Utilization of two methods assisting perforator identification for brachial artery perforator propeller flap application.

The brachial artery perforator propeller (BAPP) flap has the advantages of both local and perforator propeller flaps, and it remains relatively underused partly because of the anatomical variations of perforators in the medial arm. We aimed to review our preliminary experience using two different methods for perforator localization of a BAPP flap, including the application of a refined coordinate system (the ABC system) in the medial arm and indocyanine green angiography (ICGA). We evaluated the advantages and disadvantages of these methods and selected the optimal examination mode depending on detailed clinical settings. The perforator was identified for each patient using the ABC system and/or ICGA, depending on the clinical setting. Twenty-two patients underwent soft-tissue reconstructions with 22 BAPP flaps, and perforator localization for all the flaps was performed before surgery using the ABC system. Thirty-one perforators were localized before surgery and marked accordingly, all of which were visualized during surgery, except two, which were not found during the surgery. ICGA was used in six pre-expanded flaps at both stages of surgeries. Twenty-seven perforators were detected before surgery, and all of them were identified during surgery; the previously localized perforators found using the ABC system in the six patients were all reidentified using ICGA. Both the ABC system and ICGA were found to be useful for preoperative perforator localization in BAPP flap transfers. Each method has its unique downsides; however, they can supplement each other to facilitate safe and effective flap elevation. Therefore, selection of the optimal method based on the clinical settings is recommended.

Comparative Benefits of Open versus Closed Reduction of Condylar Fractures: A Systematic Review and Meta-Analysis.

BACKGROUND: Many fractures of the mandibular condylar neck are amenable to both open reduction and internal fixation (ORIF) and closed treatment. Clinical outcomes following these two modalities remains a topic of debate. This systematic review critically appraises the literature to compare them following these treatment options. METHODS: A systematic review and meta-analysis was performed to test the null hypothesis of no difference in clinical outcomes in ORIF versus closed treatment of mandibular condyle fractures. The PubMed, Embase, Cochrane Library, Elsevier text mining tool database, and clinicaltrials.gov trial registries were queried from 1946 to 2020. The quality of evidence was determined using Grading of Recommendations Assessment, Development, and Evaluation methodology. RESULTS: Of 1507 screened articles, 14 met inclusion criteria. ORIF was favored significantly when evaluating temporomandibular joint pain [relative risk (RR), 0.3; 95% CI, 0.1 to 0.7] (number needed to treat to prevent an outcome in one patient, 3; 95% CI, 2 to 6), laterotrusive movements of the mandible (mean difference, 2.3; 95% CI, 1.7 to 3.0) (standardized mean difference, 0.9; 95% CI, 0.4 to 1.3), and malocclusion (RR, 0.5; 95% CI, 0.4 to 0.7) (number needed to treat to prevent an outcome in one patient, 19; 95% CI, 10 to 200). However, ORIF yielded a higher incidence of postoperative infection (RR, 3.6; 95% CI, 0.9 to 13.8) and must be weighed against the understood risk of facial nerve injury. CONCLUSIONS: Meta-analysis of high-level evidence in randomized controlled trial suggests that ORIF significantly improves functional outcomes, decreases pain, and restores occlusion and jaw symmetry. These long-term benefits must be weighed against the increased risk of postoperative infection and exposure of the facial nerve to potential injury.

Breast Reconstruction Trends in the Setting of Postmastectomy Radiation Therapy: Analysis of Practices among Plastic Surgeons in the United States.

Radiation is an integral part of breast cancer therapy. The ideal type and timing of breast reconstruction with relation to radiation delivery are not well established. The study aimed to identify reconstructive practices among American plastic surgeons in the setting of pre- and postmastectomy radiation. Methods: A cross-sectional survey of members of the American Society of Plastic Surgery was performed. Practice/demographic information and breast reconstruction protocols were queried. Univariate descriptive statistics were calculated, and outcomes were compared across cohorts with χ2 and Fischer exact tests. Results: Overall, 477 plastic surgeons averaging 16.3 years in practice were surveyed. With respect to types of reconstruction, all options were well represented, although nearly 60% preferred autologous reconstruction with prior radiation and 55% preferred tissue expansion followed by implant/autologous reconstruction in the setting of unknown postoperative radiation. There was little consensus on the optimal timing of reconstruction in the setting of possible postoperative radiation. Most respondents wait 4-6 or 7-12 months between the end of radiation and stage 2 implant-based or autologous reconstruction. Common concerns regarding the effect of radiation on reconstructive outcomes included mastectomy flap necrosis, wound dehiscence, capsular contracture, tissue fibrosis, and donor vessel complications. Conclusions: Despite considerable research, there is little consensus on the ideal type and timing of reconstruction in the setting of pre- and postoperative radiation. Understanding how the current body of knowledge is translated into clinical practice by different populations of surgeons allows us to forge a path forward toward more robust, evidence-based guidelines for patient care.

Identifying Public Perceptions, Attitudes, and Concerns about Breast Implants and Their Complications: A National Survey.

BACKGROUND: Aesthetic and reconstructive implant-based breast operations are among the most common plastic surgery procedures. This study assessed the baseline knowledge of common breast implant-associated complications, and their influence on consideration of breast implants among adult laywomen within the United States. METHODS: Five hundred women were recruited through Amazon's Mechanical Turk. Respondents self-reported demographics and experience with breast implants. Questions were asked addressing respondents' understanding of complications and concerns regarding breast implants. RESULTS: Of the authors' cohort (average age, 37.8 ± 11.7 years), 12.0% had received breast implants, 72.8% knew someone with implants, and nearly 50% would consider receiving implants in the future. As many as 82.2% reported at least one concern influencing their consideration of implants: safety (75.2%), cost (70.0%), unnatural shape (43.3%), and feel (45.2%). Respondents not considering implants were significantly concerned by foreign body implantation ( P < 0.001). Almost 75% believed that implants last longer than 10 years. Following education about risks of capsular contracture and implant rupture, one-third of respondents considering implants and half of those unsure were "less likely" to receive implants. The majority were unchanged in their likelihood after learning about infection (74.4%) and implant migration (69.2%). Respondents with a history of implants were significantly less likely to believe there is strong evidence supporting the aforementioned complications ( P < 0.001). CONCLUSIONS: The rising awareness surrounding breast implant safety has the potential to significantly impact perceptions and receptivity. This study identifies public perceptions of common breast implant-associated complications and primary long-term concerns, highlighting the importance of education on postoperative complications in informed consent and surgical decision-making.

Policies and Price Tags: The Public's Perception of Face Transplantation and Its Funding.

Study Design: Survey study. Objective: Facial vascularized composite allotransplantation (FVCA) can cost over 1 million dollars per procedure and is usually not covered by insurance, yet this financial burden and public opinion surrounding this procedure are not well understood. This study is the first to evaluate the layperson's opinions on the allocation of financial responsibility for FVCA and its inclusion in organ donation registries. Methods: Eight hundred and fifteen laypersons were surveyed through MTurk to assess their agreement with 11 statements about FVCA perceptions, funding, and inclusion on organ donation registries. Responses were analyzed with the Wilcoxon Signed-Rank test, the Kruskal-Wallis test, and the Dunn's test. Results: The majority of respondents were supportive of FVCA in 10 out of 11 statements (P < 0.0001). They would be willing to undergo FVCA if they suffered from facial disfigurement; believe FVCA is as important as other organ transplants; believe faces should be included on the organ donation registry; support insurance companies providing coverage for FVCA regardless of trauma etiology; support tax dollars funding the procedure; and believe FVCA improves physical appearance and quality of life. Although respondents generally supported their tax dollars funding the procedure, fewer supported this for self-inflicted trauma (P > 0.01). Conclusions: This study highlights a disconnect between public preference for insurance coverage of FVCA and current lack of coverage in practice. Respondents' acceptance of including faces in organ donation registries may help alleviate the issue of locating a donor, and increasing financial coverage may broaden this procedure's accessibility to a wider range of individuals.

Successful use of an autologous homologous skin construct for the management of acute surgical and traumatic wounds: a clinical experience in two patients.

INTRODUCTION: Autologous homologous skin construct promises to regenerate appendage-bearing skin using a small ellipse of full-thickness tissue that is harvested from the patient and sent to the manufacturer for processing. With so many surgical treatments available for wound management, data on the value and efficacy of this product will play a particularly important role in determining its indications for use. OBJECTIVE: It was hypothesized that the AHSC would be most beneficial in patients who are unable to undergo conventional reconstruction with skin grafts or flaps. The experience of successfully using the product in 2 patients with a relative contraindication to skin grafting is described. CASE REPORTS: The first patient had a history of a collagen genetic mutation and presented after traumatic degloving of the lower extremity, which was initially treated with a dermal regeneration template. The second patient had a previous history of failed skin grafting of a surgical wound following excision of a recurrent nonmelanoma skin cancer of the back. The patients were followed to the end point of complete wound healing at 4 months (case 1) and 5 weeks (case 2). CONCLUSIONS: Although more rigorous medical and financial analysis of this treatment will be necessary, these early data suggest a potential role for the AHSC in the management of wounds for patients who cannot receive conventional techniques for wound coverage.

A Systematic Review of Muscle Synergies during a Walking Gait to Define Optimal Donor-Recipient Pairings for Lower Extremity Functional Reconstruction.

Functional lower extremity reconstruction primarily aims to restore independent ambulation. We sought to define the synergies recruited during a walking gait to inform donor selection for various motor deficits. With these findings, we discuss the functional neuromuscular components of independent gait with the goal of informing lower extremity reconstruction. Methods: A systematic review was performed using MEDLINE for articles published between January 2000 and December 2020. Search terms included (1) "motor module(s)," "synergy," "motor pattern," or "motor primitive" and (2) "gait," "walking," "ambulation," or "locomotion." Abstracts/full texts were reviewed by two independent reviewers. Results: A total of 38 studies were selected. The average reported number of synergies and variance accounted for was 4.5 ± 0.9 and 88.6% ± 7.7%, respectively. Four motor modules were conserved across nearly all studies. Conclusions: Walking can be reduced to the sequential activation of four motor modules. Activities during the stance phase are critical for both standing stability and forward progression and should be prioritized for reconstruction with the goal of preserving efficient gait. Muscles recruited during swing, except those used for ankle dorsiflexion, are less prone to injury and benefit from greater redundancy, less often necessitating reconstruction. With the emphasis on stability during stance, several synergistic or sometimes even antagonistic tendons can be used to replace their counterparts and restore efficient, independent ambulation. With a finite supply of donor tissues, and in the absence of well-defined clinical outcomes data, this research allows us to effectively prioritize reconstructive goals and maximize patient outcomes.

A Comparison of Handheld Doppler and Indocyanine Green Angiography for Perforator Localization.

BACKGROUND: The preoperative identification of perforators is critical to the success of perforator flaps. Several technologies, including handheld Doppler (HHD) and indocyanine green angiography (ICGA), facilitate this process; however, each technology comes with unique downsides. This study directly compares the performance of HHD and ICGA in preoperative perforator identification and measures the effects of flap thickness and body mass index (BMI) on perforator localization. METHOD: Data from preoperative HHD and ICGA assessments were compared with the criterion standard of intraoperative perforator localization. Sensitivity, specificity, accuracy, and positive predictive values were calculated for both and correlated with flap thickness and BMI. RESULTS: Thirty flaps were transferred in 30 patients across 15 different donor sites. Indocyanine green angiography had higher sensitivity, accuracy, and positive predictive value (79.2%, 74.2%, and 87.5%, respectively) than HHD (55.6%, 46.6%, and 69.4%, respectively). Perforators detected by ICGA were used as flap pedicles in 21 cases compared with 13 with HHD. There were no correlations between HHD or ICGA performance and patient BMI (both P > 0.05). Increasing flap thickness was negatively correlated with the accuracy of ICGA ( P = 0.001) but not HHD ( P > 0.05). CONCLUSIONS: Indocyanine green angiography was more sensitive, specific, and accurate than HHD in identifying perforators across various donor sites; however, its performance suffered in thicker flaps, whereas HHD did not. Patient BMI was not correlated with the performance of either technology. Additional research can further delineate the interrelationships of flap thickness and technologies for perforator localization.

Personality, Success, and Beyond: The Layperson's Perception of Patients With Facial Transplantation.

BACKGROUND: While the goal of facial vascularized composite allotransplantation (FVCA) is to provide patients with improved physical and social function, no study has evaluated layperson perception of social acceptance and perceived career success of patients with FVCA. The purpose of this study was to determine how FVCA changes social acceptance and perceived career success of patients with facial disfiguration. METHODS: Eight hundred fifteen laypersons were surveyed through Mechanical Turk to evaluate their perceptions of patients with FVCA. Respondents were shown facial photographs of patients pre-FVCA, post-FVCA, and matched controls and evaluated these photos on 26 items of perceived social acceptance and career success. Responses were analyzed using descriptive statistics and the Wilcoxon signed-rank test. RESULTS: Both male and female post-FVCA photos were perceived as significantly more socially accepted and professionally successful than their pre-FVCA photos in at least 21 out of 26 items (P < 0.001 for all), but the posttransplant patients scored lower than their control in at least 25 out of 26 items (P < 0.001 for all). Additionally, there were discrepancies in findings based on patient gender. CONCLUSIONS: This study suggests that while FVCA has a significantly positive impact on social acceptance and perceived professional success, it does not fully reinstate these qualities. Furthermore, varying surgical outcomes and/or cognitive biases (such as gender) may impact perceptions of the individual by the public. Our findings suggest a need to standardize practices to better predict and improve outcomes and encourage surgeons to consider patient factors such as gender when planning these procedures.

Comparing Load-Sharing Miniplate and Load-Bearing Plate Fixation in Atrophic Edentulous Mandibular Fractures: A Systematic Review and Meta-Analysis.

PURPOSE: To critically examine reported data to compare patient outcomes between load-sharing and load-bearing plate fixation for edentulous mandibular fractures. MATERIALS AND METHODS: A systematic review and meta-analysis were designed to test the null hypothesis of no difference in postoperative outcomes between load-sharing and load-bearing plate fixation in atrophic, edentulous mandibular fractures. The PubMed, EMBASE, Cochrane Library, Elsevier text mining tool database, and clinicaltrials.gov trial registries were queried up until July 2016. The quality of evidence was determined using the Grading of Recommendations Assessment, Development, and Evaluation method. RESULTS: A total of 1212 studies were screened for inclusion of which we included 1 high-quality Cochrane review, 6 narrative reviews, and 21 publications of case reports and case series. Overall, the quality of evidence was low. No difference was found between load-bearing and load-sharing fixation in functional recovery, nonunion, or infection. An uncontrolled case series portrayed complete functional and morphological restoration in 96.9% of patients (83.2-99.5; 95% confidence interval) in load-bearing osteosynthesis while another demonstrated the same outcome in only 40.0% of patients (17.5-65.0; 95% confidence interval). CONCLUSIONS: The authors did not find a statistically significant difference between load-bearing and load-sharing plate fixation in edentulous atrophic mandibular fracture patients; although this finding may be influenced by type 2 statistical error. Surgeons should continue to use their best clinical judgment in deciding on treatment approach for these challenging fractures. Future studies with higher level evidence are necessary to guide optimal fracture management.

Quantifying the Effect of Topical Nitroglycerin on Random Pattern Flap Perfusion in a Rodent Model: An Application of the ViOptix Intra.Ox for Dynamic Flap Perfusion Assessment and Salvage.

BACKGROUND: Near-infrared spectroscopy can detect changes in tissue oxygenation postoperatively that predict flap necrosis. The authors hypothesized that this technology can be applied along with topical nitroglycerin to measure an improvement in tissue oxygenation that correlates with tissue salvage. METHODS: Dorsal, random pattern flaps measuring 10 × 3 cm were raised using Sprague-Dawley rats. Tissue oxygenation was measured after flap elevation in 10 locations using the ViOptix Intra.Ox. Animals were divided into three groups that received 30 mg of topical nitroglycerin daily, twice-daily, or not at all. Oxygenation measurements were repeated on postoperative day 1 and animals were euthanized on day 7 and evaluated for tissue necrosis. RESULTS: Tissue necrosis was greatest in controls (51.3 mm) compared to daily (28.8 mm) and twice-daily nitroglycerin (18.8 mm; p = 0.035). Three flap perfusion zones were identified: healthy (proximal, 50 mm), necrotic (distal, 20 mm), and watershed. Immediate postoperative tissue oxygenation was highest in healthy tissue (57.2 percent) and decreased to 33.0 and 19.3 percent in the watershed and necrotic zones, respectively (p < 0.001). One day after treatment with nitroglycerin, oxygenation in the healthy zone did not increase significantly (mean difference, -1.5 percent). The watershed (17.8 percent; p < 0.001) and necrotic zones (16.3 percent; p <0.001) did exhibit significant improvements that were greater than those measured in control tissues (7.9 percent; both p < 0.001). CONCLUSIONS: Serial perfusion assessment using the ViOptix Intra.Ox measured a significant improvement in flap oxygenation after treatment with topical nitroglycerin. Within the watershed area of the flap, this increase in tissue oxygenation was associated with the salvage of ischemic tissue.

The Intra.Ox Near-Infrared Spectrometer Measures Variations in Flap Oxygenation That Correlate to Flap Necrosis in a Preclinical Rodent Model.

BACKGROUND: Mastectomy flap necrosis affects 7 to 40 percent of patients undergoing immediate breast reconstruction, with many cases resulting in infection and/or explantation. The Intra.Ox near-infrared spectrometer is a novel device that assesses tissue perfusion by measuring the interactions of light with oxygenated and deoxygenated hemoglobin. This handheld device facilitates serial flap perfusion assessment and may objectively identify at-risk tissues and guide evidence-based treatment algorithms. In this preliminary study, we hypothesized that the Intra.Ox spectrometer detects differences in tissue oxygenation that correlate to tissue necrosis. METHODS: Dorsal, random-pattern flaps measuring 10 × 3 cm were raised in eight male Sprague-Dawley rats. Intraoperative tissue oxygen saturation was measured using Intra.Ox in 10 standardized locations. On postoperative day 7, the skin flaps were evaluated for full-thickness necrosis. Data were analyzed using the chi-square test and one-way analysis of variance. A receiver operating characteristic curve assessed the accuracy of intraoperative tissue oxygenation in predicting the risk of flap necrosis. RESULTS: Tissue oxygen saturation exhibited a strong negative correlation to distance from the flap pedicle (r = -0.798). Oxygen saturation in tissue that developed necrosis averaged 32 percent, compared to 59 percent in tissues that did not (p < 0.001). The area under the receiver operating characteristic curve was 0.969. Post hoc oxygen saturation cutoffs with 100 percent specificity and sensitivity in predicting necrosis were identified at 46 percent and 54 percent, respectively. CONCLUSIONS: Intra.Ox detects significant differences in tissue oxygenation saturation that are associated with the risk for flap necrosis. This technology can be used to identify at-risk tissues and represents an avenue for research aimed at preventing flap necrosis.

Thinking Outside the Black Box: Current Perceptions on Breast Implant Safety and Utility.

BACKGROUND: There is growing public concern surrounding breast implant safety. In fact, the U.S. Food and Drug Administration recently proposed changes to breast implant labeling, which include a boxed warning. Given such efforts to increase transparency on breast implant safety, this study assessed laywomen's perceptions of breast implant safety, and the impact of proposed changes to breast implant labeling on laywomen's decision-making regarding breast implants. METHODS: This was a cross-sectional investigation of women recruited through Amazon Mechanical Turk. Discrete choice modeling was used to query opinions on breast implants after viewing proposed labeling changes. Chi-square and analysis of variance were used for subgroup analyses, and McNemar analyses were used to assess changes in participants' responses. RESULTS: The authors received 500 survey responses. At baseline, 353 participants (70.6 percent) considered breast implants to be at least somewhat safe. After viewing the proposed boxed warning, 252 participants (50.4 percent) responded that they would be less likely to receive implants. In fact, a significantly greater proportion of participants considered breast implants to be either unsafe or very unsafe after viewing suggested changes to implant labeling than at baseline (58.4 percent versus 28.8 percent; p = 0.001). By the end of the survey, willingness to consider alternative options for breast augmentation/reconstruction increased significantly from baseline. CONCLUSIONS: Improved labeling can enhance laywomen's understanding of breast implant safety and can impact decision-making. However, greater scrutiny of breast implants should not prevent women who need implants from receiving them. Transparency and objectivity in the surgeon-patient dialogue can ensure the appropriate use of medical devices such as breast implants.

Noninvasive Management of Pediatric Isolated, Condylar Fractures: Less Is More?

BACKGROUND: The purpose of this study was to examine injury patterns in pediatric mandibular condylar fractures and to propose and evaluate the validity of an institutional treatment algorithm for such fractures. METHODS: A retrospective chart review was conducted on pediatric patients who presented to the authors' institution with isolated mandibular condylar fractures between 1990 and 2016. Patients were categorized by dentition, and information regarding demographics, injury characteristics, management, and complications was compiled. RESULTS: Forty-three patients with 50 mandibular condylar fractures were identified. Twelve patients (27.9 percent) had deciduous dentition, 15 (34.9 percent) had mixed dentition, and 16 (37.2 percent) had permanent dentition. The most common fracture pattern in all groups was diacapitular [n = 30 (60 percent)]; however, older groups showed higher rates of condylar base fractures and bilateral fractures (p = 0.029 and p = 0.011, respectively). Thirty-one patients (72.1 percent) were treated with nonoperative management, 10 (23.2 percent) with closed treatment and mandibulomaxillary fixation, and two (4.7 percent) with open treatment and mandibulomaxillary fixation; nonoperative treatment was more common in younger patients (p = 0.008). Management for 10 patients (23.2 percent) was nonadherent to the treatment algorithm. Eight patients had complications (18.6 percent). Common complications included temporomandibular joint ankylosis (n = 2) and malocclusion (n = 2). Although complications were seen in all groups, adherence to the algorithm was associated with an 81.8 percent reduction in odds of complications (p = 0.032). CONCLUSIONS: Nonoperative management has a low complication rate in deciduous children. Children with permanent/mixed dentition may undergo closed treatment and mandibulomaxillary fixation if they have malocclusion/contralateral open bite, significant condylar dislocation, and ramus height loss greater than 2 mm. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Pectoral placement of tissue expanders affects inpatient opioid use.

Prepectoral breast reconstruction promises to minimize breast animation deformity and decrease pain associated with subpectoral dissection and tissue expansion. This latter benefit is particularly timely given the ongoing opioid epidemic; however, this theoretical benefit remains to be demonstrated clinically. As such, this study aimed to compare inpatient opioid use and prescription practices following prepectoral and subpectoral expander-based breast reconstruction. A retrospective review was performed of patients undergoing immediate tissue expander placement between January 2017 and April 2018. Medical records were reviewed for surgical details, 24-hour inpatient PRN opioid usage (oral morphine equivalents [OME]), and discharge prescriptions. Comparisons were made using chi-squared and student's t tests where appropriate. Two hundred and thirty-one patients were identified, (mean age 48.8 years), 222 of which met inclusion criteria. 89 underwent subpectoral and 133 prepectoral tissue expander placements. All but two subpectoral patients and two prepectoral patients were opioid-naïve. The rate of bilateral procedures did not differ between cohorts (P = .194). Overall, 94% of patients were discharged within 24 hours, and length of stay did not differ between cohorts (P = .0753). Two subpectoral and two prepectoral patients required prolonged admission due to postoperative pain. All patients were ordered standing acetaminophen, celecoxib, and gabapentin, and subpectoral patients cyclobenzaprine. Narcotic pain medication was offered on an "as needed" (PRN) basis. Opioid usage within the first 24-hours was halved in the prepectoral cohort (22.2 vs 44.5 OME, P = .0003), which was not associated with bi/unilaterality of procedure or the presence of any psychiatric conditions. The amount of opioids prescribed on discharge was not significantly different between cohorts (308.42 OME prepectoral vs 336.99 subpectoral, P = .3197). Prepectoral expander placement appears to be associated with decreased inpatient opioid use postoperatively. This may represent an opportunity to improve patient satisfaction and safety by decreasing outpatient opioid prescriptions.

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.

Tissue Expander-Based Breast Reconstruction in the Prepectoral Versus Subpectoral Plane: An Analysis of Short-Term Outcomes.

BACKGROUND: Breast reconstruction is becoming an increasingly important and accessible component of breast cancer care. We hypothesize that prepectoral patients benefit from lower short-term complications and shorter periods to second-stage reconstruction compared with individuals receiving reconstruction in the subpectoral plane. METHODS: An institutional review board-approved retrospective review of all adult postmastectomy patients receiving tissue expanders (TEs) was completed for a 21-month period (n = 286). RESULTS: A total of 286 patients underwent mastectomy followed by TE placement, with 59.1% receiving prepectoral TEs and 40.9% receiving subpectoral TEs. Participants receiving prepectoral TEs required fewer clinic visits before definitive reconstruction (6.4 vs 8.8, P <0.01) and underwent definitive reconstruction 71.6 days earlier than individuals with subpectoral TE placement (170.8 vs 242.4 days, P < 0.01). Anesthesia time was significantly less for prepectoral TE placement, whether bilateral (68.0 less minutes, P < 0.01) or unilateral (20.7 minutes less, P < 0.01). Operating room charges were higher in the prepectoral subgroup ($31,276.8 vs $22,231.8, P < 0.01). Partial necrosis rates were higher in the prepectoral group (21.7% vs 10.9%, P < 0.01). CONCLUSIONS: Patients undergoing breast reconstruction using prepectoral TE-based reconstruction benefit from less anesthesia time, fewer postoprative clinic visits, and shorter time to definitive reconstruction, at the compromise of higher operating room charges.

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.

Indocyanine Green Angiography Predicts Tissue Necrosis More Accurately Than Thermal Imaging and Near-Infrared Spectroscopy in a Rat Perforator Flap Model.

BACKGROUND: Clinical examination alone is neither sensitive nor specific for predicting flap necrosis, so several technologies, including indocyanine green angiography, thermal imaging (using the FLIR ONE), and near-infrared spectroscopy, have been developed to supplement perfusion assessment. This study aims to compare the accuracy of these three methods for intraoperatively predicting clinical flap necrosis in a rat perforator flap model. The authors hypothesized that near-infrared spectroscopy, assessing oxygenation rather than direct perfusion, would yield significantly different predictions. METHODS: A 10 × 3-cm epigastric perforator flap was elevated in 14 adult male rats weighing 250 ± 50 g. Flap perfusion was assessed immediately after flap elevation using thermal imaging, near-infrared spectroscopy, and indocyanine green angiography. Measurements were correlated to the clinical endpoint and gold standard of flap necrosis on postoperative day 7. RESULTS: All three technologies detected significant differences in perfusion along flap length (all p < 0.001), and were associated with significant differences in the odds of developing flap necrosis (all p < 0.001). The areas under the receiver operating characteristic curves were 0.948 for indocyanine green angiography as an absolute value, 0.873 for relative changes with thermal imaging, and 0.792 for tissue oxygenation. The sensitivity, specificity, and accuracy for indocyanine green angiography measured as an absolute value were the highest at 97.8, 87.5, and 92 percent, respectively. CONCLUSIONS: Indocyanine green angiography most accurately predicted flap necrosis in this study; however, tissue oximetry and thermal imaging were also capable of predicting necrosis and represented potentially less expensive or more readily available alternatives for objective perfusion assessment. Additional research can further delineate their roles and cost-efficacy in clinical practice.

Use of Indocyanine Green Imaging for Perforator Identification in Preexpanded Brachial Artery Perforator Flaps.

The tissues of the medial arm as a donor site for perforator flap design have several advantages. However, they are relatively underused with limited reports, partly due to unreliable perforator anatomy. Therefore, we aimed to review our preliminary experience using indocyanine green (ICG) angiography to design and elevate preexpanded pedicled brachial artery perforator (BAP) flaps for regional reconstruction. All patients underwent soft tissue reconstructions using a preexpanded BAP flap in two or three stages. ICG angiography was used to localize perforators during both expander insertion and flap elevation. The pedicle was divided at the third stage 3 weeks following flap elevation for head and neck cases. Sixteen patients underwent reconstructions of the head and neck (n = 13) or shoulder/trunk (n = 3) using 14 perforator-plus and 2 propeller BAP flaps. In total, 50 perforators were identified using ICG imaging, all of which were appreciable during both expander placement and flap elevation. Thirty-five perforators were directly visualized during flap elevation, and an additional 15 perforators were not explored but incorporated into the flap. All flaps survived without necrosis, and the donor sites healed uneventfully without complications. The medial arm provides thin and pliable skin for the resurfacing of regional defects with relatively minimal donor-site morbidity. With the assistance of ICG angiography, perforators of the brachial artery can be reliably identified, facilitating the preexpansion and elevation of pedicled BAP flaps for use in head-neck and trunk reconstruction.