Surgical approach to penile reconstruction for shaft skin excision from circumcision.

PURPOSE: Circumcision is one of the most frequently performed surgical procedures. Complications are infrequent, including bleeding, though can be significant such as shaft skin excision. The aim of this study was to identify mechanism of injury and reconstructive techniques for skin excision using a full thickness skin graft (FTSG) or with the novel application of tissue expanders (TE). METHODS: Patients who underwent penile reconstruction following shaft skin excision from an overzealous circumcision were retrospectively reviewed. The penis was covered using a FTSG, harvested from the groin/hip, or using TE, with expanders placed in residual shaft skin. RESULTS: Twelve patients experienced significant skin loss (range 65-95%) including 2 with partial glans loss. Ten were reconstructed using a FTSG and 2 with TE. Injury was most frequently from a Mogen clamp (n = 9), or from a Gomco clamp, Plastibell device, and electrocautery burns. Six FTSG patients experienced complications with lymphedema (n = 3) most common. CONCLUSION: Shaft skin excision is a devastating complication with risk greatest from Mogen clamp use. TE is preferred as this avoids donor site morbidity which reassures parents but requires sufficient residual skin that can be expanded. Both techniques effectively provide soft tissue coverage with acceptable appearance and long-term function.

Orthodontic and Orthognathic Surgical Treatment in a Patient with a Large Lymphatic Malformation of the Face: A Case Report.

Lymphatic malformations (LMs) are congenital abnormalities in the development of the lymphatic system. They can damage other structures including the airway, blood vessels, nerves, or bones. LMs of the face can result in malocclusion, and many patients with LMs of the face require orthognathic surgery to correct the malocclusion. Surgery-first is a treatment modality which should be considered for individuals with LMs and is a protocol in which orthognathic surgery is performed prior to orthodontic treatment. This case report describes surgery-first and subsequent orthodontic treatment in a patient with a class III malocclusion due to a large facial LM.

Design of a Novel Orthodontic Appliance to Prevent Pedicle Trauma in Patients Undergoing Double-Opposing Buccal Flaps for Palatal Lengthening.

OBJECTIVE: To describe a novel orthodontic appliance to prevent pedicle trauma in patients undergoing double-opposing buccal flap surgery for secondary palatal lengthening. DESIGN: Case series. SETTING: Cleft and craniofacial clinic, Johns Hopkins Children's Center. PATIENTS, PARTICIPANTS: Four patients undergoing double-opposing buccal flap surgery for repair of velopharyngeal insufficiency. INTERVENTIONS: Patients were fitted with the device, which consists of a lower lingual holding arch with acrylic bite blocks. MAIN OUTCOME MEASURE: Presence of pedicle trauma postsurgery and tolerability of the device. RESULTS: The appliance was well tolerated in all 4 patients and no biting trauma to the pedicles was observed. CONCLUSIONS: A reliable appliance has been developed to prevent biting trauma to the pedicles in patients undergoing double-opposing buccal flap surgery in the permanent dentition stage.

Postnatal Progressive Craniosynostosis in Syndromic Conditions: Two Patients With Saethre-Chotzen Due to TWIST1 Gene Deletions and Review of the Literature.

Saethre-Chotzen syndrome (SCS) is a known craniosynostosis syndrome with a variable presentation of craniofacial and somatic involvement. Congenital coronal craniosynostosis is most commonly observed in SCS; however, progressive postnatal craniosynostosis of other sutures has been reported. The authors present 2 infants with progressive postnatal craniosynostosis and SCS caused by chromosome 7p deletions including the TWIST1 gene. The evolution of their clinical features and a literature review of patients with syndromic, postnatal progressive craniosynostosis illustrate the importance of longitudinal observation and management of these patients.

An Oncoplastic Approach to Primary Pediatric Pterygomaxillary Osteosarcoma.

Osteosarcomas arising within the pterygomaxillary/infratemporal fossa region are rare among the pediatric population. Survival rates are most influenced by tumor resection with negative margins, which can be dependent on surgical accessibility of the tumor site. The pterygomaxillary/infratemporal fossa location poses several challenges to safe and adequate tumor resection, including proximity of the facial nerve and great vessels and scarring associated with traditional transfacial approaches. In this article, we present the case of a 6-year-old boy with an osteosarcoma of the left pterygomaxillary/infratemporal fossa region successfully managed with an "oncoplastic" approach, incorporating the use of CAD/CAM and mixed reality technologies.

Integrated Plastic Surgery Residency Applicant Perceptions of Virtual Interviews.

PURPOSE: The 2020-2021 interview cycle for integrated plastic surgery applicants was the first to be held virtually because of the COVID-19 pandemic. Here, we detail the largest study on integrated plastic surgery applicant perceptions after the virtual interview cycle. METHODS: A 35-question institutional review board-approved survey was distributed to medical students who had applied to the Johns Hopkins/University of Maryland or University of California San Diego integrated residency programs during the 2020-2021 interview cycle. Survey questions assessed the structure, strengths, and weaknesses of the exclusively virtual interview process. Survey administration and data collection were performed using the Qualtrics platform. RESULTS: Of 318 distributed surveys, 94 were completed. In addition, 91.5% of respondents preferred in-person interviews before the interview season, whereas 54.3% preferred in-person interviews afterward. Applicants who favored virtual interviews did not view being unable to physically meet with program staff as a detriment (P = .001) and felt they could effectively advocate for themselves (P = .002). Overall, the most cited strengths were the ability to complete more interviews (P = .01) and cost benefits (P = .02). Criticisms were directed at the impersonal nature of the exchange (86.2%), lack of physical tour (56.4%), and difficulties at self-advocacy (52.1%). CONCLUSION: Preference for virtual interviews increased from 7.5% to 34.0% after the virtual interview cycle. For several students, the ideal interview structure permits both in-person and virtual interviews to maximize flexibility. Augmenting with virtual city tours and one-on-one interviews may mitigate the impersonal nature of virtual interviews as perceived by some applicants.

A Single Institutional Review of Periauricular Vestiges and Renal Anomalies: The Role of Screening Renal Ultrasonography.

ABSTRACT: Children with minor ear malformations including periauricular vestiges often undergo renal ultrasonography (RUS) to exclude renal anomalies associated with genetic conditions. The aim of this study is to assess the association between isolated periauricular vestiges and renal anomalies and delineate the indication for RUS in screening for renal anomalies. This is a retrospective review of infants who underwent surgical consultation for periauricular vestige excision to probe a possible relationship with renal anomalies. Patients with an isolated vestige were compared to patients presenting with additional clinical findings suggestive of a possible genetic disorder. A total of 150 infants underwent periauricular vestige excision; 47 were referred for RUS, 23 with no additional clinical findings, and 24 with periauricular vestiges in addition to other suspicious clinical and/or developmental findings. Of these 47 patients, 10 had renal anomalies: 4 (17.4%) with an isolated periauricular vestige had minor anomalies and 6 (25.0%) with a vestige plus suspicious clinical signs had 5 minor anomalies and one major anomaly. The odds of a patient with an isolated periauricular vestige having positive RUS findings were not significantly different than a patient with additional clinical findings having positive RUS findings (P = 0.72).The incidence of renal anomalies in infants with an isolated periauricular vestige was similar to that in patients with associated clinical signs suggestive of a possible genetic disorder. This was higher than the background population rate. Although most anomalies in patients with isolated ear findings were minor, our results suggest routine screening RUS should be considered.

Many Moving Pieces: Virtual Preoperative Surgical Planning for Traumatic Occlusal Splints.

INTRODUCTION: Achieving anatomic reduction and re-establishing premorbid occlusion in patients with complex maxillomandibular fractures is challenging even for seasoned surgeons. Historically, surgeons have utilized occlusal splints to help establish occlusal relationships before fracture reduction and fixation. These acrylic splints are fabricated from dental impressions and require manual repositioning of tooth bearing segments along the fracture line to reapproximate premorbid occlusion. The process is laborious, requires a dental lab, and is less efficacious in edentulous patients or those with significantly comminuted fractures; as such it has largely fallen out of practice. Recently, with advances in virtual 3D modeling and printing, we demonstrate that occlusal splints can be designed from computed tomography scans, manipulated virtually, and printed without obtaining impressions from the patient. METHODS/RESULTS: In our series of 3 patients with complex maxillomandibular fractures, occlusal splints were created by 1) obtaining maxillofacial computed tomography scans, 2) reducing the fractures virtually, and 3) using orthognathic virtual surgery software to create the splint. The time between planning and delivery of the splint was 4 to 7 days. These splints were successfully utilized to help establish premorbid occlusion in conjunction with maxillomandibular fixation and aided in expeditious intraoperative fracture reduction and fixation. CONCLUSIONS: In the treatment of complex facial fractures, occlusal splints can be a useful adjunct in the operative reduction and fixation of fractures. With the advent of virtual preoperative surgical planning via 3D modeling and 3D printing, these occlusal splints can be created of a sufficient fidelity to avoid the strict need for dental impressions.

Craniofacial Fellowship Applicant Perceptions of Virtual Interviews.

INTRODUCTION: The 2021 interview cycle for craniofacial fellowship applicants was the first to be held virtually due to the coronavirus disease 2019 pandemic. Here, we detail the craniofacial fellowship applicant perceptions and experience on the virtual interview process. MATERIALS AND METHODS: An institutional review board-approved 35-question survey study on the perception of the virtual interview process among craniofacial fellowship applicants was conducted. Surveys were distributed to individuals who had applied through the match, overseen by the American Society of Craniofacial Surgeons (ASCFS). RESULTS: Ten surveys were fully completed with a corresponding response rate of 48%. The average number of interviews completed was 12.7±7.7 and 50% of applicants interviewed at >1 program in a single day. Overall, 90% of respondents preferred in-person interviews before the interview season, however, only 10% preferred the in-person format afterwards. Preference for a virtual-only format increased from 10% to 70%. Applicants cited cost (100%), ease of scheduling (90%), and ability to participate in more interviews (70%) as the primary strengths of the virtual platform; none reported difficulties with self-advocacy. After the interview cycle, 90% stated they would recommend virtual interviews. CONCLUSIONS: The greatest strengths of virtual interviews were the ability to participate in more interviews, the ease of scheduling, and the cost benefits. Most applicants reported the same or increased ability for self-advocacy with virtual interviews. Following the index interview cycle for 2021, the majority of fellowship applicants now appear to prefer a virtual-only or hybrid format and would recommend virtual interviews in the future.

Academic Productivity Among Plastic Surgery Subspecialty Fellowship Applicants.

INTRODUCTION: Plastic surgery subspecialty fellowships are highly competitive. Academic productivity is an objective metric that can be used to compare candidates. This study aims to evaluate intersubspecialty differences in academic profiles of plastic surgery fellows. METHODS: We performed a cross-sectional analysis of the plastic surgery fellows in the United States from 2015 to 2019. We used the San Francisco Match website and individual program websites to obtain details of fellowship programs (microsurgery, aesthetic, hand, and craniofacial) and plastic surgery fellows. Bibliometric data at the time of fellowship application were obtained for each fellow. RESULTS: A total of 235 fellows were included. There was a significant difference in the median number of publications (P = 0.0067) and h-index (P = 0.0229) across subspecialties. Multivariate analysis demonstrated that dedicated research time was predictive for a high publication count (odds ratio [OR], 3.59; P = 0.0007) and h-index (OR, 4.88; P < 0.0001) at the time of fellowship application. Although international residency and aesthetic fellowship application were predictive of a reduced number of publications (OR, 0.17; P < 0.0001, and OR, 0.43; P = 0.0190, respectively), H-index was increased by possession of an advanced degree (OR, 2.00; P = 0.0291) and decreased with international residency (OR, 0.26, P = 0.0021). CONCLUSIONS: All plastic surgery fellows have highly qualified academic profiles at the time of fellowship application. Academic productivity differs between subspecialty fellowships. Those wishing to match into competitive subspecialties should consider taking dedicated time for research or attaining an advanced degree.

Mandibular Reconstruction Following Central Giant Cell Granuloma Resection in Primary Dentition: A Case for the Use of a Costochondral Graft.

Central giant cell granuloma is a benign, intraosseous lesion that may affect the pediatric craniofacial skeleton, particularly the mandible. When surgery is indicated, the role of the craniofacial surgeon is to ameliorate the sequelae of ablative surgery by restoring facial symmetry, ensuring appropriate postoperative occlusion, and allowing for adequate interincisal opening, all in the setting of a growing craniofacial skeleton. Herein, we report the case of a 3-year-old female presenting for reconstruction after resection of the right hemimandible proximal to the unerupted first permanent molar. We highlight the various reconstructive challenges associated with mandibular reconstruction during primary dentition and make a case for the use of a costochondral graft, with a successful outcome demonstrated at 2 years of follow-up.

Laryngoscopy Grade Improvement and Difficult Airway Resolution in Infants With Robin Sequence Undergoing Mandibular Distraction Osteogenesis: A Multi-Institutional Study.

OBJECTIVE: Mandibular distraction osteogenesis (MDO) aims to relieve tongue-based airway obstruction in Robin Sequence (RS). We investigated direct laryngoscopy grade (DLG) improvement and difficult airway (DA) resolution following MDO. DESIGN: Retrospective cohort analysis. SETTING: Three tertiary care institutions. PATIENTS: Sixty-four infants with RS who underwent a single MDO procedure in their first year of life were identified from January 2010 to January 2019. MAIN OUTCOME MEASURES: The primary outcome was DLG pre- and post-MDO. Secondary outcomes included DA designation, pre- and post-MDO polysomnographic assessment for obstructive sleep apnea (OSA), length of stay, need for gastrostomy, and major/minor adverse events. RESULTS: Median DLG improved from II pre-MDO to I at the time of distractor removal (n = 43, P < .001). No significant change was seen in patients with a third recorded time point (eg, palatoplasty; n = 78, P = .52). Twenty-six (47%) of 55 patients were designated as DA pre-MDO, and 10 (18%) of 55 patients retained the label post-MDO (P < .01). Five (50%) of these 10 patients appeared to be inappropriately retained. Median obstructive apnea-hypopnea index improved from 38.6 (range 31.2-62.8) pre-MDO to 2.9 (range 1-3.9) post-MDO (n = 12; P = .002). CONCLUSION: Mandibular distraction osteogenesis allowed for DLG improvement that was stably maintained as well as functional improvement in OSA, with minimal morbidity. Difficult airway designation persisted in the electronic record of some infants despite clinical resolution.

Infectious Complications After Open Cranial Vault Remodeling for Craniosynostosis.

BACKGROUND: Surgical site infection (SSI) after open cranial vault reconstruction (CVR), while relatively uncommon, has received little attention in the literature to date. Here, the authors report our institution's experience with the perioperative management of infectious complications following CVR for craniosynostosis and present the first systematic review of the literature on this topic. METHODS: The authors performed a retrospective chart review for patients with syndromic and nonsyndromic craniosynostosis who underwent open CVR between 1990 and 2015 at a single institution to determine predictors of SSIs and a systematic review of studies that evaluated for SSI after CVR to ascertain the pooled incidence of SSI, common infectious organisms, and prophylactic antibiotic protocols. RESULTS: Out of 548 primary and 163 secondary CVR cases at our institution, 6 primary reconstruction patients (1.09%) and 9 secondary reconstruction patients (5.52%) developed an SSI requiring extended hospital stay or readmission (P <0.001); overall infection rate was 2.11%. Streptococcus and Staphylococcus species were the most common organisms isolated. On multivariate analysis, syndromic status conferred more than 7 times greater odds of SSI (OR 7.7, P = 0.023). Pooled analysis of the literature yielded an overall SSI rate of 1.05% to 2.01%. In contrast to our institutional findings, the most common organisms reported were Candida species and Pseudomonas aeruginosa. The most common prophylactic antibiotic protocol was a first-generation cephalosporin for 24 to 72 hours post-operatively. CONCLUSIONS: Patients undergoing secondary reconstruction have higher infection rates after CVR, and syndromic status is an important predictor of infection when controlling for other patient factors. Our literature review reveals nosocomial organisms to be the most commonly reported source of infection, though this is contrary to our institutional findings of skin flora being most common. Antibiotic prophylaxis varies institutionally.

The Prevalence of Blood-Borne Pathogens in Maxillofacial Trauma Patients.

BACKGROUND: Blood-borne pathogen infections (BPIs), caused by the human immunodeficiency virus, hepatitis C and hepatitis B viruses pose an occupational hazard to healthcare workers. Facial trauma reconstruction surgeons may be at elevated risk because of routine use of sharps, and a higher than average incidence of BPIs in the trauma patient population. METHODS: The authors retrospectively reviewed health records of patients admitted to a level 1 trauma center with a facial fracture between January 2010 and December 2015. Patient demographics, medical history, mechanism of injury, type of fracture, and procedures performed were documented. The authors detemined the frequency of human immunodeficiency virus, hepatitis B, and hepatitis C diagnosis and utilized univariable/multivariable analyses to identify risk factors associated with infection in this population. RESULTS: In total, 4608 consecutive patients were included. Infections were found in 4.8% (n = 219) of patients (human immunodeficiency virus 1.6%, hepatitis C 3.3%, hepatitis B 0.8%). 76.3% of BPI patients in this cohort were identified by medical history, while 23.7% were diagnosed by serology following initiation of care. 39.0% of all patients received surgical treatment during initial hospitalization, of whom 4.3% had a diagnosed BPI. History of intravenous drug use (odds ratio [OR] 6.79, P < 0.001), assault-related injury (OR 1.61, P = 0.003), positive toxicology screen (OR 1.56, P = 0.004), and male gender (OR 1.53, P = 0.037) were significantly associated with a BPI diagnosis. CONCLUSION: Patients presenting with facial fractures commonly harbor a BPI. The benefit of early diagnosis and risk to surgical staff may justify routine screening for BPI in high risk facial trauma patients (male, assault-related injury, and history of intravenous drug use).

Non-Midline Frontal Encephalocele Presenting as Disappearing Dermoid.

Congenital masses in the lateral brow are most commonly dermoid cysts and can often be excised surgically without additional investigation. These dermoids may rarely develop intracranial extension due to underlying bony erosions and become less prominent over time - a "disappearing dermoid." However, the authors present an unusual alternative case in which an off-midline frontal encephalocele initially presented as a firm irreducible mass but exhibited changing characteristics over time.

Postoperative Drain Use in Cranial Vault Remodeling: A Survey of Craniofacial Surgeon Practices and a Review of the Literature.

BACKGROUND: The use of subgaleal drains following primary cranioplasty for craniosynostosis has undergone limited investigation. Proposed benefits include prevention of seroma, detection of postoperative bleeding, and cerebrospinal fluid leak. We conducted a systematic review of the literature and surveyed craniofacial surgeons to ascertain the current evidence pertaining to drain use following primary cranioplasty for craniosynostosis and to determine surgical practice patterns. METHODS: PubMed and Embase databases were searched to identify relevant articles. Abstracts were reviewed by 2 investigators, and a Cohen κ statistic was calculated. Patient demographic and outcome data were extracted and compared. A 9-question survey was e-mailed to active and associate members of the American Society of Craniofacial Surgeons. RESULTS: A total of 7395 unique citations were identified. Only 2 retrospective chart reviews met inclusion criteria. All objective parameters demonstrated no difference between patients with and without drains. A subjective benefit of limiting facial swelling was proposed without objective analysis. Fifty (32.5%) of the 154 craniofacial surgeons responded to the survey. Forty-two percent used postoperative drains. A significant association (P = .01) was found between the belief that drains limited facial swelling and their use. CONCLUSIONS: The literature examining postoperative drain use in primary cranioplasty for craniosynostosis is restricted. The current studies show no definite benefit to drain use but are limited in their assessment of key outcomes. There is wide variability among surgeons regarding drain use, and this seems to be motivated by belief and tradition.

Cleft and Craniofacial Team Orthodontic Care in the United States: A Survey of the ACPA.

OBJECTIVE: To better understand the capacity for orthodontic care, service features, and finances among members of the American Cleft Palate-Craniofacial Association (ACPA). DESIGN: Cross-sectional survey. SETTING: ACPA-approved multidisciplinary cleft teams. PARTICIPANTS: Cleft team coordinators. INTERVENTIONS: Coordinators were asked to complete the survey working together with their orthodontists. MAIN OUTCOME MEASURE: Model for orthodontic care. RESULTS: Coordinators from 82 out of 167 teams certified by ACPA completed the survey (response rate = 49.1%). Most orthodontists were private practice volunteers (48%) followed by university/hospital employed (22.8%). Care was often delivered in community private practice facilities (44.2%) or combination of university and private practice facilities (39.0%). Half of teams reported offering presurgical infant orthopedics (PSIO), with nasoalveolar molding being the most common. Cleft/craniofacial patients typically comprise 25% or less of the orthodontists' practices. The presence of a university/hospital-based orthodontist was associated with higher rates of offering PSIO (P < .001) and an increased percentage dedication of their practice to cleft/craniofacial care (P < .001). CONCLUSION: Orthodontic models across ACPA-certified teams are highly varied. The employment of full-time craniofacial orthodontists is less common but is highly correlated with a practice with a high percentage of cleft care and the offering of advanced services such as PSIO. Future work should focus on how to effectively promote such roles for orthodontists to ensure high-level care for cleft/craniofacial patients requiring treatment from infancy through skeletal maturity.

Primary Abbe Flap for Median Cleft Lip Deformity: New Trends on an Old Concept.

OBJECTIVE: The authors present our experience using primary Abbe flaps for median cleft lip. METHODS: The records of 9 patients who underwent primary Abbe flaps were reviewed for indications, operative details, and complications. Flap design is discussed, including the "W" method to facilitate columellar reconstruction. Maxillomandibular fixation was not used. RESULTS: From 2004 to 2015, 9 patients with median cleft lip received primary Abbe flaps. Mean age was 10.2 ± 6.2 months. Lobar holoprosencephaly was confirmed by imaging in 5 of the 9 patients. Operative time averaged 70 ± 22 minutes. Flap division was performed at a mean of 3.6 ± 0.9 weeks. Patients were followed for a mean of 45 ± 49 months. No flaps were lost to vascular compromise and no dehiscences or infections were noted after initial repair. Five patients required prolonged intubation ranging from 4 to 7 days and 3 required transition to gastric feedings postoperatively. One patient with holoprosencephaly expired for reasons independent of surgery. Four patients have undergone 5 lip revisions to date. CONCLUSIONS: Patients with holoprosencephaly-spectrum disorder and median cleft lip have more favorable prognoses today. The Abbe flap may be safely and advantageously used for the primary repair of median cleft lip with extreme prolabial tissue deficiency.

Evaluating the effects of subclinical, cyclic ischemia-reperfusion injury on wound healing using a novel device in the rabbit ear.

OBJECTIVE: This study aimed to evaluate the effect of cyclic ischemia-reperfusion (IR) injury on wound healing using a novel rabbit ear model. MATERIALS AND METHODS: A lightweight clamp apparatus was developed for reversible occlusion of the central ear artery. Ventral ear wounds were analyzed postoperatively for epithelialization and granulation as well as gene expression after 3 consecutive days of IR cycling. RESULTS: By postoperative day #7, ears showed no gross tissue necrosis, but histologic analysis of wounds confirmed a significant impairment in epithelial and granulation tissue gaps as well as total epithelial and granulation tissue areas (P < 0.001). Quantitative polymerase chain reaction analysis of IR wounds indicated significant up-regulation of heat shock protein-70 and down-regulation of superoxide dismutase 1 relative to sham controls (P < 0.05). CONCLUSIONS: A novel rabbit ear model for the induction of subclinical, cyclic IR injury in cutaneous tissue has been developed that will serve as a valuable tool for the testing of new therapeutics.