Recurrent Syndrome of the Trephined in the Setting of Multiple Craniectomy and Cranioplasty.

Decompressive craniectomy is an increasingly implemented intervention for relief of intracranial hypertension refractory to medical therapy. Despite its therapeutic benefit, a myriad of short and long-term complications may arise when the once fixed-volume cranial vault remains decompressed. The authors present a case of recurrent Syndrome of the Trephined in a patient undergoing repeated craniectomy and cranioplasty.A 70-year old male with history significant for smoking and chronic obstructive pulmonary disease presented with frontoparietal subdural hematoma with midline shift following a ground level fall necessitating craniotomy and hematoma evacuation. Three months postoperatively, the patient developed an infection of his craniotomy bone flap necessitating craniectomy without cranioplasty. Six weeks post-craniectomy the patient began demonstrating right sided sensorimotor deficits with word finding difficulties. Alloplastic cranioplasty was performed following resolution of infection, with resolution of neurologic symptoms 6 weeks post cranioplasty. Due to recurrent cranioplasty infections, multiple alloplastic cranioplasties were performed, each with reliable re-demonstration of neurologic symptoms with craniectomy, and subsequent resolution following each cranioplasty. Final cranioplasty was successfully performed using a new alloplastic implant in combination with latissimus muscle flap, with subsequent return of neurologic function.Decompressive craniectomy is a life-saving procedure, but carries many short- and long-term complications, including the Syndrome of the Trephined. Our case is the first published report, to our knowledge, to demonstrate recurrent Syndrome of the Trephined as a complication of craniectomy, with reliable resolution of the syndrome with restoration of the cranial vault.

Optimal Timing of Alveolar Cleft Bone Grafting for Maxillary Clefts in the Cleft Palate Population.

PURPOSE: Timing of bone grafting for maxillary alveolar clefts is not standardized. Secondary bone grafting is often performed; however, consensus does not exist regarding use of chronologic versus dental age to guide treatment. Several authors suggest an early chronologic age is associated with greater success. Available literature was systematically reviewed for evidence for optimal timing for grafting maxillary alveolar clefts. METHODS: PubMed, MEDLINE, and Cochrane Central Registrar of Controlled Trials databases were queried for manuscripts pertaining to maxillary alveolar cleft bone grafting. Inclusion criteria included manuscripts with level of evidence 4 or greater. Studies not using bone graft, lacking postoperative follow up, and clinical reports were excluded. Seventeen articles met criteria. RESULTS: Nine manuscripts recommended grafting based on dental age prior to eruption of the permanent canines, while 8 recommended grafting between ages 7 to 12. The most commonly reported complication was wound dehiscence, followed by graft-site infection. Ten studies used perioperative treatment protocols, 8 of which included preoperative and/or postoperative orthodontia for maxillary expansion. Correlation between chronologic age and success was not significant, but trended towards greater success with increasing age. CONCLUSION: Success of secondary grafting is high, but significant variability exists in the timing of grafting. Evidence is lacking to support specific chronologic age; rather, perioperative protocols, systematic surgical technique, and a multidisciplinary discussion are likely more substantial in achieving success, and may be confounders in studies where an early age at grafting appears associated with success. The timing of bone grafting for maxillary alveolar clefts would benefit from a prospective randomized study.

State Variations in Public Payer Reimbursement for Common Plastic Surgery Procedures.

BACKGROUND: Existing data suggest decreased willingness of plastic surgeons to participate in Medicare and Medicaid. Significant disparities exist in Medicare and Medicaid reimbursement for various general surgical procedures. The aims of this study were to investigate variations in Medicare and Medicaid reimbursement across the nation for common plastic surgery procedures. METHODS: Medicare and Medicaid reimbursement data for 2017 were obtained by means of the Centers for Medicare & Medicaid Services and publicly available fee schedules from each state, respectively, for eight common plastic surgery procedures. The difference in Medicare and Medicaid reimbursement was calculated across all states. The difference in value ascribed to each procedure was determined by comparing the payment from each payer to the work relative value units. RESULTS: Medicaid reimbursement rates were significantly lower for the selected procedures, with a median national discount of -25 percent ($16.09 per work relative value unit) compared to Medicare. There were higher median rates of reimbursement per work relative value unit by Medicaid in only five states when compared to Medicare. Significant variations of more than 15 percent in the Medicaid-to-Medicare reimbursement ratios between our selected procedures were identified in 28 states. CONCLUSIONS: Variations exist between Medicare and Medicaid reimbursement for common plastic surgery procedures. The within-state variations in Medicaid reimbursement are likely reflective of important yet nontransparent differences in determining Medicaid reimbursement. These variations likely affect access to care for underserved populations. Professional societies should continue to convey the value of these important procedures and raise awareness regarding disparities in access to care.

Thermal Burn Injury from a Wedding Ring: An Unusual Case.

Thermal ring injuries are rarely reported in the literature. For this reason, treatment is varied without a standard approach. We describe a case of a thermal wedding ring injury sustained during a welding accident. It is critical to understand the 3 zones of burn injuries when managing these infrequent cases. Furthermore, the dynamic progression that ensues a thermal burn will directly affect outcome. A case is presented along with a graduated approach to the management of such injuries.