Decision-Making in Adult Cranial Vault Reconstruction.

LEARNING OBJECTIVES: After studying this article, the participant should be able to: 1. Define and classify different types of cranial defects 2. Compare both autologous and alloplastic options for reconstruction 3. Develop an optimal approach for cranial vault reconstruction in various clinical scenarios. SUMMARY: Defects of the cranium result from various causes, including traumatic loss, neurosurgical intervention, skull tumors, and infection. Cranial vault reconstruction aims to restore both the structural integrity and surface morphology of the skull. To ensure a successful outcome, the choice of appropriate cranioplasty reconstruction will vary primarily based on the cause, location, and size of the defect. Other relevant factors that must be considered include adequacy of soft-tissue coverage, presence of infection, and previous or planned radiation therapy. This article presents an algorithm for the reconstruction of various cranial defects using both autologous and alloplastic techniques, with a comparison of their advantages and disadvantages.

Parental Perceptions Following Cleft Lip Repair in Their Children.

OBJECTIVE: Cleft lip (CL) repair at 3 months is chosen mostly out of convention and offers minimal functional benefit. Potentially, a better cosmetic outcome is possible by delaying repair. This study examines parental perceptions around repair at 3 months to determine if current guidelines are appropriate. DESIGN: Retrospective cross-sectional survey. SETTING: Tertiary-care institution. PARTICIPANTS: Parents of children with CL ±â€ŠP under age 6 years who underwent CL repair from 2004 to 2011 at our center were surveyed (n = 64). Response rate was 61% (n = 37). METHODS: Open-ended survey asked about various aspects of parental perceptions before and after repair. Qualitative data analysis is used to interpret survey responses. STATISTICS: Fisher exact test using contingency tables to identify statistically significant results. RESULTS: Nearly all (36/37) parents felt repair was important, citing reasons such as feeding, speech, and appearance. Most (28/37) felt surgery would fix the problem. A portion of parents (15/37) would delay repair if better aesthetics were possible later, but most would not (20/37). Most parents were satisfied with repair quality (33/37). On average, repair did not impact parent-child bonding, and eliminated negative interactions with strangers that parents found distressing. CONCLUSIONS: Arguably, positive parental perceptions of their child's condition reflect favorably on the child's well-being, and may outweigh any future aesthetic benefit. Therefore, current recommendations should be upheld. However, given that some parents would consider delaying repair, they could be offered this option. Future efforts should examine cultural factors, and aesthetic and developmental outcomes of repair at different ages to determine optimal repair timing.

Intraoperative Autoderm Decontamination for Use in Immediate Single-stage Direct-to-implant Breast Reconstruction.

Acellular dermal matrix (ADM) in direct-to-implant breast cancer reconstruction is the standard of care due to superior cosmetic results and decreased capsular contracture, but can be cost prohibitive. Although more economical, using patient's own dermis ("Autoderm") instead of ADM has undescribed sterility. Sterility is essential, as bacterial contamination may cause infection and capsular contraction. This study aimed to determine the sterility and optimal decontamination protocol of Autoderm. METHODS: A prospective controlled study of 140 samples from 20 DIEP (deep inferior epigastric perforator) breast cancer reconstruction patients was performed. Seven de-epithelialized dermal samples (2 × 1 cm) per patient were collected from excess abdominal tissue (6 decontamination protocols and one control). Samples were submerged in povidone-iodine, chlorhexidine, or cefazolin/tobramycin/bacitracin for 15 minutes; half of the samples were agitated (150 rpm) for 15 minutes, and half were not. The control was normal saline without agitation. The solution was removed, and the tissue was sent for aerobic colony count cultures. Patient's demographic data and complications were also collected. RESULTS: Of 140 samples, 3 of 20 non-agitated povidone-iodine and 1 of 20 control samples had aerobic bacterial growth. All of the other 100 samples from 5 experimental groups (povidone-iodine + agitation, chlorhexidine ± agitation, and cefazolin/tobramycin/bacitracin ± agitation) had no aerobic bacterial growth. CONCLUSIONS: This study suggests povidone-iodine + agitation, chlorhexidine ± agitation, and cefazolin/tobramycin/bacitracin ± agitation are effective at sterilizing de-epithelialized dermis, whereas povidone-iodine without agitation and saline are ineffective. Autoderm with the appropriate decontamination protocol may be a potential sterile alternative to ADM.

Congenital Calvarial Hemangioma.

OBJECTIVES: The authors describe a case of congenital calvarial hemangioma successfully managed using propranolol therapy. Presenting symptoms, radiological and pathological features, differential diagnosis, and management of this rare congenital mass are described. CASE PRESENTATION: A 2-year-old boy presented with a 1-year history of a growing right parietal skull mass. No obvious etiology was apparent. No focal neurological deficits or associated craniofacial anomalies were identified. Plain film imaging demonstrated focal thickening of the right parietal bone with internal trabeculations in a sunburst appearance. Computed tomography (CT) scan showed bone thickening with coarsening of the bony trabeculae, minor irregularity of the outer table, unaffected inner table, and no evidence of aggressive features. A diagnostic biopsy of the lesion was performed in the operating room. Microscopic examination was consistent with hemangioma. Based on histological and radiological features of the lesion, it was identified as a cavernous hemangioma. Medical treatment utilizing propranolol was initiated for over 3 years with interval reduction in the lesion size. MRI head following treatment with propranolol demonstrated reduction of the mass compared to preoperative imaging. CONCLUSIONS: Although a rare entity, it is important to consider congenital calvarial hemangioma in the differential diagnosis of slow growing skull lesions due to the possibility of complications as a result of the hemangioma's intracranial extension, and the potential for treatment. En bloc resection has classically been described as a treatment for such lesions, although our case demonstrates that medical treatment with propranolol therapy may be appropriate in certain situations.

Three-dimensional Printed Surgical Simulator for Kirschner Wire Placement in Hand Fractures.

Closed reduction and percutaneous pinning (CRPP) of hand fractures can be a deceptively challenging procedure that requires significant hands-on time to teach and learn. We created a realistic three-dimensional simulator that can be used for teaching junior residents the CRPP. Computer-aided design and computer-aided manufacturing (CAD/CAM) software was used to create a three-dimensional hand model incorporating several common hand fractures: Bennett's fracture, transverse fifth metacarpal neck, and transverse second proximal phalanx. Three-dimensional printing was used to create molds in which the bones and soft tissue were poured. A polyurethane foam was utilized for the bones with iron incorporated to render them radiopaque, whereas silicone of varying viscosities was used for the soft tissues. Five plastic surgery residents and 5 consultants evaluated the model. Individuals then completed an anonymous 12-question survey evaluating the model based on realism, educational utility, and overall usefulness. Survey responses obtained from both residents and consultants were strongly in favor of the simulator. Average realism was graded as 4.48/5 by residents and 4.68/5 by consultants. Average educational utility was graded as 5/5 by residents and 4.95/5 by consultants. Average overall usefulness was graded as 5/5 by both groups. We created an anatomically accurate and realistic simulator for CRPP of hand fractures that was low cost and easily reproducible. Initial feedback was encouraging in regard to realism, educational utility, and overall usefulness.

Objective Outcomes of Minimally Invasive Temporalis Tendon Transfer for Prolonged Complete Facial Paralysis.

OBJECTIVES: We describe an approach to reanimation of complete, prolonged facial paralysis using minimally invasive temporalis tendon transfer (MIT3) by the melolabial or transoral approach. Objective outcome measures are evaluated based on symmetry, and grading of preoperative/post-operative results and the scar at the melolabial fold. STUDY DESIGN: Retrospective cohort study. METHODS: Twenty-five patients undergoing the MIT3 technique were studied. Photographic analysis was used to determine the percentage of difference between the 2 sides (symmetry). Using the Delphi method to achieve consensus, a panel of experts graded pre/post-operative photos using the Terzis' Facial Grading System and a 1 to 10 Likert-type scale and the melolabial scar using the Beausang Scar Scale. RESULTS: Percentage of difference (symmetry) with smiling improved from 18.6% ± 1.5% (mean ± standard error of the mean [SEM]) preoperatively to 5.0 ± 0.9% (mean ± SEM) post-operatively. Expert grading by the Terzis system showed improvement post-operatively (mean 3.7/5; median 3.6/5) versus preoperatively (mean 1.5/5; median 1.2/5). Perceived improvement was also largely favourable (mean 8.1/10; median 8.0/10). Melolabial scar grading was favourable in terms of colour (mean 1.53/4), surface character (mean 1.05/2), contour (mean 1.60/4), and distortion (mean 1.74/4). CONCLUSIONS: The MIT3 technique offers immediate, predictable, and symmetrical return of smile function. Objective symmetry analysis and favourable expert grading of both pre-/post-operative photographs and the scar at the melolabial fold demonstrate applicability for facial reanimation in patients where other procedures have failed, or when a direct return to function is desired. Both the melolabial approach and transoral approach were found to be acceptable and effective, although applicability varies.

OBJECTIFS: Les auteurs décrivent une approche de la réanimation d'une paralysie faciale complète et prolongée par transfert mini-invasif du tendon temporal (MIT3) par l'abord mélolabial ou transoral. Les mesures objectives de résultats sont évaluées en fonction de la symétrie, du classement des résultats préopératoires et postopératoires et de la cicatrice au pli mélolabial. CONCEPTION: Étude rétrospective de cohorte. MÉTHODOLOGIE: Les chercheurs ont étudié 25 patients qui avaient subi la technique MIT3. L'analyse photographique a déterminé la différence en pourcentage entre les deux côtés (symétrie). À l'aide de la méthode Delphi pour parvenir à un consensus, un groupe d'experts a classé les photos préopératoires et postopératoires à l'aide du système de classement facial de Terzis et de l'échelle de Likert de 1 à 10. Il a aussi classé la cicatrice mélolabiale à l'aide de l'échelle de cicatrices de Beausang. RÉSULTATS: La différence du sourire en pourcentage (symétrie) est passée de 18,6±1,5 % (moyenne±erreur-type) avant l'opération à 5,0±0,9 % (moyenne±erreur-type) après l'opération. Le classement par les experts à l'aide du système de Terzis a démontré une amélioration après l'opération (moyenne 3,7/5; médiane 3,6/5) par rapport à l'aspect préopératoire (moyenne 1,5/5; médiane 1,2/5). De plus, l'amélioration perçue était largement favorable (moyenne 8,1/10; médiane 8,0/10). Le classement de la cicatrice mélolabiale était positif sur le plan de la couleur (moyenne 1,53/4), de l'aspect de la surface (moyenne de 1,05/2), du contour (moyenne de 1,60/4) et de la distorsion (moyenne de 1,74/4). CONCLUSIONS: La technique MIT3 assure un retour immédiat, prévisible et symétrique du sourire. L'analyse de symétrie objective, un classement favorable par des experts d'après des photos avant-après l'opération et la cicatrice au pli mélolabial démontrent la possibilité de réanimation faciale des patients lorsque d'autres interventions ont échoué ou qu'un retour direct à la fonction est souhaité. Tant l'abord mélolabial que transoral étaient acceptables et efficaces, même si leur applicabilité varie.

A Limited Submuscular Direct-to-Implant Technique Utilizing AlloMax.

This study evaluates a novel limited submuscular direct-to-implant technique utilizing AlloMax where only the upper few centimeters of the implant is covered by the pectoralis, whereas the majority of the implant including the middle and lower poles are covered by acellular dermal matrix. METHODS: The pectoralis muscle is released off its inferior and inferior-medial origins and allowed to retract superiorly. Two sheets of AlloMax (6 × 16 cm) are sutured together and secured to the inframammary fold, serratus fascia, and the superiorly retracted pectoralis. Thirty-seven breasts in 19 consecutive patients with follow-up at 6 months were reviewed. RESULTS: Nineteen consecutive patients with 37 reconstructed breasts were studied. Average age was 50 years, average BMI was 24.3. Ptosis ranged from grade 0-III, and average cup size was B (range, A-DDD). Early minor complications included 1 seroma, 3 minor postoperative hematomas managed conservatively, and 3 minor wound healing problems. Three breasts experienced mastectomy skin flap necrosis and were managed with local excision. There were no cases of postoperative infection, red breast, grade III/IV capsular contractures, or implant loss. A single patient complained of animation postoperatively. One patient desired fat grafting for rippling. CONCLUSIONS: The limited submuscular direct-to-implant technique utilizing AlloMax appears to be safe with a low complication rate at 6 months. This technique minimizes the action of the pectoralis on the implant, reducing animation deformities but still providing muscle coverage of the upper limit of the implant. Visible rippling is reduced, and a vascularized bed remains for fat grafting of the upper pole if required.

In vitro measurements of burn dressing adherence and the effect of interventions on reducing adherence.

PURPOSE: There is a paucity of research on reducing dressing adherence. This is partly due to lack of an in vitro model, recreating the clinical variability of wounds. Previously we described an in vitro gelatin model to evaluate adherence in a standardized manner. We present evaluation of strategies to reduce adherence in six dressings. PROCEDURES: Dressing materials used were: PET (Control), fine mesh gauze coated in bismuth and petroleum jelly (BIS), nanocrystalline silver (NS), wide mesh polyester coated in polysporin ointment (WM), fine mesh cellulose acetate coated in polysporin ointment (FM), and soft silicone mesh (SIL). The dressing material was applied to gelatin and incubated for 24h. Adherence was tested using an Instron 5965 force-measurement device. Testing was repeated with various adherence reducing agents: water, surfactant, and mineral oil. RESULTS: Adherence from least to greatest was: SIL, NS, BIS, WM, FM, PET. Water reduced adherence in all dressings; the effect increasing with exposure time. Surfactant reduced adherence of NS. Mineral oil effectively decreased adherence of BIS, and WM. CONCLUSION: This model allows for reproducible measurement of dressing adherence. Different interventions affect various dressings. No single intervention optimally decreases adherence for all dressings.

Stapedial synkinesis causing change in hearing threshold with facial motion.

OBJECTIVE: Synkinetic facial movement after facial nerve regeneration is a well-documented phenomenon. Rarely, patients recovering from facial nerve injury report feelings of auditory ringing, fullness, and a sensation of ear tightness as a result of stapedial muscle involvement. It is exceedingly rare for such synkinesis to produce perceivable changes in hearing threshold. We report a unique case of stapedial synkinesis causing pure-tone changes in hearing threshold with activation of the facial musculature. PATIENT: A single patient is presented who developed stapedial synkinesis after suboccipital resection of a unilateral acoustic neuroma. RESULTS: Despite facial nerve sparing, surgery resulted in House-Brackmann grade V/VI right facial nerve paralysis that improved to Grade III/VI after 7 months. Synkinesis developed that caused eye closure with puckering of the lips. Puckering of the lips likewise caused decreased hearing in the right ear, corresponding to a measured decrease of 10 dB in the PTA. Over the next several months, facial motion continued to improve, and hearing changes became less bothersome, so no intervention was undertaken. CONCLUSION: The changes presented in the hearing threshold fit within the classically described 15-dB attenuation provided by the stapedial reflex. Although no intervention was undertaken in this particular case, some patients with unremitting stapedial synkinesis might benefit from sectioning of the stapedial muscle. Thus, consideration should be made for audiometric evaluation with and without facial muscle contraction in the evaluation of individuals with synkinetic facial movement.

Capnocytophaga canimorsus infection presenting with complete splenic infarction and thrombotic thrombocytopenic purpura: a case report.

BACKGROUND: Animal bites are typically harmless, but in rare cases infections introduced by such bites can be fatal. Capnocytophaga canimorsus, found in the normal oral flora of dogs, has the potential to cause conditions ranging from minor cellulitis to fatal sepsis. The tendency of C. canimorsus infections to present with varied symptoms, the organism's fastidious nature, and difficulty of culturing make this a challenging diagnosis. Rarely, bacterial cytotoxins such as those produced by C. canimorsus may act as causative agents of TTP, further complicating the diagnosis. Early recognition is crucial for survival, and the variability of presentation must be appreciated. We present the first known case of C. canimorsus infection resulting in TTP that initially presented as splenic infarction. CASE PRESENTATION: 72-year-old Caucasian male presented with a four-day history of abdominal pain, nausea, vomiting, diarrhea, and intermittent confusion. On presentation, vital signs were stable and the patient was afebrile. Physical examination was unremarkable apart from petechiae on the inner left thigh, and extreme diffuse abdominal pain to palpation and percussion along with positive rebound tenderness. Initial investigations revealed leukocytosis with left shift and thrombocytopenia, but normal liver enzymes, cardiac enzymes, lipase, INR and PTT. Abdominal CT demonstrated a non-enhancing spleen and hemoperitoneum, suggesting complete splenic infarction. Although the patient remained afebrile, he continued deteriorating over the next two days with worsening thrombocytopenia. After becoming febrile, he developed microangiopathic hemolytic anemia and hemodynamic instability, and soon after was intubated due to hypoxic respiratory failure and decreased consciousness. Plasma exchange was initiated but subsequently stopped when positive blood cultures grew a gram-negative organism. The patient progressively improved following therapy with piperacillin-tazobactam, which was switched to imipenem, then meropenem when Capnocytophaga was identified. CONCLUSIONS: There is a common misconception amongst practitioners that the presence of systemic infection excludes the possibility of TTP and vice versa. This case emphasizes that TTP may occur secondary to a systemic infection, thereby allowing the two processes to coexist. It is important to maintain a wide differential when considering the diagnosis of either TTP or C. canimorsus infection since delays in treatment may have fatal consequences.

Enhanced gene and siRNA delivery by polycation-modified mesoporous silica nanoparticles loaded with chloroquine.

PURPOSE: To prepare mesoporous silica-based delivery systems capable of simultaneous delivery of drugs and nucleic acids. METHODS: The surface of mesoporous silica nanoparticles (MSN) was modified with poly(ethylene glycol) (PEG) and poly(2-(dimethylamino)ethylmethacrylate) (PDMAEMA) or poly(2-(diethylamino)ethylmethacrylate) (PDEAEMA). The particles were then loaded with a lysosomotropic agent chloroquine (CQ) and complexed with plasmid DNA or siRNA. The ability of the synthesized particles to deliver combinations of CQ and nucleic acids was evaluated using luciferase plasmid DNA and siRNA targeting luciferase and GAPDH. RESULTS: The results show a slow partial MSN dissolution to form hollow silica nanoparticles in aqueous solution. The biological studies show that polycation-modified MSN are able to simultaneously deliver CQ with DNA and siRNA. The co-delivery of CQ and the nucleic acids leads to a significantly increased transfection and silencing activity of the complexes compared with MSN not loaded with CQ. CONCLUSION: PEGylated MSN modified with polycations are promising delivery vectors for combination drug/nucleic acid therapies.