTRACT: Correction (and over-correction) of asymmetries of the orbital shape and brow position in unilateral coronal craniosynostosis (UCS) is critical to successful fronto-orbital advancement. Here we quantify and three-dimensionally assess fronto-orbital irregularities in UCS patients compared to controls.Twenty-three patients with UCS evaluated at the Children's Hospital of Pittsburgh between 2006 and 2016 were age and gender-matched to controls. Computed tomography scans were reconstructed and evaluated for orbital metrics. A three-dimensional heat map of orbital regions was generated and evaluated for shape differences.Brow protrusion of the orbit ipsilateral to the synostotic suture did not differ significantly from healthy controls. Orbital height was significantly increased while orbital width was decreased on the UCS ipsilateral side compared to the contralateral side and controls. The ipsilateral cornea was overprojected relative to the brow and the infraorbital rim, but similar to controls relative to the lateral rim. The contralateral orbit had increased brow protrusion with decreased orbital height. The cornea was underprojected relative to the brow, but overprojected relative to the lateral orbital rim and similar to controls at the infraorbital rim. Three-dimensional comparison demonstrated significant overprojection of the contralateral brow, with some more mild and inconsistent underprojection of the lateral aspect of the ipsilateral brow.Key orbital and brow differences exist between the affected and unaffected sides in UCS. This study provides quantitative data that further characterize the orbital dysmorphology observed in UCS and identifies unique aspects of the diagnosis that should be taken into consideration during surgical planning.
Asunto(s)
Craneosinostosis , Niño , Craneosinostosis/diagnóstico por imagen , Cara , Humanos , Lactante , Órbita/diagnóstico por imagen , Estudios Retrospectivos , Tomografía Computarizada por Rayos XRESUMEN
ABSTRACT: Irradiated cadaveric costal cartilage (CC) has been utilized as an alternative to autologous cartilage (AC) in functional and aesthetic nasal surgery. The impact of graft choice between AC and CC on functional outcomes in rhinoplasty has yet to be studied. A systematic review was performed in PubMed, Embase, and Cochrane databases according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines to identify comparative studies evaluating the efficacy and safety of CC in nasal surgery. Functional and aesthetic outcomes and complications were reviewed and compared between AC and CC. Meta-analytic comparisons were performed when appropriate using data from comparative studies using a random-effects model. Four studies met inclusion criteria. The indication for surgery was functional in the majority of cases, and 34.6% of cases were revision rhino- or septorhinoplasties. Disparate data across studies prevented meta-analysis on functional outcomes; however, qualitative review of function outcomes demonstrated comparable outcomes between the CC and AC groups. No differences in graft infection, warping, and resorption rates were detected. Analysis of all graft-related complications was higher in the CC group (Pâ=â0.02); however, when AC donor site-related complications were included, no significance between the two groups was observed. In conclusion, limited, high quality data was available for analysis. Of the available studies, this systematic review suggest that the use of AC or CC may lead to comparable results in terms of functional outcomes. More long-term studies directly comparing AC and CC functional outcomes would be welcomed.
Asunto(s)
Cartílago Costal , Rinoplastia , Cadáver , Estética Dental , Humanos , Medición de Resultados Informados por el Paciente , Estudios Retrospectivos , Trasplante AutólogoRESUMEN
BACKGROUND: The role of perioperative antibiotics in cleft palate remains a topic of debate. Advocates stress their importance in preventing local and systemic infections and decreasing the incidence of oronasal fistula formation. However, few studies to date have directly evaluated the role of antibiotics and other antimicrobial measures in cleft palate surgery. OBJECTIVE: The aim of this review is to evaluate the evidence surrounding the use of perioperative antibiotics and other antimicrobial interventions in cleft palate surgery. Additionally, we review the literature on the oral flora unique to the cleft palate patient population. METHODS: This was accomplished utilizing PubMed, Medline, and the Cochrane Library with MeSH and generic terms. Articles were selected based on predefined inclusion and exclusion criteria. RESULTS: This review highlights the lack of higher level evidence on perioperative antibiotic use and other antimicrobial interventions in cleft palatoplasty and calls for further research on the matter. CONCLUSIONS: The literature appears to support the use of preoperative antibiotics for cleft palatoplasty, but the benefits of prolonged postoperative antibiotic use remain questionable.
Asunto(s)
Labio Leporino , Fisura del Paladar , Enfermedades Nasales , Antibacterianos , Fisura del Paladar/cirugía , Humanos , Lactante , Fístula Oral , Complicaciones Posoperatorias , Estudios Retrospectivos , Resultado del TratamientoRESUMEN
BACKGROUND: The fibula free flap (FFF) remains the criterion standard for complex mandibular reconstruction. Surgeons have incorporated virtual surgical planning (VSP) into the reconstructive algorithm with the assertion that VSP increases operative efficiency and may improve clinical outcomes. To date, no large-scale studies have analyzed these claims. This study examines the literature and tests the hypothesis that VSP improves operative efficiency, clinical outcomes, and accuracy when compared with traditional techniques. METHODS: A systematic review was performed to identify articles utilizing VSP and traditional techniques for FFF-based mandibular reconstruction. Two reviewers independently assessed all articles for methodological quality using a validated instrument (weighted Cohen κ for interrater reliability = 0.70). Outcomes included operative time, length of stay, complications, and accuracy. Meta-analytic comparisons were performed using data from comparative studies using a random-effects model and differences of means analysis for outcomes measured on identical scales. RESULTS: One hundred thirty-one articles were identified, and 25 met the inclusion criteria: 12 were VSP only, whereas 13 were comparative. There were 241 VSP patients and 214 traditional patients available for meta-analysis. Patients undergoing reconstruction with VSP had a significant reduction in operative time by 44.64 minutes (95% confidence interval [CI], -74.69 to -14.58 minutes; P < 0.01) and demonstrated a mean trend toward shorter hospital admission (mean difference, -1.24 days; 95% CI, -4.00 to 1.52 days; P = 0.38). There was no statistical difference between cohorts for major (odds ratio, 1.03; 95% CI, 0.46-2.31; P = 0.95) or minor complications (odds ratio, 0.97; 95% CI, 0.54-1.71; P = 0.90). Insufficient data were available for cost analysis and accuracy. CONCLUSIONS: Virtual surgical planning-guided mandibular reconstruction with FFF is associated with significantly decreased operative time and a mean trend toward shorter hospital admission. While multiple studies reported a high degree of accuracy, no standard measurement was available for meta-analysis.
Asunto(s)
Colgajos Tisulares Libres , Reconstrucción Mandibular/métodos , Cirugía Asistida por Computador , Peroné/trasplante , HumanosRESUMEN
OBJECTIVE: The tumor suppressor protein p53 regulates angiogenesis and is a key regulatory mediator of cellular apoptosis, proliferation, and growth. p53 expression is induced in response to ischemia; however, its role in regulating ischemia-induced angiogenesis and arteriogenesis remains undefined. The objective of this study was to define the role of p53 in regulating ischemia-induced angiogenesis and arteriogenesis and to identify mechanisms by which this regulation occurs in vivo. METHODS: Surgically induced hindlimb ischemia or mesenteric artery ligation was performed in wild-type (p53+/+) and p53 knockout (p53-/-) mice. Limb perfusion and revascularization were assessed by laser Doppler perfusion imaging, capillary density, and collateral artery development. Mesenteric collateral artery flow and development were determined by arterial flow measurement and by histologic analysis, respectively. An in vitro aortic ring assay was performed on p53+/+ and p53-/- aortic tissue to evaluate endothelial function. The p53 inhibitor and activator pifithrin-α and quinacrine, respectively, were used to modulate p53 activity in vivo after ischemia. RESULTS: Absence of p53 in mice resulted in increased limb perfusion (P < .05), capillary density (P < .05), and collateral artery development (P < .05) after induction of hindlimb ischemia. In the nonischemic mesenteric artery ligation model of arteriogenesis, p53 expression was induced in collateral arteries and increased arterial blood flow in mice lacking p53 (P < .05). Lack of p53 decreased apoptosis in ischemic hindlimb tissue (P < .05) and increased proangiogenic factors hypoxia-inducible factor 1α and vascular endothelial growth factor (VEGF). Endothelial cell outgrowth in vitro increased in the absence of p53 (P < .05). Pharmacologic augmentation of p53 expression after ischemia impaired perfusion and collateral artery formation and decreased VEGF levels (P < .05). Conversely, inhibition of p53 with pifithrin-α augmented limb perfusion (P < .05) and collateral artery formation (P < .05) and increased protein levels of hypoxia-inducible factor 1α and VEGF. Pharmacologic augmentation and inhibition of p53 had no significant effect in mice lacking p53. CONCLUSIONS: p53 negatively regulates ischemia-induced angiogenesis and arteriogenesis. Inhibition of p53 increases ischemia-induced arteriogenesis and limb perfusion and thus represents a potential therapeutic strategy for arterial occlusive disease.
Asunto(s)
Músculo Esquelético/irrigación sanguínea , Neovascularización Fisiológica , Daño por Reperfusión/metabolismo , Proteína p53 Supresora de Tumor/metabolismo , Inductores de la Angiogénesis/farmacología , Inhibidores de la Angiogénesis/farmacología , Animales , Benzotiazoles/farmacología , Velocidad del Flujo Sanguíneo , Circulación Colateral , Modelos Animales de Enfermedad , Células Endoteliales/metabolismo , Miembro Posterior , Subunidad alfa del Factor 1 Inducible por Hipoxia/metabolismo , Ratones de la Cepa 129 , Ratones Endogámicos C57BL , Ratones Noqueados , Neovascularización Fisiológica/efectos de los fármacos , Quinacrina/farmacología , Flujo Sanguíneo Regional , Daño por Reperfusión/patología , Daño por Reperfusión/fisiopatología , Daño por Reperfusión/prevención & control , Transducción de Señal , Técnicas de Cultivo de Tejidos , Tolueno/análogos & derivados , Tolueno/farmacología , Proteína p53 Supresora de Tumor/agonistas , Proteína p53 Supresora de Tumor/antagonistas & inhibidores , Proteína p53 Supresora de Tumor/genética , Factor A de Crecimiento Endotelial Vascular/metabolismoRESUMEN
The challenges of cleft reconstruction have been present for centuries. However, understanding of the cleft nasal tip and the evolution of techniques decidedly began in the 20th century and refinement continues into the present day. Although a multitude of technical descriptions and case series have been published, a compendium of seminal techniques, which have shaped modern thought, has not been compiled in the literature. In this review, we discuss the anatomical disturbances in the cleft nasal tip anomaly, the timing and strategy of tip correction, and the major classic techniques for management of the cleft nasal tip. In addition, we have categorized the classic techniques into concepts that they embody.
Asunto(s)
Labio Leporino/cirugía , Nariz/anomalías , Nariz/cirugía , Rinoplastia/métodos , HumanosRESUMEN
BACKGROUND: A key educational component of the integrated plastic and reconstructive surgery (PRS) training model is the prerequisite, or core, experiences. The aim of this study is to assess the integrated PRS residents' experience with this early part of training. METHODS: A 20-question survey was developed and piloted before deployment to integrated PRS training programs from 4 United States Census regions. Respondents were asked to characterize their prerequisite clinical and operative experiences. Results were analyzed using pairwise correlation statistics and logistic regression modeling following Bonferroni correction for multiple hypothesis testing. RESULTS: One hundred ninety six residents (22 programs) participated in the study (response rate, 65.3%). The majority of residents were satisfied with their prerequisite experiences. Most did not take the American Board of Surgery In-Training Examination, which was perceived as noncontributory to PRS training. The majority of residents preferred to have fewer prerequisite experiences. Operative hours per week were predictive of resident satisfaction with the clinical and operative prerequisite experiences (both P < 0.001). Perception of general surgery program director investment in PRS education was also predictive of resident satisfaction with clinical and operative experiences (P = 0.05 and P < 0.001, respectively). CONCLUSIONS: The present study demonstrates that PRS residents are satisfied with the quality of prerequisite training but prefer less overall. Reevaluation of the benefits of the American Board of Surgery In-Training Examination and individual essential rotations for resident education would be welcomed. Furthermore, this study identifies the residents' clinical and operative experience and perceived general surgery program director involvement as important determinants of integrated resident satisfaction with prerequisite training.
Asunto(s)
Educación de Postgrado en Medicina , Internado y Residencia , Satisfacción Personal , Cirugía Plástica/educación , Adulto , Competencia Clínica , Humanos , Encuestas y Cuestionarios , Estados Unidos , Carga de Trabajo/estadística & datos numéricosRESUMEN
Fibroblast growth factor receptor 2 (FGFR2) signaling is critical for proper craniofacial development. A gain-of-function mutation in the 2c splice variant of the receptor's gene is associated with Crouzon syndrome, which is characterized by craniosynostosis, the premature fusion of one or more of the cranial vault sutures, leading to craniofacial maldevelopment. Insight into the molecular mechanism of craniosynostosis has identified the ERK-MAPK signaling cascade as a critical regulator of suture patency. The aim of this study is to investigate the role of FGFR2c-induced ERK-MAPK activation in the regulation of coronal suture development. Loss-of-function and gain-of-function Fgfr2c mutant mice have overlapping phenotypes, including coronal synostosis and craniofacial dysmorphia. In vivo analysis of coronal sutures in loss-of-function and gain-of-function models demonstrated fundamentally different pathogenesis underlying coronal suture synostosis. Calvarial osteoblasts from gain-of-function mice demonstrated enhanced osteoblastic function and maturation with concomitant increase in ERK-MAPK activation. In vitro inhibition with the ERK protein inhibitor U0126 mitigated ERK protein activation levels with a concomitant reduction in alkaline phosphatase activity. This study identifies FGFR2c-mediated ERK-MAPK signaling as a key mediator of craniofacial growth and coronal suture development. Furthermore, our results solve the apparent paradox between loss-of-function and gain-of-function FGFR2c mutants with respect to coronal suture synostosis.