A Scoping Review of Innervated Breast Reconstruction.

BACKGROUND: After breast surgery, patients experience significant alterations to breast sensation, which can diminish quality of life. Nerve coaptation technique, introduced in the 1990s, has gained traction in recent years. We performed a scoping review of the literature to determine the available outcomes in sensate breast reconstruction. METHODS: The review was conducted using Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews statement guidelines. EMBASE and PubMed databases were queried using standardized terminology. Studies were included if they reported original sensory outcomes following innervation techniques during breast reconstruction and were published from January 1, 1990, to April 18, 2022. Data extraction and analyses were performed on Microsoft Excel. RESULTS: From 602 screened articles, 27 studies met the inclusion criteria. Innervated autologous reconstructive procedures were described in 24, whereas the remaining 3 (all published after 2019) described direct reinnervation of the nipple-areola complex. Most (88.9%) of the studies comparing innervated versus noninnervated reconstruction reported improved sensory outcomes in at least 1 modality. Two studies investigated patient-reported outcomes using validated questionnaires, both of which reported improvement with innervated reconstruction. CONCLUSIONS: Sensate breast reconstruction has the potential to improve outcomes for patients. There is a recent progressive increase in studies involving direct nipple-areolar reinnervation. Larger, prospective studies are needed to better characterize the quality-of-life outcome using validated scales, as well as evaluate sensory and patient-reported outcomes with implant and autologous reconstruction.

Alterations in Sphenoid Anatomy in Craniosynostosis: Implications for Fronto-Orbital Advancement.

OBJECTIVE: Fronto-orbital advancement involves removal of the fronto-orbital bandeau. Visualization of the saw blade is lost as it passes through the fronto-orbital-sphenoid junction (FOSJ), placing the temporal lobe at risk of injury. We aim to provide a 3D analysis of the space surrounding this osteotomy to differentiate various types of craniosynostoses. DESIGN: Retrospective cohort. SETTING: Institutional. PATIENTS: Thirty patients with isolated unicoronal synostosis, nonsyndromic bicoronal synostosis, metopic synostosis, Apert syndrome, Crouzon syndrome, and Muenke syndrome. INTERVENTIONS: CT scans conducted between 2 months to 2 years of age were 3D reconstructed to compare craniometrics against normal controls. MAIN OUTCOME MEASURE(S): Craniometrics. RESULTS: The mean bone thickness of the FOSJ at the level of the supraorbital rim was significantly small for the Apert, unicoronal and bicoronal groups. The mean vertical height of the middle cranial fossa from the lesser sphenoid wing was significantly greater in the unicoronal group. The mean vertical height of the tip of the temporal lobe from the lateral sphenoid ridge was greater in the unicoronal, isolated bicoronal, and Apert groups. The mean corneal protrusion beyond the lateral orbital rim was significantly greater in the Apert and unicoronal groups. The mean horizontal depth of the orbit was smallest in the Apert group. The mean vertical distance between the dacryon and the foramen cecum, and the mean volume of temporal lobe beneath the sphenoid shelf were the largest in the Apert group. CONCLUSIONS: Patients with Apert syndrome have the most unfavorable morphology of the anterior and middle cranial fossae.

Patient-specific Composite Anatomic Models: Improving the Foundation for Craniosynostosis Repair.

Preoperative surgical planning incorporating computer-aided design and manufacturing is increasingly being utilized today within the fields of craniomaxillofacial, orthopedic, and neurosurgery. Application of these techniques for craniosynostosis reconstruction can include patient-specific anatomic reference models, "normal" reference models or patient-specific cutting/marking guides based on the presurgical plan. The major challenge remains the lack of tangible means to transfer the preoperative plan to the operating table. We propose a simple solution to utilize a digitally designed, 3D-printed "composite model" as a structural template for cranial vault reconstruction. The composite model is generated by merging the abnormal patient cranial anatomy with the "dural surface topography" of an age-matched, sex-matched, and ethnicity-matched normative skull model. We illustrate the applicability of this approach in 2 divergent cases: 22-month-old African American male with sagittal synostosis and 5-month-old White male with metopic synostosis. The aim of this technical report is to describe our application of this computer-aided design and modeling workflow for the creation of practical 3D-printed skulls that can serve as intraoperative frameworks for the correction of craniosynostosis. With success in our first 2 cases, we believe this approach of a composite model is another step in reducing our reliance on subjective guesswork, and the fundamental aspect of the workflow has a wider application within the field of craniofacial surgery for both clinical patient care and education.

Virtual Reality Planning in Reconstructive Surgery for Orbital Prosthetic Rehabilitation Using ImmersiveTouch Platform: Preliminary Report.

BACKGROUND/PURPOSE: Virtual reality (VR) is emerging as an effective and intuitive surgical planning and 3D visualization tool. Digital surgical planning is the gold standard for planning the placement of implants in maxillofacial prosthetics, but the field lacks a platform exclusively designed to perform the task. Virtual reality planning (VRP) specific for maxillofacial prosthetics offers the clinician improved control of the presurgical planning and the potential to limit the need to adapt other advanced segmentation software. Furthermore, the virtual plan can be directly translated to the patient through custom 3D printed (3DP) surgical guides and visual aids. To the best of our knowledge, this article outlines the development of the world's first virtual reality planning platform and workflow for pre-operatory planning within a VR environment for clinical use specific to facial prosthetics and anaplastology. METHOD: The workflow was applied to managing 2 patients presenting with unilateral total exenteration and severe contracture enucleation, respectively (n=2). A cone-beam CT was acquired for each patient, and their data set was directly imported into the ImmersiveView Surgical Plan VR environment (ImmersiveTouch Inc, Chicago, IL). The clinicians virtually selected appropriately sized craniofacial implants and placed the implants in the desired orientation. Various measurement tools are available to aid in clinical decision-making. The ideal location of craniofacial implants was set according to an orbital and auricular prosthetic reconstruction. The resultant VR plan was exported for 3DP. The patients were evaluated preoperatively and postoperatively using the proposed VRP treatment. The workflow's data accuracy was validated postoperatively by comparing posterative CT data and the proposed VRP. Analysis was performed using Mimics software (Materialise, Leuven, Belgium). RESULT: It takes, on average, 10 minutes to place 4 implants in the virtual reality space. The 3DP files resulting from VRP take ~2 hours to print and are constructed with a biocompatible resin appropriate for clinical use as surgical guides. Our user-friendly VRP workflow allows for an accurate simulation of surgical and nonsurgical procedures with an average displacement in XYZ of 0.6 mm and an SD of 0.3 mm. In addition, VRP is an excellent tool to simulate the craniofacial placement procedure and improves unsupervised self-learning teaching. CONCLUSION: VRP is an exciting tool for training clinicians and students in complex surgical procedures. This study shows the promising applicability and efficiency of VR in clinical planning and management of facial rehabilitation. Patients allowed to interact with VR have been engaged, which would aid their treatment acceptance and patient education. A valuable advantage of surgical simulation is the reduced costs associated with renting instruments, buying implant dummies, and surgical hardware. The authors will explore VR to plan and treat surgical and nonsurgical reconstructive procedures and improve soft tissue manipulation. This study outlines the development of an original platform and workflow for segmentation, preoperative planning, and digital design within a VR environment and the clinical use in reconstructive surgery and anaplastology.

Craniometric and Aesthetic Outcomes in Craniosynostosis Surgery: A Systematic Review and Meta-Analysis.

OBJECTIVE: To systematically review the published comparative aesthetic outcomes, and its determinants, for craniosynostoses surgically treated by minimally-invasive cranial procedures and open cranial vault remodeling (CVR). DESIGN: PRISMA-compliant systematic review. SETTING: Not-applicable. PATIENTS/PARTICIPANTS: Articles were included if they compared spring cranioplasty, strip minimally-invasive craniectomy or CVR for outcomes related to aesthetics or head shape. Forty-two studies were included, comprising 2402 patients. INTERVENTIONS: None. MAIN OUTCOME MEASURE(S): The craniometric and PROM used to determine surgical outcomes. RESULTS: Twenty-five studies (59%) evaluated sagittal craniosynostosis, with metopic (7;17%) and unicoronal (4;10%) the next most prevalent. Thirty-eight studies (90%) included CVR, 24 (57%) included strip craniectomy with helmeting, 9 (22%) included strip craniectomy without helmeting, 11 (26%) included spring cranioplasty, and 3 (7%) included vault distraction. A majority of studies only used 1 (43%) or 2 (14%) craniometric measures to compare techniques. In sagittal synostosis, 13 (59%) studies showed no difference in craniometric outcomes, 5 (23%) showed better results with CVR, 3 (14%) with strip craniectomy, and 1 (5%) with springs. In studies describing other synostoses, 10/14 (71%) were equivocal. Subjective outcome measures followed similar trends. Meta-analysis shows no significant difference in cranial index (CI) outcomes between CVR and less invasive procedures in patients with sagittal synostosis. CONCLUSIONS: There is no difference in CI outcomes between CVR and less invasive procedures. The majority of literature comparing craniometric and aesthetic outcomes between CVR and less invasive procedures shows equivocal results for sagittal synostosis. However, the heterogeneity of data for other craniosynostoses did not allow meta-analysis.

Differences in Practice in Alveolar Bone Grafting Among American Cleft Palate-Craniofacial Association Members.

The purpose of this study is to determine areas of agreement and disagreement among American Cleft Palate-Craniofacial Association (ACPA)members in the clinical practice of alveolar bone grafting (ABG), to guide further research to optimize ABG practices.A cross-sectional survey was conducted.The respondents were in an academic, combination, or private practice.The respondents were either plastic or oral and maxillofacial surgeons (OMFS) from various countries.A de-identified 24-question online survey was distributed to ACPA surgeon members utilizing the Research Electronic Data Capture (REDCap) tool.Data collected included surgeon specialty, use of various alveolar bone graft surgical techniques, as well as protocols.There was more variability than consensus between specialties with regards to the preoperative workup, timing of surgery, materials used for bone graft, surgical techniques, perioperative management, and postoperative evaluation. There was consensus on grafting during mixed dentition, not staging soft and hard tissue closure, and using iliac crest for primary and secondary grafting. Disagreements involved factors used to time the procedure and type of imaging used to assess viability. Technical differences involved incision type, part of bone grafted, use of minimally invasive technique, and material used for revisions.Aside from areas of consensus among surgeons on ABG, several areas, including use of bone substitutes in revision grafting, incision and type of iliac crest graft used during initial grafting, and postoperative protocols, had no consensus. These areas should be targets of further research to determine if there truly is an optimal method to perform ABG.The study was approved by the University of Illinois at Chicago Institutional Review Board. A de-identified 24-question online survey was distributed to surgeon members of the ACPA utilizing the REDCap tool on August 7, 2020. The survey questions consisted of multiple choice and multiple selection questions including an option to select "other" and specify the information in a blank space. Data collected included surgeon specialty, use of various alveolar bone graft surgical techniques, as well as pre and postoperative protocols. The full survey is included in online Supplemental material. Data analysis was performed in SPSS Statistics 27 (IBM Corp.). Descriptive statistics were performed, and chi-square was used to test for significant differences in survey responses between groups.

A Systematic Review of Primary Rhinoplasty in Patients With Bilateral Cleft Lip.

BACKGROUND: Primary rhinoplasty (PR)at the time of cleft lip repair is controversial. We previously performed a systematic review that supported PR during unilateral cleft lip repair. We now aim to determine whether the same idea translates to care of patients with bilateral cleft lip. METHODS: A systematic review was conducted adhering to Preferred Reporting Items for Systematic Reviews and Meta-analysis statement guidelines. PubMed and Embase databases were searched for studies that met our inclusion criteria: (1) English language, (2) human subjects, (3) rhinoplasty at the time of bilateral cleft lip repair, and (4) evaluation of nasal outcome. Studies were excluded in case of: (1) inclusion of a large proportion of syndromic patients, (2) case reports, (3) editorials, (4) letters, (5) reviews, and (6) exclusive to unilateral clefts. Out of 281 studies that showed up on initial search, 12 were included in our review. Research quality and level of evidence rating were determined for each study. RESULTS: Of the 12 included studies, 9 supported PR at the time of bilateral cleft lip repair; 8 studies evaluated nasal growth and found no restriction over time; 4 studies followed 158 patients to an average of 15 years and showed 77% did not need secondary rhinoplasty. CONCLUSION: Although the available literature supports PR in patients with bilateral cleft lip with respect to subjective and objective outcomes, nasal growth, and reducing the need for secondary/revision rhinoplasty, there are significant limitations, necessitating large volume studies.

Magnitude of Horizontal Advancement is Associated With Apnea Hypopnea Index Improvement and Counter-Clockwise Maxillary Rotation After Subcranial Distraction for Syndromic Synostosis.

PURPOSE: Subcranial midface distraction is used to treat central midface deficiency in syndromic synostosis. Our aim was to determine which maxillary movements were associated with improvement in measures of obstructive sleep apnea. METHODS: This was a retrospective cohort study that reviewed patients with syndromic midface retrusion and documented sleep apnea who underwent subcranial midface distraction via either Le Fort 3 osteotomy or Le Fort 2 osteotomy with zygomatic repositioning. The predictor variables measured on cephalograms were the magnitude and direction of midface and mandibular movements. The primary outcome was the change in the apnea hypopnea index (AHI) from polysomnography before and after surgery. The secondary outcomes were volumes of upper airway containing bone spaces calculated from computed tomography scans. Data analysis included linear regression to estimate the effect of distraction vectors on bone space volumes and AHI changes. RESULTS: We included 18 patients primarily with Crouzon or Apert syndrome. The magnitude of distraction in a horizontal direction was the most significant factor for AHI improvement and primarily expanded the nasopharyngeal space, but with a smaller impact on the oral cavity space. Clockwise palate rotation was most influenced by a downward direction of distraction, with 24° below horizontal creating a neutral advancement. The greater the magnitude of advancement, the more likely a counterclockwise rotation was observed. CONCLUSIONS: Horizontal magnitude of advancement had the greatest impact on AHI improvement. Vertical lengthening and closure of anterior open bite deformities can be done without compromising airway results as long as total advancement is not compromised. Palate rotation is best controlled by a downward distraction vector, but counterclockwise rotation increases with greater advancement.

Perioperative Management of Cleft Lip Repair: A Meta-Analysis and Clinical Practice Guideline.

OBJECTIVE: Few studies have focused on perioperative management of cleft lip repair. We sought to evaluate the available data on this topic to create evidence-based clinical guidelines. DESIGN: Systematic review, meta-analysis. METHODS: A PubMed search was performed focusing on perioperative management of cleft lip repair. Studies were included if they included comparative data. A systematic review and meta-analysis was performed according to preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines. MAIN OUTCOME MEASURES: Systematic review of literature regarding wound closure, postoperative arm restraints, perioperative antibiotics, outpatient or ambulatory surgery, or feeding restrictions postoperatively. RESULTS: Twenty-three articles met inclusion criteria after initial screening of 3103 articles. This included 8 articles on wound closure, 2 on postoperative restraints, one on perioperative antibiotics, 6 on outpatient surgery, and 6 on postoperative feeding. Meta-analysis could be performed on dehiscence rates with postoperative feeding regimen and readmission rates after outpatient versus inpatient lip repair. There were few studies with low risk of bias. Outpatient cleft lip repair does not increase readmission (odds ratio [OR]: 0.92, 95% CI: 0.28-3.07). Allowing postoperative breastfeeding or bottle-feeding does not increase dehiscence (OR: 0.61, 95% CI: 0.19-1.95). There was no evidence of publication bias. CONCLUSION: Within the limitations of available data, there is no evidence of a clearly superior closure material. The evidence does not support use of postoperative arm restraints. The evidence does not support the use of preoperative nasal swabs for antibiotic guidance. With careful patient selection, outpatient cleft lip repair appears safe. The evidence supports immediate breastfeeding or bottle-feeding after cleft lip repair.

Pushing the Limits in Cheek Reconstruction: The Sub-Superficial Musculo-Aponeurotic System "Deep Plane" Cervicofacial Flap for Reconstruction of Large Eyelid-Cheek Junction Defects.

The cervicofacial flap is a workhorse flap for reconstruction of moderate to large sized defects of the cheek. Defects that involve the eyelid-cheek junction are often the most challenging of these. While the ideal plane of dissection has been debated, it is our belief that dissection in the sub-superficial musculo-aponeurotic system (SMAS) plane provides better aesthetic and functional outcomes due to enhanced vascularity, fascial support, and additional bulk of the flap itself. The authors present a series of 9 patients who presented with heterogeneous defects of the eyelid-cheek junction after cancer resection and underwent reconstruction using a sub-SMAS cervicofacial flap. At a mean follow-up time of 20 months, the cohort had 2 patients who developed lower lid retraction requiring revision and 2 other minor complications. This series lends support to the versatility and reliability of the sub-SMAS cervicofacial flap for large defects of the eyelid-cheek junction.

Fibrous Dysplasia and Juvenile Psammomatoid Ossifying Fibroma: A Case of Mistaken Identity.

Juvenile psammomatoid ossifying fibroma (JPOF) is a rare benign osseous tumor, usually presenting in the midface. There are many similarities in location, presentation, and radiographic appearance between fibrous dysplasia (FD) and JPOF. Awareness of this entity is important for craniofacial surgeons, as surgical timing and intraoperative management differ between these tumors. Findings that should raise suspicion of JPOF preoperatively include rapid growth, a shell of cortical bone surrounding the lesion, and clearly demarcated borders of the lesion on imaging, as opposed to a gradual transition between normal and abnormal bone. Definitive excision is the treatment of choice, and earlier surgery may provide better results by addressing the lesion at the smallest size possible. In contrast to FD, JPOF is not known to "burn out," so there is minimal benefit to be gained from delay. We present a summary of the evidence for diagnosis and treatment of JPOF as well our experience with JPOF in an 11-year-old female who was initially diagnosed with FD. We aim to draw attention to the similar presentations of these entities so the reader will be able to more accurately manage these patients.

Mandibular Catch-Up Growth in Pierre Robin Sequence: A Systematic Review.

OBJECTIVE: The concept of mandibular catch-up growth is often quoted in the literature regarding Pierre Robin sequence (PRS). We endeavored to perform a systematic review of whether the literature supports this concept. DESIGN: Systematic review. INTERVENTIONS: A PubMed-based systematic review of the English literature was performed of articles objectively measuring mandibular growth or position after nonoperative management of PRS. MAIN OUTCOME MEASURES: Rate and end point of mandibular length, ramus length, gonial angle, and maxillomandibular discrepancy. RESULTS: The initial search delivered 607 English-language abstracts. Of these, 16 met inclusion criteria. Eight articles evaluating 143 patients followed longitudinal patient data and therefore allowed comparison of growth rates to controls. Ten articles evaluating 228 patients presented cross-sectional data and therefore could only evaluate a single time point. Two of the 8 longitudinal studies reported faster than normal growth of mandibular length in a significant portion of their cohort. Five of 8 reported equal growth rates. One of 16 studies reported that mandibular length of patients with PRS normalized compared to controls. Two of 16 studies reported no difference in maxillomandibular discrepancy between PRS and controls, whereas 10 reported a posteriorly displaced mandible relative to the maxilla in PRS. Significant differences in control groups, patients, and age existed between studies. CONCLUSIONS: While the concept of catch-up growth in PRS is often quoted, a minority of objective studies suggest increased mandibular growth rates in isolated PRS. Even fewer studies suggest that the maxillomandibular discrepancy in PRS completely resolves.

Determining the Differential Effects of Stretch and Growth in Tissue-Expanded Skin: Combining Isogeometric Analysis and Continuum Mechanics in a Porcine Model.

BACKGROUND: The relative effects of skin growth and stretch during tissue expansion have not been studied. The authors use novel analytic techniques that allow calculation of these factors at any point of a skin patch. OBJECTIVE: The authors sought to determine how stretch and growth change with different expansion rates and to correlate these values with histologic and cellular changes in skin. MATERIALS AND METHODS: Two minipigs were implanted with a total of 5 tissue expanders under tattooed skin grids. One pig was expanded over 35 days and the second over 15 days. Isogeometric analysis allowed calculation of growth and stretch. Expanders with similar total deformation were compared between protocols. Regression analysis determined predictive effects of stretch and growth on histologic data from the second animal. RESULTS: Deformation was more attributable to stretch in rapid than in slow expansion (1.40 vs1.12, p < .001). Growth was higher in slow expansion than in rapid (1.52 vs 1.07, p < .001). Both growth and stretch predicted epidermal thickness, dermal thinning, and keratinocyte proliferation. Growth predicted vascularity. CONCLUSION: Isogeometric analysis allows determination of precise surface area changes for correlation to microscopic-level data. Using the model, the authors identified that skin deformation in rapid expansion is more attributable to stretch.

Long-term Outcomes After Pediatric Free Flap Reconstruction.

INTRODUCTION: Whereas free tissue transfer has evolved to minimize morbidity in adults, less is known about outcomes after free flaps in children. This study sought to assess short- and long-term outcomes after microvascular reconstruction in the pediatric population. METHODS: Short- and long-term outcomes of free tissue transfer were assessed using chart-review and quality-of-life surveys. The Pediatric Outcomes Data Collection Instrument was used to evaluate overall health, pain, and ability to participate in normal daily and more vigorous activities. Patient or parent responses were compared against normative data. RESULTS: Forty-two patients underwent 48 flap reconstructions at a mean age of 8 years. Median follow-up was 14.9 years. Indications included congenital nevi (n = 19, 42%), lymphatic/vascular malformations (n = 8, 19%), and trauma/burns (n = 6, 14%). There were 21 fasciocutaneous (44%), 19 muscle/myocutaneous (40%), 6 fascial/peritoneal (13%), and 2 osteocutaneous flaps (4%). Major flap complications were observed in 4 patients (9%), whereas major donor-site complications occurred in 2% (1 patient). Valid contact information was available for 25 patients; 16 of these completed surveys (64%). Pediatric Outcomes Data Collection Instrument scores for mobility (median, 52), sports/physical functioning (median, 56), happiness (median, 50), and pain/comfort (median, 56) were not significantly different from normative population score of 50. Similarly, median global functioning score was 99 (maximum, 100) and did not differ between flap types. DISCUSSION: Free tissue transfer in the pediatric population is reliable and well-tolerated over time. Surgeons should not hesitate to use free flaps when clinically indicated for pediatric patients.

Orbital Fracture Reconstruction Using Prebent, Anatomic Titanium Plates: Technical Tips to Avoid Complications.

Orbital fractures are common. In patients where there is significant loss of the medial wall and orbital floor, anatomic prebent 3-dimensional plates allow efficacious restoration of orbital volume. However, the large size of these plates can result in technical difficulties with plate placement, especially in fractures with complete loss of 2 walls of the orbit. In this article, the authors review the pertinent anatomy of the bony orbit with respect to fracture and landmarks in fracture reduction. The authors also note the 3 most commonly encountered problems with the placement of anatomic plates: poor exposure, failure to identify the posterior ledge for the plate, and rotational issues with plate placement resulting in impingement. Technical tips are given to help overcome these issues intraoperatively.

Algorithm for Airway Management in Patients With Pierre Robin Sequence.

PURPOSE: Airway management in neonates with Pierre Robin sequence (PRS) can be challenging. The goal was to describe the algorithm developed by the authors over the past 8 years. METHODS: A retrospective case series analyzing airway management in neonates with PRS admitted to the neonatal intensive care unit at a tertiary care pediatric hospital was performed. The utility of the proposed algorithm for airway management incorporating more consistent use of polysomnography (PSG), and airway assessment was assessed. RESULTS: A total of 31 neonates with PRS (12 men, 19 women) with a mean gestational age of 38.2 weeks were analyzed. Thirteen (41.9%) patients had a named syndrome, chromosomal abnormality, or global delay. Twenty (64.5%) patients had pre-intervention PSG, and severe obstructive sleep apnea with an apnea-hypopnea index (AHI) ≥ 10 events/hour was identified in 19 (95.0%). Mandibular distraction osteogenesis was performed in 18 (58.1%) patients, and improved the AHI on post-operative PSGs. Direct assessment of the upper and lower airways was performed in 19 patients, and 13 (68.4%) were found to have secondary airway pathology. Presence of a concomitant syndrome was significantly associated with need for tracheostomy. CONCLUSION: The algorithm differs from previous ones in that it relies on rigorous pre- and post-intervention PSG (including with a nasopharyngeal airway), as well as that it allows flexibility between treatment options given the whole-patient clinical scenario and endoscopic findings. Results from these studies may be integrated to stratify patients into those who are most likely to benefit from conservative interventions or surgical procedures.

Conical Modification of Forearm Free Flaps for Single-Stage Reconstruction After Total Orbital Exenteration.

BACKGROUND: Orbital exenteration is a significant reconstructive challenge for plastic surgeons. Options described for these defects range from healing by secondary intention to free tissue transfer. The authors present our preferred reconstruction of orbital defects with free forearm-based flaps, which provides quality soft tissue and orbital contouring in 1 stage to consistently allow placement of bone-anchored implants for eventual orbital prosthesis. METHODS: This conical shape of the orbit is deconstructed into a "Pac-Man" type shaped flap that leaves adequate depth for a prosthesis. A retrospective chart review was performed of 2 separate patients receiving orbital exenteration reconstruction by the senior author (MFE). RESULTS: Two patients presented with adenoid cystic carcinoma of the orbit. Both patients underwent nonlid sparing orbital exenteration with adjuvant chemotherapy and radiation. Each patient subsequently developed delayed wound healing after prior local flap reconstruction. Vascularized radial forearm flaps in a Pac-Man shape were used in both patients. Both patients were discharged from the hospital on postoperative day 3. No partial or total flap loss was encountered. To date, each patient has undergone planning for osseointegrated implants. CONCLUSION: The authors present a simplified method of orbital reconstruction that provides high-quality vascularized tissue for resurfacing in 1 stage. This type of open-cavity flap reconstruction avoids the need for flap debulking procedures and facilitates 2-stage placement of osseointegrated implants.

Melanocytes Affect Nodal Expression and Signaling in Melanoma Cells: A Lesson from Pediatric Large Congenital Melanocytic Nevi.

Expression of Nodal, a Transforming Growth Factor-beta (TGF-ß) related growth factor, is associated with aggressive melanoma. Nodal expression in adult dysplastic nevi may predict the development of aggressive melanoma in some patients. A subset of pediatric patients diagnosed with giant or large congenital melanocytic nevi (LCMN) has shown increased risk for development of melanoma. Here, we investigate whether Nodal expression can help identify the rare cases of LCMN that develop melanoma and shed light on why the majority of these patients do not. Immunohistochemistry (IHC) staining results show varying degree of Nodal expression in pediatric dysplastic nevi and LCMN. Moreover, median scores from Nodal IHC expression analysis were not significantly different between these two groups. Additionally, none of the LCMN patients in this study developed melanoma, regardless of Nodal IHC levels. Co-culture experiments revealed reduced tumor growth and lower levels of Nodal and its signaling molecules P-SMAD2 and P-ERK1/2 when melanoma cells were grown in vivo or in vitro with normal melanocytes. The same was observed in melanoma cells cultured with melanocyte conditioned media containing pigmented melanocyte derived melanosomes (MDM). Since MDM contain molecules capable of inactivating radical oxygen species, to investigate potential anti-oxidant effect of MDM on Nodal expression and signaling in melanoma, melanoma cells were treated with either N-acetyl-l-cysteine (NAC), a component of the anti-oxidant glutathione or synthetic melanin, which in addition to providing pigmentation can also exert free radical scavenging activity. Melanoma cells treated with NAC or synthetic melanin showed reduced levels of Nodal, P-SMAD2 and P-ERK1/2 compared to untreated melanoma cells. Thus, the potential role for Nodal in melanoma development in LCMN is less evident than in adult dysplastic nevi possibly due to melanocyte cross-talk in LCMN capable of offsetting or delaying the pro-melanoma effects of Nodal via anti-oxidant effects of MDM.

Operation Smile and the Guwahati Comprehensive Cleft Care Center: Multidisciplinary Global Activism in Plastic Surgery.

Participation in a medical mission in an underserved area is both a challenging and deeply satisfying experience. The global burden of cleft lip and palate is significant, and as plastic surgery providers we are all empowered to help these patients. Surgery for cleft lip and palate is life changing for patients, and the privilege of participating in a mission can be life altering for the providers as well. The Comprehensive Cleft Care Center in Guwahati, India, is a prime example of multidisciplinary collaboration resulting in excellent care in the developing world.

Assessment of Head Shape by Craniofacial Teams: Structuring Practice Parameters to Optimize Efficiency.

INTRODUCTION: Since the initiation of the "Back to Sleep Campaign" by the American Academy of Pediatrics in 1992, the incidence of referrals for positional plagiocephaly has increased by 600%. Although patients with positional plagiocephaly rarely require operative intervention, they often do require treatment with cranial molding helmets or positioning changes. The increased volume of patients makes the task of separating cases of craniosynostosis from positional head shape problems more difficult. The authors sought to determine how providers are handling this increased workload of head shape abnormality patients, especially with respect to the largest practices. MATERIALS AND METHODS: An electronic survey was created and distributed to members of the American Society of Maxillofacial Surgeons and the American Cleft Palate Association (ACPA). Practices were categorized by head shape patient volume as low (<4 new patients/month), medium (5-20 new patients/month), and high (>21 new patients/month). A Pearson's χ test was used to determine characteristics that differed significantly with practice volume. RESULTS: Response rate was 6.6%, with 88 responses. Regarding head shape evaluation, 17.6% of practices used a laser scanner (portable or stationary), 35.3% used caliper anthropometric measurements, 28.5% used two-dimensional digital photography, and 9.4% used three-dimensional digital photography. In high-volume centers, 80% had a dedicated head shape clinic (P < 0.0005), 33.3% used a stationary laser scanner (P = 0.023), and 53.3% used a licensed independent provider (LIP) such as a nurse practitioner or physician assistant in the initial evaluation of head shape abnormalities (P = 0.032). Although using a multidisciplinary clinic was not a significant difference amongst groups, the most common additional provider in multidisciplinary clinic was orthotics (68%). CONCLUSIONS: High-volume practices are significantly more likely to use LIPs, stationary laser scanners, and plain films, as well as organizing head shape abnormality patients into a dedicated clinic.