Secondary Salvage of the Unsatisfactory Microtia Reconstruction.

BACKGROUND: Because auricular reconstruction is a complex and relatively uncommon procedure, there are many patients that have had disappointing reconstructions. This study describes the authors' large experience with secondary procedures in patients with unsatisfactory or failed initial ear reconstruction. METHODS: A prospectively maintained database of all consecutive patients who underwent secondary total ear reconstruction from March of 1991 to December of 2017 was reviewed. Demographic data and outcomes were assessed. Patients with acquired absence of the ear were not included. RESULTS: There were 144 microtia patients that met the inclusion criteria. Patient age at the time of the secondary reconstruction ranged from 3 to 59 years. Follow-up duration ranged from 1 to 21 years. Primary reconstruction was performed with rib cartilage in 91 patients, porous polyethylene implant in 47 patients, prosthesis in four patients, and irradiated cadaver rib cartilage in two patients. All secondary reconstructions were performed with porous polyethylene implants. The alloplastic framework was covered with a temporoparietal fascia flap in 76 patients, an occipital fascia flap in 64 patients, and a free fascia flap in four patients (two radial forearm flaps in the same patient, one contralateral temporoparietal fascia flap, and one lateral arm flap). Fourteen patients (10 percent) had complications requiring revision surgery. Secondary surgery was successful in all but one patient. CONCLUSIONS: These data represent the largest series of secondary total ear reconstructions. The use of a porous polyethylene implant is an ideal method for these patients because of its minimal morbidity and relatively low complication rate. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Cosmetically Challenging Congenital Melanocytic Nevi.

BACKGROUND: Congenital melanocytic nevi (CMN) have a 1% to 5% lifetime risk for malignant transformation, with 50% of transformations occurring before the age of 5 years.The aim of this study is to assess the risk of melanoma development in pediatric patients with facial CMN involving the eyebrows, eyelid margins, and nasal alae where a margin of CMN was not excised to preserve these structures. METHODS: A retrospective chart review of all pediatric patients with CMN from 1986 to 2014 was performed to review demographic information, diagnosis, and number of surgeries. Patients' clinical photographs were evaluated for residual nevi after completion of the treatment. RESULTS: More than 950 medical charts of patients with CMN of the face area were reviewed. We identified 32 patients (13; 41% male) that met the study criteria with pathology-confirmed diagnosis of facial CMN with an average age of 4.4 years (3.3 months-15.8 years) at the time of initial surgery. The CMNs were classified into small (1; 3%), medium (14; 44%), large (14; 44%), and giant (3; 9%) based on their projected adult sizes. No patients developed melanoma within the small residual lesions left over the eyebrows and eyelids and inside nostrils at an average follow-up time of 5.6 (1.0-14.4) years and average age of 9.6 (1.8-19.2) years at the time of last follow-up. CONCLUSIONS: Although a lifelong risk of malignant transformation of the residual CMN cannot be concluded, our results found no transformation in follow-up visits at an average age beyond the highest risk of melanoma development in childhood. We feel that leaving residual lesions on the face in areas of important anatomic structures for better cosmetic outcome is an acceptable risk.

The Occipital Artery-Based Fascial Flap for Ear Reconstruction.

BACKGROUND: The temporoparietal fascia flap is frequently used in ear reconstruction. When the temporoparietal fascia flap is unavailable, options for primary or secondary salvage reconstruction are limited. In these patients, an inferiorly based occipital artery fascia transpositional flap is a good alternative for soft-tissue coverage over a framework. This article describes the use of the occipital artery fascia flap for ear reconstruction in conjunction with a porous polyethylene framework. METHODS: The authors included all patients who underwent occipital artery fascia flap surgery with a porous polyethylene framework for ear reconstruction performed by the first author from 1992 to 2017. RESULTS: A total of 83 patients received an occipital artery fascia flap: 24 for primary microtia reconstruction and 59 for revision or salvage of unsatisfactory results. All had contraindications for temporoparietal fascia flap use: prior use, flap injury from previous surgery, trauma, inappropriate flap location, or inadequate flap perfusion. Twelve patients (14 percent) developed occipital artery fascia flap complications (infection or necrosis) and underwent further revision to achieve satisfactory results. CONCLUSIONS: Given the paucity of reported techniques for large-scale auricular salvage/revision, the authors offer a versatile option that remains available when other conventional flaps are unavailable. The occipital artery fascia flap may be used with either alloplastic or autologous frameworks. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Getting a Valid Survey Response From 662 Plastic Surgeons in the 21st Century.

INTRODUCTION: Web-based surveys save time and money. As electronic questionnaires have increased in popularity, telephone and mailed surveys have declined. With any survey, a response rate of 75% or greater is critical for the validity of any study. We wanted to determine which survey method achieved the highest response among academic plastic surgeons. METHODS: All American Association of Plastic Surgeons members were surveyed regarding authorship issues. They were randomly assigned to receive the questionnaire through 1 of 4 methods: (A) emailed with a link to an online survey; (B) regular mail; (C) regular mail + $1 bill, and (D) regular mail + $5 bill. Two weeks after the initial mailing, the number of responses was collected, and nonresponders were contacted to remind them to participate. The study was closed after 10 weeks. Survey costs were calculated based on the actual cost of sending the initial survey, including stationary, printing, postage (groups B-D), labor, and cost of any financial incentives. Cost of reminders to nonresponders was calculated at $5 per reminder, giving a total survey cost. RESULTS: Of 662 surveys sent, 54 were returned because of incorrect address/email, retirement, or death. Four hundred seventeen of the remaining 608 surveys were returned and analyzed. The response rate was lowest in the online group and highest in those mailed with a monetary incentive. CONCLUSIONS: Despite the convenience and low initial cost of web-based surveys, this generated the lowest response. We obtained statistically significant response rates (79% and 84%) only by using postal mail with monetary incentives and reminders. The inclusion of a $1 bill represented the greatest value and cost-effective survey method, based on cost per response.

HEAR MAPS a classification for congenital microtia/atresia based on the evaluation of 742 patients.

OBJECTIVE: Describe anatomical and radiological findings in 742 patients evaluated for congenital aural atresia and microtia by a multidisciplinary team. Develop a new classification method to enhance multidisciplinary communication regarding patients with congenital aural atresia and microtia. METHODS: Retrospective chart review with descriptive analysis of findings arising from the evaluation of patients with congenital atresia and microtia between January 2008 and January 2012 at a multidisciplinary tertiary referral center. RESULTS: We developed a classification method based on the acronym HEAR MAPS (Hearing, Ear [microtia], Atresia grade, Remnant earlobe, Mandible development, Asymmetry of soft tissue, Paralysis of the facial nerve and Syndromes). We used this method to evaluate 742 consecutive congenital atresia and microtia patients between 2008 and January of 2012. Grade 3 microtia was the most common external ear malformation (76%). Pre-operative Jahrsdoerfer scale was 9 (19%), 8 (39%), 7 (19%), and 6 or less (22%). Twenty three percent of patients had varying degrees of hypoplasia of the mandible. Less than 10% of patients had an identified associated syndrome. CONCLUSION: Patients with congenital aural atresia and microtia often require the intervention of audiology, otology, plastic surgery, craniofacial surgery and speech and language professionals to achieve optimal functional and esthetic reconstruction. Good communication between these disciplines is essential for coordination of care. We describe our use of a new classification method that efficiently describes the physical and radiologic findings in microtia/atresia patients to improve communication amongst care providers.

Authorship conflicts: a study of awareness of authorship criteria among academic plastic surgeons.

BACKGROUND: Authorship is an important yardstick in academic medicine. The purpose of this study was to assess the prevalence of authorship conflicts among academic plastic surgeons and determine any change in authorship awareness over an 8-year period. METHODS: In 2003, members of the American Association of Plastic Surgeons were surveyed using an anonymous, 15-item, one-page questionnaire. In 2011, members were resurveyed using a similar questionnaire. In both surveys, nonresponders were contacted by telephone at 2 weeks to encourage response. RESULTS: The authors obtained a response rate of 80.4 percent (258 of 321) in 2003 and 81.6 percent (486 of 595) in 2011. In both cohorts, one-third of respondents felt that they had not been appropriately acknowledged as authors at some point during their career. Furthermore, in 2003, 29 percent of respondents admitted to being involved in a dispute with a colleague over authorship issues. This had decreased slightly to 22 percent by 2011. Interestingly, 64 percent of respondents in 2003, compared with only 37 percent of respondents in 2011, stated that they had included someone as an author who had not fulfilled any authorship criteria. In 2003, only 16 percent of respondents were aware of any journal authorship criteria. This had increased to 59 percent by 2011. CONCLUSIONS: The authors found an increase in awareness of authorship criteria among academic plastic surgeons in 2011 compared with those in 2003. In addition, academic plastic surgeons surveyed more recently reported more rigorous justification for including individuals as authors, supporting a trend toward increasing transparency and accountability.

Hypertrophic scarring in cleft lip repair: a comparison of incidence among ethnic groups.

BACKGROUND: Although hypertrophic scar (HTS) formation following cleft lip repair is relatively common, published rates vary widely, from 1% to nearly 50%. The risk factors associated with HTS formation in cleft patients are not well characterized. The primary aim of this retrospective study of 180 cleft lip repairs is to evaluate the frequency of postoperative HTS among various ethnic groups following cleft lip repair. METHODS: A retrospective chart view of patients undergoing primary cleft lip repair over a 16-year period (1990-2005) by the senior surgeon was performed. The primary outcome was the presence of HTS at 1 year postoperatively. Bivariate analysis and multivariable logistic regression were used to evaluate potential risk factors for HTS, including ethnicity, type and laterality of cleft, and gender. RESULTS: One hundred and eighty patients who underwent cleft lip repair were included in the study. The overall rate of postoperative HTS formation was 25%. Ethnicity alone was found to be an independent predictor of HTS formation. Caucasian patients had the lowest rate of HTS formation (11.8%) and were used as the reference group. HTS rates were significantly higher in the other ethnicities, 32.2% in Hispanic patients (odds ratio [OR]: 3.51; 95% confidence interval [CI]: 1.53-8.85), and 36.3% for Asian patients (OR 4.27; 95% CI: 1.36-13.70). Sex, cleft type, and cleft laterality were not associated with increased rates of HTS. CONCLUSIONS: Differences in ethnic makeup of respective patient populations may be a major factor influencing the wide variability of reported HTS rates. Consideration should be given to potential prophylactic treatments for HTS in susceptible ethnic populations.

Guide to early surgical management of lip hemangiomas based on our experience of 214 cases.

BACKGROUND: Hemangiomas are the most common vascular lesions in infancy. The majority of hemangiomas occur on the face and cause significant parental distress because of their high visibility. Traditionally, they have been managed by a "watch and wait" approach due to their known propensity to improve significantly over time. This is a particularly difficult approach for hemangiomas of the lips due to their high visibility and their tendency to leave residual deformity even after resolution. METHODS: The authors performed a retrospective chart review of pediatric patients who underwent surgical excision of upper and lower lip hemangiomas at Children's Hospital Los Angeles between 1992 and 2006. RESULTS: The authors identified 214 patients with an average age of 23.6 months at the time of surgery. All patients had improvements in lip appearance, with minimal complications. No transfusions were required, and all but two patients (lip switch flaps for major tissue loss) were managed on an outpatient basis. Overall, complications were minimal, with a high degree of parent satisfaction. CONCLUSION: The authors conclude that many children would benefit from early excision and present guidelines for the early surgical management of lip hemangiomas.

Algorithmic approach to the management of hemangiomas.

Hemangiomas are a common benign vascular tumor that can occur in all parts of the body. These lesions can be a distressing sight for both patient and parent. This unique vascular tumor has characteristic phases of growth. Historically, these tumors have been treated nonoperatively, but with variable results. Often, the residual-resolved tumor produces contour defects, unpredictable scarring, and pigmentation problems. The authors devised an algorithmic diagram for treating hemangiomas based on a 30-year experience with treating these unique tumors. This step-by-step method delineates the thinking method that should be used when presented with a difficult hemangioma. This algorithmic method takes into account a multifactorial approach to management. This includes anatomic location, growth velocity, treatment response, expected outcome, and psychosocial considerations.

Ear reconstruction using a porous polyethylene framework and temporoparietal fascia flap.

Ear reconstruction is a difficult procedure requiring a framework and soft tissue covering. The traditional method uses a rib cartilage framework placed beneath scalp skin. This method has been used for 50 years despite inherent problems with both harvesting rib cartilage and using scalp for coverage. The authors describe a method using a porous polyethylene (PPE) framework covered by a large temporoparietal fascia (TFP) flap raised with the underlying subgaleal fascia (SGF). The entire implant is covered by the two-layered flap, which can be raised without any scalp incision. The skin grafts applied to the covered implant lie on the SGF. The trilaminar structure of the SGF allows the skin to move independently over the implant, resisting shear forces and reducing the probability of implant exposure. Ear reconstruction using the PPE framework was performed on 786 ears over an 18-year period. Initial complications were common. With improved implant design and complete coverage of the implant with both the TPF and SGF, exposure rate dropped to 7% with a 12-year follow-up. Implant fractures decreased to less than 3%. The PPE/TPF method allows earlier ear reconstruction in children with minimal scarring and discomfort. The reconstructed ear can closely mimic the shape and projection of the natural contralateral ear in fewer stages and with a shorter learning curve.

Cysts, pits, and tumors.

SUMMARY: This article discusses common pediatric skin and subcutaneous lesions grouped into three categories: cysts, pits, and tumors. Vascular malformations and hemangiomas are covered elsewhere in this supplement and are not discussed here. In addition, only benign tumors that typically present to the plastic surgeon are mentioned. In a minority of cases, further investigation, in the form of imaging or biopsy, will be required to establish the diagnosis and allow appropriate management. In this article, the authors concentrate on the relevant information required to triage and treat these conditions.

Surgical management of parotid hemangioma.

Hemangiomas represent one of the most common childhood neoplasms. They are often managed conservatively, requiring numerous years for spontaneous involution. No effective medical treatment has been reported for children with large, deforming hemangiomas of the parotid gland and overlying cheek. The authors retrospectively studied 17 children who underwent surgical resection of parotid hemangiomas at Childrens Hospital Los Angeles from 1997 to 2003. All 17 patients had improvements in facial asymmetry and deformity. There were no major complications. Minor complications included hematoma (11.8 percent), transient facial nerve palsy (11.8 percent), and blood transfusion (5.9 percent). All operations were performed on an outpatient basis. Surgical resection of parotid hemangiomas provides an aesthetic benefit to young children with low associated morbidity. Early resection by an experienced surgeon should be considered as a treatment option for these disfiguring lesions.

Pilomatrixoma: a review of 346 cases.

Pilomatrixoma, also known as calcifying epithelioma of Malherbe, is a benign skin neoplasm that arises from hair follicle matrix cells. Pilomatrixoma is a common skin neoplasm in the pediatric population that is often misdiagnosed as other skin conditions. This study reviews an 11-year experience at a tertiary children's hospital, examining the cause, clinical and histopathological presentation, management, and treatment outcomes of pilomatrixoma. A review of the pathology database at Children's Hospital Los Angeles revealed 346 pilomatrixomas excised from 336 patients between 1991 and 2001. The hospital charts, pathology records, and plastic surgery clinic charts were reviewed with respect to variables such as sex, age at the time of presentation, clinical and histopathological presentation, preoperative diagnosis, management, recurrence, and treatment outcome. The main presenting symptom was a hard, subcutaneous, slowly growing mass. The preoperative diagnosis was accurate and consistent with the pathological diagnosis of pilomatrixoma in only 100 cases (28.9 percent). This entity should be considered with other benign or malignant conditions in the clinical differential diagnosis of solitary firm skin nodules, especially those on the head, neck, or upper limbs. The diagnosis can generally be made with a clinical examination. Imaging studies are not required unless symptoms or the location of the lesion warrants such diagnostic assessments. The treatment of choice is surgical excision, and the recurrence rate is low.

Outpatient cleft lip repair.

The emphasis on cost reduction and increased efficiency in health care delivery has prompted an increase in outpatient (ambulatory) surgical procedures. A retrospective review of the perioperative management of patients undergoing cleft lip repair at two urban tertiary pediatric hospitals was performed to assess the safety of outpatient cleft lip repair. The hospital database at Childrens Hospital Los Angeles was searched to find all patients who had been operated on for cleft lip repair during calendar years 1999 and 2000. Two groups were identified from Childrens Hospital Los Angeles: the outpatient cleft lip repair group (patients discharged the same day as the operation; n = 91) and the inpatient cleft lip repair group (n = 14). A data set was acquired from the Royal Children's Hospital in Melbourne, Australia, using the same criteria, for fiscal years 1998 to 2000 (n = 50). All patients from Royal Children's Hospital had operations as inpatients. Parameters considered for each group were age, sex, race, ethnicity, length of hospital stay, preexisting medical conditions or diagnoses, complications, and readmissions or presentation to the emergency department within 4 weeks of operation. The Childrens Hospital Los Angeles outpatient group had three readmissions that were considered to be complications of the operation. The Childrens Hospital Los Angeles inpatient group had one readmission attributable to a complication. The Royal Children's Hospital group also had one readmission for a complication. There was no significant difference in the complication rate of the Childrens Hospital Los Angeles outpatient group and the Royal Children's Hospital group (p > 0.05). There was also no significant difference in the complication rate of both of the Childrens Hospital Los Angeles groups compared with the Royal Children's Hospital group (p > 0.05). This study indicates that cleft lip repair performed in an outpatient setting may be a safe alternative to the inpatient operation. Certain preexisting medical conditions, however, may dictate the need for inpatient hospitalization after repair.

Improving care after primary cleft palate surgery.

This article reports on the use of a multidisciplinary action plan (MAP) in a tertiary care craniofacial center to evaluate one set of outcomes after primary cleft palate repair (PCPR). Two series of patients undergoing PCPR were studied. The first series of 30 patients was managed by using a set of preprinted order sets developed by plastic surgeons and clinical nurse specialists. The patients were evaluated 90 days after surgery to determine whether they had received the planned postoperative care. Most patients received care from plastic surgeons, and fewer obtained care from otolaryngologists. The second group of patients was managed by using a revised set of preprinted order sets and an MAP developed by both surgical specialty groups. In the second group, the proper postoperative follow-up care was provided by both surgical subspecialists with the revised interdisciplinary order sets and new MAP-directed care.

Maternal pulmonary adenocarcinoma metastatic to the fetus: first recorded case report and literature review.

We report the first maternal pulmonary adenocarcinoma metastatic to the fetus as well as an updated literature review. Review of the literature revealed that there have been only 67 cases of maternal malignancy metastatic to the products of conception. These were mostly malignant melanoma and hematopoietic tumors. A 46-year old multiparous woman with metastatic pulmonary adenocarcinoma, diagnosed at 23 weeks gestation, delivered a male infant who appeared normal at birth. The mother died 2 days after delivery. The child developed multiple scalp tumors a 2 weeks of age. The tumors recurred rapidly after initial resection. Wide local excision of the involved scalp and skin graft coverage was performed at 14 weeks of age. Histopathology of these tumors was identical to that of the maternal tumor. The maternal origin of these tumors was confirmed by fluorescence in situ hybridization (FISH). The child is now 5 years old and free of disease.

Somatic mutation of vascular endothelial growth factor receptors in juvenile hemangioma.

Juvenile hemangiomas are the most common tumors of infancy, occurring in as many as 10% of all births. These benign vascular lesions enlarge rapidly during the first year of life by hyperplasia of endothelial cells and attendant pericytes and then spontaneously involute over a period of years, leaving loose fibrofatty tissue. Several hypotheses have been put forth concerning hemangiogenesis, including the possibility that the tumor is the result of somatic mutation in one or more components of critical vascular growth-regulatory pathways. To test this hypothesis, we obtained 15 proliferative-phase hemangiomas after surgical resection and dissected them to enrich for the lesional (endothelial and pericytic) components of each specimen. To determine whether hemangiomas represent a clonal expansion from a single progenitor cell, we assayed X-inactivation patterns for each lesion by using the polymorphic X-linked human androgen receptor gene. Twelve of 14 informative hemangiomas showed a significant degree of allelic loss after methylation-based and transcription-based polymerase chain reaction clonality assays, suggesting a nonrandom X-inactivation pattern and, thus, a monoclonal origin. We then sequenced genes encoding the receptors of the vascular endothelial growth factors (VEGFs) as candidates for potential somatic mutation. Mutations were found in two of the 15 hemangioma specimens: a missense mutation (P1147S) in the kinase domain of the VEGFR2 (FLK1/KDR) gene in one specimen and a missense mutation (P954S) in the kinase insert of the VEGFR3 (FLT4) gene in another specimen. In each case, the mutation was detected in tumor tissue but not in adjacent normal tissue. These results suggest that one potential mechanism involved in hemangioma formation is the alteration of the VEGF signaling pathway in endothelial and/or pericytic cells.