Cleft Palate Fistula: A Review.

Background: The development of postoperative oronasal fistulae (ONF) is a complication that plagues all cleft surgeons to varying degrees. There is extensive literature discussing the incidence, functional impact, and treatment of ONF. The goal of this article is to provide an extensive review of the literature discussing the incidence, causative factors, functional impact, classification systems, and treatment of ONF. Methods: A literature review was performed using PubMed using the Medical Subject Heading terms "cleft palate" AND "fistula" OR "palatal fistula" OR "oronasal fistula". After review, a total of 356 articles were deemed relevant for this study. Results: Information regarding ONF care, prevention, and management in patients with cleft palate was collected from the articles included in this review. Treatment of ONF remains a challenging problem as there is not a consensus in the available literature on the best palatoplasty techniques for their prevention and treatment. A myriad of reconstructive options and adjunctive therapies exist, and their use is guided by the size and location of the fistula. Conclusions: Fistula treatment should be tailored to the specific needs of the patient, and consideration must be given to not only the ONF itself but also the patient's stage of growth and development. Large-scale, multicenter studies are needed in which ONF are described using standardized nomenclature, and improved outcomes reporting is necessary to better define an algorithm for a truly holistic approach to palate surgery and reduce the incidence of palatal fistula.

Complication Profile of Total Submuscular Versus Prepectoral Tissue Expander Placement: A Retrospective Cohort Study.

BACKGROUND: We sought to compare the safety profile of prepectoral breast reconstruction with total submuscular tissue expander reconstruction, previously our standard. Primary outcomes of interest in this retrospective cohort study were incidence of infection, hematoma, seroma, mastectomy flap necrosis, and reconstruction loss. METHODS: Total submuscular and prepectoral with acellular dermal matrix reconstructions consecutively performed by a single surgeon (P.D.S.) between January 1, 2016, and December 31, 2019, were compared. Demographic and clinical characteristics, as well as complications and complication types, were extracted for all patients. A t test was used to assess differences in continuous variables. Multivariate logistics regression was used to assess the association between type of reconstruction and complication rate. The statistical significance was set at 0.05 for all comparisons. RESULTS: A total of 133 patients (234 breasts) were included. There was a significantly greater incidence of infection (16.5% vs 5.5%, P < 0.01) in the prepectoral/acellular dermal matrix cohort. However, reconstructive loss was low in both cohorts (2.5% and 3.0%, P = 0.83). Adjusted odds ratio for complications in the prepectoral cohort was 2.26, but this was not statistically significant (adjusted P = 0.24). CONCLUSIONS: Prepectoral breast reconstruction shares an overall complication profile that is not greater than that of total submuscular reconstruction. It is associated with a greater risk of infection; however, the ability to salvage the reconstruction with early, aggressive intervention results in low rates of reconstructive loss, comparable with those of total submuscular reconstruction.

Maxillomandibular Advancement for the Treatment of Obstructive Sleep Apnea in Patients With Normal or Class I Malocclusion.

BACKGROUND: Maxillomandibular advancement is an effective surgical option for obstructive sleep apnea (OSA) that achieves enlargement of the upper airway by physically expanding the facial skeleton. The authors sought to determine whether an advancement of 10 mm predicts surgical success and if any correlation existed between the magnitude of mandibular/maxillary advancement and improvement in polysomnography metrics using aggregated individual patient data from multiple studies. METHODS: A search of the PubMed database was performed to identify relevant articles that included preoperative and postoperative polysomnography data and measurements of the advancement of both the maxillary and mandibular portions of the face in patients with normal or class I malocclusion. Each patient was stratified into "Success" or "Failure" groups based on criteria defining a "Success" as a 50% preoperative to post-operative decrease in AHI or RDI and a post-operative AHI or RDI <20. RESULTS: A review of the PubMed database yielded 162 articles. Review of these resulted in 9 manuscripts and a total of 109 patients who met the inclusion criteria. There was no statistically significant difference in the amount of anterior advancement of either the mandible (P = 0.96) or the maxilla (P = 0.23) between the "Success" or "Failure" groups. CONCLUSIONS: While there is a paucity of individual data available, the current data does not support an ideal amount of maxillary or mandibular advancement that is required to obtain a surgical success in the treatment of OSA. Until a multicenter, prospective, randomized trial is performed, surgical planning should be tailored to patient-specific anatomy to achieve the desired result.

Two-Stage Prosthetic Breast Reconstruction With Integrated Versus Remote Port Expanders: A Comparison of Complication Rates.

Background: Ever since their introduction, tissue expanders for breast reconstruction have undergone a gradual evolution from remote port expanders to the integrated port expanders commonly in use today. Integrated port expanders have been widely adopted because of their ease of use and reliability, and though the convenience of integrated port expanders over remote port expanders is clear, a side-by-side comparison of complications has not been performed. A same-surgeon, same-institution study was conducted comparing the complication rates of remote versus integrated tissue expanders. Methods: A retrospective review was conducted of 107 patients who underwent breast reconstruction with tissue expanders. Remote tissue expanders were used in 21 consecutive patients (n = 42) and integrated port tissue expanders in 86 consecutive patients (n = 128). Patients who had received prior or concurrent breast irradiation were excluded from the study. Overall complications were compared, followed by complications that were broken down according to mechanical and infectious complications. Results: Fisher's exact test demonstrated a statistically significant increase in the rate of overall complications in remote port expanders compared with integrated port expanders (19% vs 7%; P = .024). Similarly, a statistically significant difference in the rate of mechanical complications between the 2 groups was found (7% in remote vs 0.8% in integrated, P = .047). When the rates of infectious complications were compared between the 2 groups, however (12% in remote vs 6% in integrated), no significant difference could be found (P = .312). Conclusion: In this retrospective review of prosthetic breast reconstructions, increased overall complications were observed with remote tissue expanders that were mainly mechanical in nature. The higher rate of infection observed in the remote port group was not statistically significant. Our study shows that remote port expanders do in fact have a higher complication rate than integrated port expanders. This should be taken into account when considering the use of remote port expanders in certain clinical scenarios.

The Impact of Presurgical Infant Orthopedics on Oronasal Fistula Rates Following Cleft Repair: A Meta-Analysis.

BACKGROUND: Presurgical infant orthopedics (PSIO) techniques were introduced to improve the outcomes achieved when treating children with complete cleft lip and palate. The effect of PSIO on the incidence of postoperative fistulae has never been reliably demonstrated. We conducted a meta-analysis to assess the effectiveness of PSIO in reducing postoperative fistulas in patients with complete cleft lip and palate. METHODS: A search of the PubMed and Embase databases was performed to identify relevant articles that included primary palate repairs of patients with unilateral or bilateral complete clefts, reported the incidence of postoperative fistulae, and explicitly stated if PSIO was used. Details including author, number of subjects, use of PSIO, and fistula rate were cataloged. RESULTS: A review of the PubMed database yielded 1135 unique citations, and Embase yielded 507 articles. Review of these yielded 15 studies, comprising 1241 children, which met inclusion criteria. The overall rate of oronasal fistula development was 7.09%. The average fistula rate for studies using PSIO was 5.93% versus 9.71% in the non-PSIO group. This difference was not statistically significant ( P = .34). CONCLUSIONS: The use of PSIO prior to cleft lip and palate repair provides multiple benefits related to facial and nasal form and is supported by a body of literature. The effect of PSIO on the incidence of postoperative fistulae has received less attention in the literature. Our meta-analysis of the available literature does not provide evidence to support the premise that the use of PSIO affects the incidence of fistulae after cleft palate repair.

Combined Autologous and Prosthetic Breast Reconstruction: Defining the Upper Limits of Safe Expansion in Obesity.

BACKGROUND: Combined latissimus dorsi and prosthetic reconstruction is a useful reconstructive option in patients with a history of breast radiation who are not good candidates for abdominally based autologous reconstruction. One difficulty, particularly in obese patients, is that the thickness of the flap can impair port localization, increasing the risk of inadvertent puncture during expansion. The authors sought to investigate the upper limits of tissue thickness at which tissue expansion can be reliably performed. METHODS: A cadaveric study was designed in which 2 blinded observers attempted to localize the port of a Mentor CPX-4 expander under tissue 1, 2, 3, 4, 5, and 6 cm thick. Thirty attempts were made per tissue thickness. RESULTS: For tissue thicknesses of 1 to 4 cm, the success rate was 100% (k = 1). At 5 cm, the success rate decreased to 86.6% (k = 1); at 6 cm, 43.3% (k = 0.85). Point biserial correlation revealed a negative correlation between tissue thickness and accuracy at a thicknesses of greater than 4 cm (r = -0.55, P < 0.00001). Converting tissue thickness to a dichotomous variable based on the results (thickness, <4 and >4 cm), Fisher exact test revealed a statistically significant difference between these 2 populations (P < 0.00001). CONCLUSIONS: In obese patients with a skin pinch of greater than 8 cm or a flap thickness of greater than 4 cm, steps should be taken to minimize the risk of inadvertent puncture of the expander during postoperative expansion. This can include foregoing tissue expander placement in favor of an implant, port localization with ultrasound guidance, or the use of remote port expanders. These findings are relevant not only in breast reconstruction with latissimus flaps and implants but also in any setting where autologous and prosthetic reconstructions are combined.

The Incidence of Complex Regional Pain Syndrome in Simultaneous Surgical Treatment of Carpal Tunnel Syndrome and Dupuytren Contracture.

BACKGROUND: To determine the incidence of complex regional pain syndrome (CRPS) in the concurrent surgical treatment of Dupuytren contracture (DC) and carpal tunnel syndrome (CTS) through a thorough review of evidence available in the literature. METHODS: The indices of 260 hand surgery books and PubMed were searched for concomitant references to DC and CTS. Studies were eligible for inclusion if they evaluated the outcome of patients treated with simultaneous fasciectomy or fasciotomy for DC and carpal tunnel release using CRPS as a complication of treatment. Of the literature reviewed, only 4 studies met the defined criteria for use in the study. Data from the 4 studies were pooled, and the incidence of recurrence and complications, specifically CRPS, was noted. RESULTS: The rate of CRPS was found to be 10.4% in the simultaneous treatment group versus 4.1% in the fasciectomy-only group. This rate is nearly half the 8.3% rate of CRPS found in a randomized trial of patients undergoing carpal tunnel release. CONCLUSIONS: Our analysis demonstrates a marginal increase in the occurrence of CRPS by adding the carpal tunnel release to patients in need of fasciectomy, contradicting the original reports demonstrating a much higher rate of CRPS. This indicates that no clear clinical risk is associated with simultaneous surgical treatment of DC and CTS. In some patients, simultaneous surgical management of DC and CTS can be accomplished safely with minimal increased risk of CRPS type 1.

Bolstering Skin Grafts With a Surgical Scrub Brush: A Cost-effective Solution.

Objective: The objective of this article is to review the methods currently used for the bolstering of skin grafts and compare their advantages and disadvantages with those of the dry, sterile surgical scrub brush. We report a series of cases performed at a single institution and compare the cost-effectiveness, application, and limitations of this method with other options for skin graft bolstering. Methods: A PubMed search using the parameters "(bolster) AND skin graft" was conducted, yielding 85 results. A total of 40 publications met the criteria for our literature review. The costs of the foam bolsters utilized as stents for skin grafts were obtained from the Central Supply and Resource Division of the University of Louisville Hospital for a cost analysis. The cost per square centimeter of each bolster material was calculated. Results: At $0.003/cm2, the 3M Reston foam is the most inexpensive of the 3 bolster materials analyzed. The dry, sterile surgical scrub brush has a similar cost at $0.006/cm2 but carries the advantage of sterility. The material cost of negative pressure wound therapy is $0.47/cm2, and the cost of the system as a whole makes it a much more expensive alternative. In 6 patients with defects of varying size and location, the scrub brush bolster showed a near 100% graft take and no complications. Conclusions: The dry, sterile surgical scrub brush presents a readily available and low-cost option for the stenting of small skin grafts and should be considered a viable method in the armamentarium of available skin graft bolsters.

Immediate Breast Reconstruction of a Nipple Areolar Lumpectomy Defect With the L-Flap Skin Paddle Breast Reduction Design and Contralateral Reduction Mammoplasty Symmetry Procedure: Optimizing the Oncoplastic Surgery Multispecialty Approach.

Objective: We describe a modification of the inferior pedicle reduction mammoplasty for oncoplastic reconstruction of a central tumor defect. Our technique involved a deepithelialized L-shaped medial inferior based flap with removal of lateral breast tissue after central lumpectomy with a contralateral Wise-pattern mastopexy with inferior pedicle for symmetry. This technique is ideal for patients with large, ptotic breasts that desire breast conservation with immediate reconstruction. Methods: A 47-year-old woman with size 38 DD breasts presented with a palpable 2-cm subareolar mass of the left breast. Surgical oncology performed a left lumpectomy with nipple-areola complex excision and a sentinel lymph node biopsy. Immediate left breast reconstruction was performed with an inferior pedicle island flap. An additional 30 g of breast tissue was excised laterally for contour, and the neo-nipple-areola complex was rotated into the defect to facilitate inverted-T closure. A standard Wise-pattern mastopexy with inferior pedicle was then performed on the right breast and an additional 205 g of tissue was removed for symmetry. Results: The patient showed excellent symmetry at the conclusion of the procedure. Final pathology demonstrated complete excision of the tumor with negative margins. The entire neo-nipple-areola complex skin island was viable postoperatively. Conclusions: Immediate reconstruction of a nipple-areola complex lumpectomy defect with a L-shaped medial inferior based skin paddle flap and contralateral reduction mammoplasty provides an excellent cosmetic outcome in patients with large, ptotic breasts and central defects following oncologic tumor resection.