Part II: Blood Transfusion and Donor Exposure in the Surgical Management of Trigonocephaly Patients: A Protocol From Alder Hey Craniofacial Unit.

Trigonocephaly is a craniofacial malformation caused by premature fusion of the metopic suture. Surgical correction frequently results in the need for blood transfusion. Transfusion complications include transfusion-transmitted infections (TTIs), immune-mediated reactions, and volume overload. Donor exposure (DE) describes the number of blood products from unique donors with increasing DE equating to an increased risk of TTI. We evaluate data on 204 trigonocephaly patients covering 20 years of practice with respect to blood transfusions and DE. This represents the largest series from a single unit to date. A protocol based on our experiences has been devised that summarizes the key interventions we recommend to minimize blood transfusions and DE in craniofacial surgery. Patients operated on between 2000 and 2020 were included. DE and a range of values were calculated including estimated red cell loss (ERCL) and estimated red cell volume transfused (ERCVT). Groups were established by relevant interventions and compared using the Mann-Whitney U test. Mean DE fell from 1.46 at baseline to 0.85 ( P <0.05). Median allogenic transfusion volume fell from 350 mL at baseline to 250 mL ( P <0.05). Median ERCL fell from 15.05 mL/kg at baseline to 12.39 mL/kg and median ERCVT fell from 20.85 to 15.98 mL/kg. Changes in ERCL and ERCVT did not reach statistical significance. DE can be minimized with the introduction of key interventions such as a restrictive transfusion policy, preoperative iron, cell saver, tranexamic acid, and use of a matchstick burr for osteotomies.

Human intracerebroventricular (ICV) injection of autologous, non-engineered, adipose-derived stromal vascular fraction (ADSVF) for neurodegenerative disorders: results of a 3-year phase 1 study of 113 injections in 31 patients.

We have chosen to test the safety of human intracerebroventricular (ICV) brain injections of autologous non-genetically-modified adipose-derived stromal vascular fraction (ADSVF). In this IRB-approved trial, 24 patients received ICV ADSVF via an implanted reservoir between 5/22/14 and 5/22/17. Seven others were injected via their ventriculo-peritoneal shunts. Ten patients had Alzheimer's disease (AD), 6 had amyotrophic lateral sclerosis (ALS), 6 had progressive multiple sclerosis (MS-P), 6 had Parkinson's "Plus" (PD+), 1 had spinal cord injury, 1 had traumatic brain injury, and 1 had stroke. Median age was 74 (range 41-83). Injections were planned every 2-3 months. Thirty-one patients had 113 injections. Patients received SVF injection volumes of 3.5-20 cc (median:4 cc) containing 4.05 × 105 to 6.2 × 107 cells/cc, which contained an average of 8% hematopoietic and 7.5% adipose stem cells. Follow-up ranged from 0 to 36 months (median: 9.2 months). MRIs post injection(s) were unchanged, except for one AD patient whose hippocampal volume increased from < 5th percentile to 48th percentile (NeuroQuant® volumetric MRI). Of the 10 AD patients, 8 were stable or improved in tests of cognition. Two showed improvement in P-tau and ß-amyloid levels. Of the 6 MS-P patients all are stable or improved. Four of 6 ALS patients died of disease progression. Twelve of 111 injections (11%) led to 1-4 days of transient meningismus, and mild temperature elevation, which resolved with acetaminophen and/or dexamethasone. Two (1.8% of injections) required hospitalization for these symptoms. One patient (0.9% of injections) had his reservoir removed and later replaced for presumed infection. In this Phase 1 safety trial, ADSVF was safely injected into the human brain ventricular system in patients with no other treatment options. Secondary endpoints of clinical improvement or stability were particularly promising in the AD and MS-P groups. These results will be submitted for a Phase 2 FDA-approved trial.

A critical review of complications in non-surgical rhinoplasty and their management.

BACKGROUND: In recent years, there has been a rise in non-surgical rhinoplasty (NSR) due to its minimally invasive approach. As with all procedures, NSR can result in complications. Although rare, the consequences of complications can result in a devastating outcome and therefore an evidence-based approach to enable the recognition and management of NSR complications is required. AIMS: This paper aims to review and appraise current literature to determine the evidence base for complications experienced with NSR including their causes and management. METHODS: A systematic review was conducted using a PRISMA methodology. The PubMed and WebofScience databases were queried. Papers relating to the three most commonly used filler materials; hyaluronic acid (HA), calcium hydroxyapatite and collagen were collated. RESULTS: Four hundred and ninety studies were identified in the initial literature search and after applying an inclusion and exclusion criteria, 12 papers were included. CONCLUSION: The results of this literature review showed a paucity of high-level evidence which may indicate underreporting of NSR complications. Although treatment is not always effective, it is clear that early recognition and treatment favors better outcomes with the potential for complete resolution in some cases. Immediate availability of hyaluronidase is important when undertaking NSR with HA as this review showed early use was critical in the management of serious complications such as vascular occlusion.

An audit of routine practice: a prospective study on the use of mouth props in oral surgery.

Introduction Mouth props are routinely used for patients treated under general but not local anaesthesia (LA). Patient discomfort and excess operator time is an often cited argument against the routine use of mouth props.Aim and methods We surveyed patients, surgeons and assistants following the use of mouth props during minor oral surgical procedures under LA in order to assess their acceptability and utility in clinical practice.Results Forty-seven patients were included, with 24 patients treated using mouth props and 23 without. Thirty-three patients had dental extractions, three had intraoral biopsies and one underwent a tube removal following cyst marsupialisation.Discussion Patients reported less difficulty in mouth opening where a mouth prop was used. Patients reported similarly low levels of discomfort with or without a mouth prop. Ninety-five percent of patients who used a mouth prop reported they would recommend their use. The surgeon and assistant reported mouth opening as less problematic and assisting as easier where a mouth prop was used.Conclusion The results of this study demonstrate the benefits and broad acceptability of mouth prop use in the awake patient. We question current practice in that mouth props are not routinely offered to patients during oral surgical and dental procedures.

Simple bone cyst of the mandibular condyle.

Simple bone cysts (SBCs) are benign lesions often found in the long bones of children between their first and second decades. They occasionally occur in the mandible but rarely in the mandibular condyle. A case of a 7-year-old female child with an increasing enlargement of the left mandibular condyle is presented. A 2 cm × 3 cm lytic lesion was explored and curetted through an intraoral vestibular incision and proved to be an SBC. Postoperative recovery was uncomplicated with remodeling of the condylar observed at 3 years follow-up.