Simultaneous Zygomatic Osteotomies With Reduction Mandibuloplasty - An Approach to Mid- and Lower-Facial Feminization in the Transfeminine Patient.

BACKGROUND: Facial feminization surgery (FFS) is effective at treating gender dysphoria associated with anthropometrically masculine facial features. For many transgender women, FFS is a crucial component of the gender transition process. The purpose of this study is to report our experience with a pragmatic technique for simultaneous mid- and lower-face feminization by zygomatic osteotomy malarplasty and reduction mandibuloplasty. METHODS: The technique to perform zygomatic osteotomy malarplasty and reduction mandibuloplasty is described, utilizing harvested bone from the mandible for bone grafting the zygomatic osteotomy gap. A retrospective chart review was performed for patients who underwent simultaneous middle and lower FFS using the described technique. Independent reviewers evaluated cropped preoperative and postoperative photographs of the mid and lower face and assigned each photograph a "femininity score." RESULTS: Seventeen transgender women underwent simultaneous zygomatic osteotomy malarplasty and reduction mandibuloplasty over the study period with adequate follow-up (average 11.1 months). Transient nerve weaknesses were the primary complications noted. A statistically significant improvement in femininity score was reported in postoperative photographs, compared to preoperative photographs ( P < 0.01). CONCLUSIONS: The technique described in this study is an effective application of craniofacial approaches and techniques for feminizing the facial skeleton in transgender women by utilizing harvested mandibular bone for simultaneous malarplasty.

Optimizing Perioperative Red Blood Cell Utilization and Wastage in Pediatric Craniofacial Surgery.

Utilization, wastage, and adverse consequences of assigning one full red blood cell (RBC) unit were investigated for children undergoing craniosynostosis surgery. The authors hypothesized that significant RBC wastage in the perioperative period exists for pediatric craniofacial surgery. The authors sought to determine what factors could guide patient-specific blood product preparation by evaluating utilization and wastage of RBCs in pediatric patients undergoing surgical correction of craniosynostosis. Eighty-five children with craniosynostosis undergoing surgical correction at our institution between July 2013 and June 2015 were identified. Fifty-three patients received RBC transfusion in the perioperative period, while 32 patients were not transfused. Primary outcome measures were intraoperative, postoperative, and total percent of RBC wastage. Secondary analysis compared the impact of patient weight and procedure type on perioperative RBC wastage. Of the 53 patients who received perioperative RBC transfusion, 35 patients received a volume of blood less than the full volume of the RBC unit while 18 patients received the full volume of blood. There was no significant relationship between perioperative RBC wastage, the type of craniofacial procedure performed, or the duration of surgical time. Children who received a perioperative transfusion and had RBC wastage weighed significantly less than those who received a full volume. These findings suggest that for craniofacial surgical patients weighing less than 10 kg, a protocol that splits cross-matched RBC units can decrease perioperative RBC wastage and blood donor exposure. A future prospective study will determine the success of this intervention as well as the potential to decrease exposure to multiple blood donors.

A Novel Application of Virtual Surgical Planning to Facial Feminization Surgery.

Feminization of the frontonasal-orbital complex is a critical aspect in surgical management of gender dysphoria. Here, we describe our utilization of a prefabricated cutting guide to facilitate frontal sinus setback.

The Impact of Ethnicity on Craniosynostosis in the United States.

While many studies have examined potential risk factors for nonsyndromic craniosynostosis, there have been no publications to date investigating the role of ethnicity in the United States. The current study was undertaken as the first multi-center investigation to examine the relationship between ethnicity and nonsyndromic craniosynostosis, looking at both overall prevalence as well as potential correlation between ethnicity and pattern of affected suture site. A chart review of patients diagnosed with nonsyndromic craniosynostosis treated at four major children's hospitals was performed to obtain ethnicity data. Analysis was preformed based on ethnic group as well as suture site affected. To account for potentialOne regional selection bias, the KID database (1997-2012) was utilized to identify all cases of craniosynostosis on a national level. This data was analyzed against birth rates by ethnicity obtained from CDC WONDER natality database.Amongst the 2112 cases of nonsyndromic craniosynostosis at all institutions, Caucasians and African Americans were consistently the predominant ethnic groups. There was a statistically significant difference in the distribution of affected suture type with African Americans more likely to present with unicoronal synostosis and Caucasians more likely to present with metopic synostosis (P = 0.005). The national data revealed that there were more cases of craniosynostosis in Caucasians and fewer in African Americans than expected when compared to population birth rates. Our findings demonstrate that the Caucasian race is associated with increased rates of synostosis.

A Novel Association of Martorell Ulcer With Liddle Syndrome.

Pseudohyperaldosteronism, or Liddle syndrome, is a rare, autosomal dominant condition characterized by early-onset hypertension, often associated with hypokalemia and metabolic alkalosis. Martorell hypertensive ischemic leg ulcer is a rare, underdiagnosed ulcer characterized by subcutaneous arteriolosclerosis, classically appearing over the dorsolateral lower extremity or Achilles tendon in patients with hypertension and diabetes. It presents an important diagnostic challenge because it can appear grossly similar to other entities such as pyoderma gangrenosum or venous stasis ulcers, but requires surgical intervention. This article presents a case study of surgical management of a Martorell ulcer in a 69-year-old woman with Liddle syndrome. To the authors' knowledge, this is the first case reported in the literature of this rare ulcer occurring secondary to this rare cause of hypertension.

The "Double" Tessier 7 Cleft: An Unusual Presentation of a Transverse Facial Cleft.

Congenital macrostomia, or Tessier number 7 cleft, is a rare craniofacial anomaly. We present a unique patient with bilateral macrostomia that consisted of a "double" transverse cleft on the left side and a single transverse cleft on the right side. A staged reconstructive approach was used to repair the "double" left-sided clefts. This staged technique produced a satisfactory aesthetic and functional outcome.

Factors Predicting Hospital Length of Stay Following Pharyngeal Flap for Velopharyngeal Insufficiency.

OBJECTIVE: Routine hospital admission following pharyngeal flap (PF) to correct velopharyngeal insufficiency (VPI) is the standard at most hospitals. Nevertheless, there is increasing resistance from third-party providers to approve stays longer than a "short stay" (23-hour) observation period. The purpose of the current study was to evaluate length of stay (LOS) and document potential influencing factors following PF. DESIGN: Retrospective chart review. Demographic and perioperative data were collected, and statistical analyses were performed to determine associations with hospital length of stay (LOS). Readiness for discharge was determined by oral intake, analgesic requirement, and respiratory status. SETTING: Tertiary care children's hospital Participants: All patients undergoing PF for VPI between 1990 and 2014. OUTCOME MEASURES: (1) LOS, (2) % satisfying all discharge criteria within a 23-hour observational time frame. RESULTS: Seventy-five patients were studied, with an average age of 6.8 years. Mean LOS was 65.4 hours. Only 11 patients (14.9%) met all discharge criteria by 23 hours. Multivariate predictors of shorter LOS were increasing patient age, male gender, lack of syndromic association, administration of an intraoperative antiemetic and steroids, and shorter anesthetic duration. Time to first oral intake correlated positively with LOS. Administration of intraoperative antiemetics increased the odds of meeting all discharge criteria within 23 hours by a factor of 12. CONCLUSIONS: Identification of factors associated with LOS after PF may allow providers to predict and potentially mitigate hospital stays. Nevertheless, most patients undergoing PF are not clinically ready for discharge within a short-stay (23-hour) observation period.

Nipple Resection and Reconstruction After Attempted Nipple-Sparing Mastectomy.

BACKGROUND: Occult nipple malignancy is detected in 0% to 58% of attempted nipple-sparing mastectomies (NSM), prompting excision of the nipple. We report our experience with nipple resection following attempted NSM and our outcomes with subsequent nipple reconstruction. METHODS: An institutional review board-approved retrospective review was performed of attempted NSM cases with immediate implant-based reconstruction from July 2006 to April 2015. Patients who underwent nipple excision were identified. Indications for excision, pathology reports, and reconstructive outcomes were reviewed. RESULTS: Five hundred sixty-eight NSMs were performed in 330 patients. Thirty-four (6%) cases underwent nipple excision, 53% for positive frozen sections, 29% for positive permanent sections, 3% for clinical suspicion, and 15% either at patient request or for symmetry. All of the cases with positive frozen sections had disease on permanent section and 56% had residual disease in the resection specimen. Of the cases with positive permanent sections, frozen sections were negative in 50%, suspicious or atypical in 30%, and not sent in 20% of cases. Thirty percent had residual disease in the resection specimen. Frozen section sensitivity was 64% (or 75% if suspicious and atypical findings are included). There were no false-positive results on frozen section. Sixty-eight percent of cases have undergone nipple reconstruction by CV flap (57%), skate flap (39%), or nipple-sharing technique (4%). The aesthetic result after reconstruction was excellent in 83% of cases. CONCLUSIONS: Our findings support the benefit of intraoperative subareolar frozen section for detection of occult disease. When nipple excision is required, patients can still achieve an excellent aesthetic result with reconstruction.

Intradiploic Epithelial Inclusion Cyst of the Cranium Mimicking Fibrous Dysplasia.

Intradiploic inclusion cysts are exceedingly rare in the pediatric population. The authors present a 16-year-old male patient who presented with a large growing calvarial mass with a preoperative diagnosis of fibrous dysplasia based on radiologic imaging. Craniectomy followed by autogenous reconstruction was performed. Histopathological examination revealed a relatively small inclusion cyst of the intradiploic space, surrounded by reactive bone. This patient demonstrates a highly unusual presentation of a rare entity, and the authors discuss the diagnosis and management of intradiploic inclusion cysts.

Columellar Reconstruction After Nasal Continuous Positive Airway Pressure Associated Necrosis.

Though a life-saving modality in neonatal intensive care units, nasal continuous positive airway pressure (nCPAP) carries a small risk of irreversible ischemia and necrosis of the columella due to the configuration of the pressure delivery system. Iatrogenic injuries to the columella after nCPAP use result in a spectrum of disfigurement and functional airway obstruction. The authors performed a retrospective review of patients evaluated for nCPAP-related columellar deformities by the Division of Plastic and Reconstructive Surgery at the authors' institution over a 10-year period to assess reconstructive outcomes. Of 7 patients evaluated, 3 underwent reconstruction using a combination of cartilaginous framework reshaping and local tissue flaps. After a mean follow-up period of 78 months, patients had satisfactory aesthetic and functional results. Based on the authors' observations, columellar necrosis secondary to nCPAP can be divided into 3 categories: Type A demonstrates mild notching of the columella; Type B has an absent columella without notable nasal tip depression; Type C has an absent columella with nasal tip depression, with or without external nasal valve obstruction. Reconstructive needs should be individually tailored based on the degree of nasal tip depression, cartilaginous support, and soft tissue availability.

Closed-Suction Drains After Subcutaneous Mastectomy for Gynecomastia: Do They Reduce Complications?

BACKGROUND: In cases of refractory gynecomastia, surgical excision of excess glandular breast tissue is often warranted. Closed-suction drain placement is commonplace; however, the effect of drains on preventing complications after male breast surgery has not been fully elucidated in the literature. OBJECTIVE: To investigate the effect of drains on reducing seroma and hematoma after subcutaneous mastectomy for gynecomastia. METHODS: Retrospective chart review of patients undergoing subcutaneous mastectomy for gynecomastia over a 10-year period. Charts were reviewed for demographics, BMI, comorbidities, type of local anesthesia, specimen weight, use of liposuction, and placement of drains. Outcomes were determined by seroma or hematoma in the 30-day postoperative period. RESULTS: A total of 163 breasts were studied (group I = no-drain, n = 46; group II = drain, n = 117). Group I had a higher rate of clinically significant seromas requiring needle aspiration than group II (6.5 vs 0%, p = 0.0214). There was no difference in rates of hematoma (group I vs II, 2.2 vs 6.0%, p = 0.443) and total fluid collections (group I vs II, 19.6 vs 16.2%, p = 0.647). BMI, use of local anesthesia, specimen weight, and use of liposuction were not significantly associated with postoperative complications. CONCLUSIONS: Closed-suction drains may reduce rates of clinically significant seromas requiring needle aspiration. Though drains carry their own pertinent adverse effects (e.g., patient discomfort and anxiety, cost, and additional clinic visits), there remains no universal standard of care and surgeon practices vary widely. Given the potential to reduce seroma rates, we recommend that surgeons consider placing drains and discuss with patients the benefits and risks of drains after surgical treatment of gynecomastia. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Alloplastic Augmentation of the Asian Face: A Review of 215 Patients.

BACKGROUND: Asian aesthetic surgery has become increasingly popular over the last decade, especially augmentation of characteristically flattened facial features. Alloplastic implants are an option for facial augmentation, however many avoid their use due to concerns for morbidity associated with their use. OBJECTIVES: To validate our hypothesis that when used properly, alloplastic implants have a low complication profile and provides excellent aesthetic results. METHODS: A retrospective review was performed of all Asian patients undergoing alloplastic facial augmentation between 2009 and 2013 by a single surgeon. Procedures included augmentation of the forehead, nasal dorsum, midface, and chin. Charts were reviewed for outcomes including infection, extrusion, malposition, and operative revision. RESULTS: Two hundred and fifteen patients had 243 implants placed. Of 141 nasal augmentations, there were 2 infections (1.4%), 1 extrusion (0.7%), 7 malpositions (4.9%), and 16 revisions (11.3%), 5 for malposition, 2 for contour irregularity, and 9 for aesthetic change. Augmentation genioplasty was performed in 40 patients with 1 malposition (2.5%) and 6 revisions (15%), 4 for under-correction and 2 for aesthetic change. Thirty-one midface and 31 forehead augmentations were performed without complications. One patient (3.2%) had forehead implant removal for aesthetic change. Overall infection and extrusion rates were 0.8% and 0.4%, respectively. CONCLUSIONS: By utilizing surgical techniques such as creation of a precise sub-periosteal pocket, placing the implant away from the incision site, and leaving well-vascularized soft tissue coverage under minimal tension, alloplastic implants can safely be used as a first-line option for Asian facial augmentation. LEVEL OF EVIDENCE: 4 Therapeutic.

Pectoralis major myocutaneous flap versus free fasciocutaneous flap for reconstruction of partial hypopharyngeal defects: what should we be doing?

BACKGROUND: Partial hypopharyngeal defects are most commonly reconstructed with the pectoralis major myocutaneous flap (PMMF) or free fasciocutaneous (FFC) flap. The purpose of this study is to determine the ideal method for reconstruction of partial hypopharyngeal defects by reviewing our institutional experience and the literature. METHODS: A retrospective review of partial hypopharyngeal reconstructions since 2009 was performed. A National Library of Medicine search of studies on partial hypopharyngeal reconstruction since 1988 was performed. Data on complications, diet, and speech were extracted and pooled. RESULTS: A total of 18 patients were studied-9 had PMMF reconstruction and 9 had FFC reconstruction. Operative time (8.75 vs. 13.0 hours, p = 0.0003) was shorter in the PMMF group. Pharyngocutaneous fistula developed in one PMMF patient (11.1%) and two FFC patients (22.2%). Late strictures occurred in three PMMF patients. Six patients in each group (66.7%) progressed to a regular diet. Three patients in each group produced tracheoesophageal speech after TEP. Literature review identified 36 relevant studies, with 301 patients reconstructed with PMMF and 605 patients with FFC. Pooled-data analysis revealed that PMMF had higher reported rates of fistula (24.7 vs. 8.9%, p < 0.0001) and requirement for second surgery (11.3 vs. 5.5%, p = 0.04). There was no difference in stricture rates or progression to regular diet. Fewer PMMF patients produced tracheoesophageal speech (17.5 vs. 52.1%, p < 0.0001). CONCLUSIONS: PMMF and FFC flaps are valid approaches to reconstructing partial hypopharyngeal defects, though rates in the literature of fistula, need for revisional surgery, and tracheoesophageal speech after laryngectomy are more favorable after free flap reconstruction.

Recurrent breast cancer in the subpectoral space after implant reconstruction.

Breast reconstruction after mastectomy is most commonly performed with a prosthetic implant placed beneath the pectoralis major. Recurrence may rarely be identified in the subpectoral space where the implant was placed. We report a case of recurrent breast cancer after implant-based reconstruction with isolated subpectoral recurrence discovered 5 years later during secondary revision of her reconstructed breast.

Continuous high-dose vasopressors in free anterolateral thigh flap transfer for pharyngeal reconstruction: a report of two cases.

Use of vasopressors is controversial in patients undergoing free flap reconstruction. Recent literature has suggested that it is safe to administer vasopressors intraoperatively during these procedures. However studies have not addressed whether this safety extends to continuous high dose use. We present two cases of patients who underwent surgery for squamous cell carcinoma of the pharyngeal region, requiring laryngopharyngectomy. Both had pharyngeal reconstruction with a free anterolateral thigh (ALT) flap. The first required intraoperative vasopressors throughout the surgery, extending into the postoperative period. The second required vasopressors in the postoperative period continuously for weeks after surgery. Vasopressors were administered at treatment levels for shock. Neither developed flap compromise, suggesting that pharyngeal reconstruction with an ALT flap may be safely performed in the setting of continuous high-dose vasopressors.

Oral rehabilitation outcomes after free fibula reconstruction of the mandible without condylar restoration.

PURPOSE: Resection of the posterior mandible for tumor or osteonecrosis may include the mandibular condyle, an integral part of the temporomandibular joint (TMJ). Condylar reconstruction, including use of prostheses, the native condylar head, or part of the fibula, all have associated drawbacks including skull base erosion and the potential for ankylosis and TMJ dysfunction as well as the increased difficulty associated with trying to recapitulate the TMJ with high fidelity. We report our experience leaving a single side of the reconstructed mandible unsecured to the glenoid fossa, allowing the mandible to "hang." We hypothesized that a good functional recovery may be achieved with this simple approach while avoiding the potential for ankylosis and TMJ dysfunction. METHODS: A retrospective chart review of all patients undergoing free fibula reconstruction of the mandible with condylar removal was performed. Outcomes were determined by maximum interincisal opening, occlusion, and diet after full recovery. RESULTS: Six patients were studied. Two had condylar reconstruction with a contoured fibular head secured to the glenoid fossa. One of them had progressive postoperative trismus and ankylosis. One patient was reconstructed with the native condyle rigidly fixed to the fibula flap, complicated by avascular necrosis requiring condylar resection, with good function afterward. Three patients were left to "hang." All 3 had either normal or improved function after surgery. Two had slight ipsilateral deviation on mouth opening. CONCLUSIONS: Function can reliably be reestablished after segmental mandibulectomy and condylectomy with a vascularized fibula flap whose distal end is not precisely contoured or actively seated in the glenoid fossa, as a valid alternative to condylar reconstruction.

Complications Following Breast Augmentation In Transfeminine Individuals: A Systemic Review And Meta-Analysis.

BACKGROUND: Breast augmentation is the most commonly performed procedure for gender affirmation in transfeminine individuals. While adverse events among breast augmentation in cis-gender females were well-described, their relative incidence in transfeminine individuals patients is less elucidated. AIM: This study aims to compare complication rates after breast augmentation between cisgender females and transfeminine patients and to evaluate the safety and efficacy of breast augmentation in transfeminine individuals. METHODS: PubMed, the Cochrane Library, and other resources were queried for studies published up to Jan 2022. A total of 1864 transfeminine patients from 14 studies were included in this project. Primary outcomes including complications (capsular contracture, hematoma or seroma, infection, implant asymmetry/malposition, hemorrhage, skin or systemic complications), patient satisfaction, and reoperation rates were pooled. A direct comparison of these rates was performed against historical rates in cisgender females. RESULTS: Within the transfeminine group, pooled rate of capsular contracture was 3.62% ((95% CI, 0.0038-0.0908); hematoma/seroma was 0.63% ((95% CI: 0.0014-0.0134); infection incidence was 0.08% (95% CI, 0.0000-0.0054); implant asymmetry was 3.89% (95% CI, 0.0149-0.0714). There was no statistical difference between rates of capsular contracture (p=0.41) and infection (p=0.71) between the transfeminine vs cis-gender groups, while there were higher rates of hematoma/seroma (p=0.0095) and implant asymmetry/malposition (p<0.00001) in the transfeminine group. CONCLUSION: Breast augmentation is an important procedure for gender affirmation, and in transfeminine individuals carries relatively higher rates of post-operative hematoma and implant malposition relative to cisgender females.

Current Trends in Surgical Airway Management of Neonates with Robin Sequence.

BACKGROUND: Robin sequence is defined by the clinical triad of micrognathia, glossoptosis, and upper airway obstruction, and is frequently associated with cleft palate and failure to thrive. Though the efficacy of certain surgical interventions to relieve airway obstruction has been well established, algorithms dictating decision making and perioperative protocols are poorly defined. METHODS: A 22-question survey was sent via e-mail to members of the American Cleft Palate-Craniofacial Association and International Society of Craniofacial Surgeons. Questions were related to surgeon experience in treating neonates with Robin sequence, and specific perioperative protocols. RESULTS: One hundred fifty-one responses were collected. Most respondents were surgeons practicing in North America(82.8%), in a university hospital setting (81.5%) and had completed a fellowship in pediatric plastic surgery or craniofacial surgery (76.2%). Preoperative protocols varied widely by years in training and location of practice. Although 78.8% of respondents always performed direct laryngoscopy, only 49.7% of respondents routinely obtained preoperative polysomnography. Mandibular distraction osteogenesis was the most common primary surgical airway intervention reported by 74.2%, with only 12.6% primarily utilizing tongue-lip adhesion. Slightly less than half of respondents ever performed tongue-lip adhesion. Operative selection was influenced by surgeon experience, with 80% of those in practice 0-5 years primarily utilizing mandibular distraction, compared with 56% of respondents in practice >15 years. CONCLUSIONS: This study documents wide variations in preoperative, operative, and postoperative protocols for the surgical airway management of neonates with severe Robin sequence. These results underscore the need to acquire more objective data, to compare different protocols and outcome measures.

Efficacy of immediate replacement of cranial bone graft following drainage of intracranial empyema.

OBJECTIVE Intracranial empyema is a life-threatening condition associated with a high mortality rate and residual deleterious neurological effects if not diagnosed and managed promptly. The authors present their institutional experience with immediate reimplantation of the craniotomy flap and clarify the success of this method in terms of cranial integrity, risk of recurrent infection, and need for secondary procedures. METHODS A retrospective analysis of patients admitted for management of intracranial empyema during a 19-year period (1997-2016) identified 33 patients who underwent emergency drainage and decompression with a follow-up duration longer than 6 months, 23 of whom received immediate bone replacement. Medical records were analyzed for demographic information, extent and location of the infection, bone flap size, fixation method, need for further operative intervention, and duration of intravenous antibiotics. RESULTS The mean patient age at surgery was 8.7 ± 5.7 years and the infections were largely secondary to sinusitis (52.8%), with the most common location being the frontal/temporal region (61.3%). Operative intervention involved removal of a total of 31 bone flaps with a mean surface area of 22.8 ± 26.9 cm2. Nearly all (96.8%) of the bone flaps replaced at the time of the initial surgery were viable over the long term. Eighteen patients (78.3%) required a single craniotomy in conjunction with antibiotic therapy to address the infection, whereas the remaining 21.7% required more than 1 surgery. Partial bone flap resorption was noted in only 1 (3.2%) of the 31 successfully replaced bone flaps. This patient eventually had his bone flap removed and received a split-calvaria bone graft. Twenty-one patients (91.3%) received postoperative CT scans to evaluate bone integrity. The mean follow-up duration of the cohort was 43.9 ± 54.0 months. CONCLUSIONS The results of our investigation suggest that immediate replacement and stabilization of the bone flap after craniectomy for drainage of intracranial empyemas has a low risk of recurrent infection and is a safe and effective way to restore bone integrity in most patients.