Long-Term Hand Function Outcomes of the Surgical Management of Complete Brachial Plexus Birth Injury.

PURPOSE: Hand function outcomes of primary nerve reconstruction for total brachial plexus birth injury (BPBI) are confounded by nerve roots left in continuity, inclusion of secondary procedures, and no assessment of the ability to perform activities of daily living. The purpose of this study was to evaluate the long-term hand function outcomes in a cohort of patients with a complete BPBI who had no nerve root in continuity prior to primary nerve reconstruction targeting the lower trunk. METHODS: This single-center retrospective case series of complete BPBI included patients who underwent primary nerve reconstruction. The outcomes were assessed using the active movement scale (AMS) and brachial plexus outcome measure preoperatively and at the age of 4 and 8 years. RESULTS: Fifty patients with a complete BPBI, of whom 82% (41/50) had an avulsion of C8-T1, underwent primary nerve reconstruction at a mean age of 4.1 months. Compared with the preoperative AMS scores, a statistically significant increase of AMS scores was observed at 4 and 8 years of age for all movements except forearm pronation. Between 4 and 8 years of age, there was a statistically significant improvement of external rotation of the shoulder and elbow flexion as well as diminution of thumb flexion. In the brachial plexus outcome measure assessment, there were 83% (24/29) at 4 years and 81% (21/26) at 8 years who had sufficient functional movement to perform wrist, finger, and thumb activities. CONCLUSIONS: Functional hand outcome was restored to sufficiently perform bimanual activity tasks in 81% (21/26) of patients with a complete BPBI at 8 years of age. This affirmed that primary nerve reconstruction reinnervating the lower trunk can result in a functional extremity. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Plastic Surgery Techniques for Wound Coverage.

This article reviews techniques for wound coverage that are not amenable to simple linear closure. The relevant anatomy and classification of flaps is discussed, as well as specific techniques for successful flap design.

Current Trends in Unilateral Cleft Lip Care: A 10-Year Update on Practice Patterns.

BACKGROUND: The care of unilateral cleft lip (UCL) patients is extremely variable. Historical benchmarks for perioperative and intraoperative choices by cleft surgeons were produced by Sitzman et al (Plast Reconstr Surg. 2008;121:261e-270e) in 2005. However, emerging data and cleft lip repair methods around this period were not captured by this study. The aim of this study was to update the current practice patterns of cleft lip surgeons. METHODS: An electronic survey was distributed to surgeons in the American Cleft Palate Association. Demographic data about the surgeon were collected as well as their choices regarding perioperative and intraoperative cleft lip care. RESULTS: Eighty-six surgeons responded to the survey. Nearly 40% of surgeons have changed their technique for UCL repair with Fisher anatomical subunit repair gaining significant popularity. Nasoalveolar molding is also being used more frequently (41% vs 22%). At the time of the cleft lip repair, closure of the nasal floor is occurring in 83.1% of patients and primary cleft rhinoplasty is being performed routinely 57% of the time. CONCLUSIONS: Over the last 10 years, there has been an increase in the use of modified rotation advancement repairs and Fisher anatomic subunit approximation technique for treatment of UCL. There continues to be a lack of evidence regarding superiority of specific repair techniques or the benefits of adjunct procedures, which results in varying practice patterns. Educating all cleft surgeons on practices that are well supported is important to improve care to cleft patients.

Perioperative Outcomes Following Pediatric Cranial Vault Remodeling: Are Improvements Possible?

PURPOSE: The Pediatric Craniofacial Collaborative Group recently reported pooled perioperative data from 31 North American centers performing open cranial vault remodeling procedures. The authors sought to determine if outcomes were different at a single higher-volume center and if identified, ascertain reasons for any differences and propose strategies for improvement. METHODS: A retrospective review was performed of all open pediatric cranial vault procedures performed at our center during the identical 3.25-year period reported by the Collaborative group, including demographic, perioperative management and outcome data, to permit multiple comparative analyses. RESULTS: The 310 procedures were performed by our center during this time period, compared to 1223 by the combined 31 institutions (median: 29.5 cases/center; interquartile range: 12-54.5). Multiple outcome differences were found: our higher-volume center had a significantly lower overall red blood cell transfusion rate (≤2 years: 7.5 percent vs 91 percent, P <0.001), those requiring transfusions were transfused considerably smaller volumes (≤2 years: 3.8mL/kg vs 45.3 mL/kg, P <0.001), and exposure to ≥3 blood donors was significantly less (none vs 20 percent, P <0.001). There were no mortalities in either group, but almost all matched adverse events were less common at our center. Both the intensive care unit and hospital lengths of stay were significantly shorter at our center (1 vs 2 days, 2 vs 4 days, both P <0.001). CONCLUSIONS: Perioperative outcomes following pediatric craniosynostosis corrections performed at a single higher-volume center compare favorably to median national data. Multiple potential strategies to reduce blood utilization, minimize perioperative complications, and shorten hospitalizations are proposed.

Direct Cost Comparison of Open Carpal Tunnel Release in Different Venues.

Background: The increased efficiency and cost savings have led many surgeons to move their practice away from the traditional operating room (OR) or outpatient surgery center (OSC) and into the clinic setting. With the cost of health care continuing to rise, the venue with the lowest cost should be utilized. We performed a direct cost analysis of a single surgeon performing an open carpal tunnel release in the OR, OSC, and clinic. Methods: Four treatment groups were prospectively studied: the hospital OR with monitored anesthesia care (OR-MAC), OSC with MAC (OSC-MAC), OSC with local anesthesia (OSC-local), and clinic with local anesthesia (clinic). To determine direct costs, a detailed inventory was recorded including the weight and disposal of medical waste. Indirect costs were not included. Results: Five cases in each treatment group were prospectively recorded. Average direct costs were OR ($213.75), OSC-MAC ($102.79), OSC-local ($55.66), and clinic ($31.71). The average weight of surgical waste, in descending order, was the OR (4.78 kg), OSC-MAC (2.78 kg), OSC-local (2.6 kg), and the clinic (0.65 kg). Using analysis of variance, the clinic's direct costs and surgical waste were significantly less than any other setting (P < .005). Conclusions: The direct costs of an open carpal tunnel release were nearly 2 times more expensive in the OSC compared with the clinic and almost 7 times more expensive in the OR. Open carpal tunnel release is more cost-effective and generates less medical waste when performed in the clinic versus all other surgical venues.

Opioid Sparing in Cleft Palate Surgery.

OBJECTIVE: This study aimed to determine whether intraoperative acetaminophen was able to decrease opioid consumption, pain scores, and length of stay while increasing oral intake in cleft palate surgery. DESIGN/SETTING/PATIENTS: One hundred consecutive patients with cleft palate who underwent a von Langenbeck or 2-flap palatoplasty and intravelar veloplasty at a tertiary medical center by the 2 senior authors from 2010 to 2015 were reviewed. INTERVENTIONS: Three intraoperative treatment groups were analyzed: intravenous (IV) acetaminophen, per rectal (PR) acetaminophen, and no acetaminophen. All patients received long-acting local anesthesia infiltration before incision. Additionally, all patients were admitted overnight and given weight-based per oral (PO) acetaminophen and oxycodone and IV morphine as needed based on pain scores. OUTCOMES MEASURED: The study outcomes included pain scores, opioid requirement, length of stay, and oral intake. RESULTS: The treatment groups were comprised of 40 patients who received IV acetaminophen, 22 PR acetaminophen, and 35 none. Concerning demographic data, there was no statistical difference between treatment groups. There was no statistically significant difference for opioid intake, although both IV and PR acetaminophen groups had decreased pain scores ( P = .029). There was no difference in oral intake ( P = .13) or length of stay ( P = .31) between treatment groups. CONCLUSION: In this study, intraoperative administration of acetaminophen was associated with decreased pain scores, but no opioid-sparing effect. As other studies have shown an opioid-sparing effect with postoperative acetaminophen, we recommend withholding the intraoperative dose and beginning therapy in the immediate postoperative period.

Structural Fat Grafting to Improve Reconstructive Outcomes in Secondary Cleft Lip Deformity.

OBJECTIVE: To describe the technique and results of structural fat grafting in cleft lip revision, including patient satisfaction and aesthetic outcome. DESIGN: Retrospective case series. SETTING: Multidisciplinary cleft care center. PATIENTS: All patients who underwent structural fat grafting between June 2006 and September 2012 for cleft lip revision, with appropriate photographic follow-up included. Twenty-two cases were reviewed; 18 had sufficient data to be included. INTERVENTIONS: Patients underwent structural fat grafting for cleft lip revision, most commonly injecting fat under deficient philtral columns, the nostril base, and upper lip. MAIN OUTCOME MEASURES: Blinded observers rated outcomes using the Asher-McDade nasolabial appearance rating scale. Patients completed questionnaires assessing their satisfaction. A paired Student's t-test was used to test outcomes for significance (alpha = 0.05). RESULTS: Patients were an average of 16 years old (range: 6-43); average length of follow up was 11.7 months. Overall symmetry and aesthetics were improved based on the nasal form (P = 0.006) and vermillion border (P = 0.04) when rated using the Asher-McDade scale. No complications were recorded. Patients were significantly happier with their appearance after fat grafting (P < 0.001) and were uniformly positive when questioned about the ease of the surgery and rate of recovery. CONCLUSIONS: Structural fat grafting is a safe and effective way to improve symmetry and enhance facial proportions in patients with cleft lip. Given the high degree of patient satisfaction, few complications, and durable results, fat grafting offers many advantages in cleft lip revision.

Orbital Expansion for Congenital Anophthalmia May Be Achievable in Infancy But Not in Childhood.

BACKGROUND: Congenital anophthalmia is a rare anomaly that results in micro-orbitism and craniofacial microsomia. Treatment with static conformers is labor-intensive and provides minimal stimulation for orbital growth that requires eventual reconstruction with orbital osteotomies after skeletal maturity. METHODS: A protocol for the treatment of congenital anophthalmia is presented. Patients underwent a preoperative low-dose radiation computed tomography (CT) scan of the facial bones to assess orbital volume. An intraorbital expander was placed and was filled on a monthly basis. Quantitative changes in the affected and unaffected orbits were assessed by a repeat CT scan obtained 1 year postoperatively. RESULTS: Two patients with left unilateral congenital anophthalmia were prospectively followed. In a 4-month-old, the affected orbital width and height increased by 171.6% and 116.7% respectively compared with the unaffected orbit. In a 4-year-old, the affected orbital width increased by 36.1% but the height decreased by 35.3% compared with the unaffected orbit. At 18 months follow-up, no complications, ruptures, infections, or extrusions have been observed. CONCLUSIONS: Our results support that accelerated expansion can be achieved in a 4-month-old orbit reversing the effects of anophthalmia. However, in a 4-year-old, minimal growth was observed. The lack of accelerated growth in this study may be explained by synostosis of the orbital sutures. As such, expansion should be initiated at the earliest age possible. Further longitudinal study is ongoing to determine if sustained catch-up growth will obviate or reduce the complexity of a secondary correction.

Evidence-based medicine: Mandible fractures.

LEARNING OBJECTIVES: After studying this article, the participant should be able to: 1. Describe the anatomy and subunits of the mandible. 2. Review the cause and epidemiology of mandible fractures. 3. Discuss the preoperative evaluation and diagnostic imaging. 4. Understand the principles and techniques of mandible fracture reduction and fixation. SUMMARY: The management of mandibular fractures has undergone significant improvement because of advancements in plating technology, imaging, and instrumentation. As the techniques in management continue to evolve, it is imperative for the practicing physician to remain up-to-date with the growing body of scientific literature. The objective of this Maintenance of Certification article is to present a review of the literature so that the physician may make treatment recommendation based on the best evidence available. Pediatric fractures have been excluded from this article.

Prolonged effects of B-type natriuretic peptide infusion on cardiac remodeling after sustained myocardial injury.

B-type natriuretic peptide (BNP) is an established first-line therapy for acute decompensated heart failure (HF), but its efficacy in preventing left ventricular (LV) remodeling after myocardial injury is unknown. The goal of this study was to evaluate the effects of BNP therapy on remodeling after ischemic injury in an awake canine model. Dogs were chronically instrumented for hemodynamics. Ischemia was created by daily coronary embolization (Embo; 3.1 x 10(4) beads/day) for 3 wk; 60 min after the first embolization, BNP (100 ng x kg(-1) x min(-1); n = 6) or saline (control; n = 6) was continuously infused via a left atrial catheter for 3 wk. Hemodynamics and echocardiography were performed in an awake state at baseline, 3 wk after Embo + BNP infusion, and 4 wk after stopping Embo + BNP infusion. End-systolic elastance (E(es)) and LV change in pressure over time (dP/dt) were preserved throughout Embo + BNP therapy versus control therapy (E(es): 3.76 +/- 1.01 vs. 1.41 +/- 0.16 mmHg/ml; LV dP/dt: 2,417 +/- 96 vs. 2,068 +/- 95 mmHg/s; both P < 0.05 vs. control). LV end-diastolic dimension was significantly smaller in BNP-treated dogs compared with control dogs (4.29 +/- 0.10 vs. 4.77 +/- 0.17 cm), and ejection fraction was maintained in treated dogs vs. control dogs (53 +/- 1% vs. 46 +/- 2%) (both P < 0.05 vs. control). Cyclooxygenase (COX)-2 expression in terminal LV tissue was significantly reduced after BNP therapy. Treatment with continuous infusion of BNP preserved LV geometry, improved systolic function, and prevented the progression of systolic HF after persistent ischemic injury.