Dehiscence and Fistula Formation Following Anterior Palatal Reconstruction With Vomer Flap.

BACKGROUND AND PURPOSE: Anterior palatal reconstruction using vomer flaps has been described during primary cleft lip repair. In this procedure, the mucoperiosteal tissue of the vomer is elevated to reconstruct the nasal mucosa overlying the cleft of the hard palate. Here the authors, evaluate the efficacy of a technique in which a superiorly based vomer flap is sutured to the lateral nasal mucosa. The authors assess vomer flap dehiscence rates and compare the likelihood of fistula development in this cohort to patients who underwent palatoplasty without vomer flap reconstruction. METHODS: A retrospective chart review was conducted of all palatoplasties performed by the senior author at an academic institution during a 7-year period. Medical records were reviewed for demographic variables, operative characteristics, and postoperative complications up to 1 year following surgery. Logistic regression analysis was conducted to assess the effects of vomer flap reconstruction on fistula formation, adjusting for age and sex. RESULTS: Fifty-eight (N=58) patients met the inclusion criteria. Of these, 38 patients (control group) underwent cleft palate reconstruction without previous vomer flap placement. The remaining 20 patients underwent cleft lip repair with vomer flap reconstruction before palatoplasty (vomer flap group). When bilateral cases were counted independently, 25 total vomer flap reconstructions were performed. Seventeen of these 25 vomer flap reconstructions (68%) were completely dehisced by the time of cleft palate repair. In the vomer flap group, 3 of the 20 patients (15%) developed fistulas in the anterior hard palate following the subsequent palatoplasty procedure. In the control group, only 1 of the 38 patients (2.6%) developed a fistula in the anterior hard palate. There was no significant association between cohorts and the development of anterior hard palate fistulas [odds ratio=10.88, 95% confidence interval (0.99-297.77) P=0.07], although analysis was limited by low statistical power due to the small sample size. CONCLUSIONS: In our patient population, anterior palatal reconstruction using a superiorly based vomer flap technique was associated with complete dehiscence in 68% of cases. Fistula formation in the anterior hard palate was also proportionately higher following initial vomer flap reconstruction (15% versus 2.6%). These results prompted the senior author to adjust his surgical technique to 1 in which the vomer flap overlaps the oral mucosa. While follow-up from these adjusted vomer flap reconstruction cases remains ongoing, early evidence suggests a reduced requirement for surgical revision following implementation of the modified technique.

Barriers of Three-Dimensional Printing in Craniofacial Plastic Surgery Practice: A Pilot Study and Literature Review.

OBJECTIVE: Three-dimensional printing (3Dp) and modeling have demonstrated increasing utility within plastic and reconstructive surgery (PRS). This study aims to understand the prevalence of how this technology is utilized in craniofacial surgery, as well as identify barriers that may limit its integration into practice. METHODS: A survey was developed to assess participant demographics, characteristics of 3Dp use, and barriers to utilizing three-dimensional technologies in practice. The survey was distributed to practicing craniofacial surgeons. A secondary literature review was conducted to identify solutions for barriers and potential areas for innovation. RESULTS: Fifteen complete responses (9.7% response rate) were analyzed. The majority (73%) reported using three-dimensional modeling and printing in their practice, primarily for surgical planning. The majority (64%) relied exclusively on outside facilities to print the models, selecting resources required to train self and staff (55%), followed by the cost of staff to run the printer (36%), as the most common barriers affecting 3Dp use in their practice. Of those that did not use 3Dp, the most common barrier was lack of exposure (75%). The literature review revealed cost-lowering techniques with materials, comparability of desktop commercial printers to industrial printers, and incorporation of open-source software. CONCLUSIONS: The main barrier to integrating 3Dp in craniofacial plastic and reconstructive surgery practice is the perceived cost associated with utilizing the technology. Ongoing literature highlights the cost-utility of in-house 3Dp technologies and practical cost-saving methods. The authors' results underscore the need for broad exposure for currently practicing attendings and trainees in 3Dp practices and other evolving technologies.

Multidisciplinary surgical considerations for en bloc resection of sacral chordoma: review of recent advances and a contemporary single-center series.

OBJECTIVE: Contemporary management of sacral chordomas requires maximizing the potential for recurrence-free and overall survival while minimizing treatment morbidity. En bloc resection can be performed at various levels of the sacrum, with tumor location and volume ultimately dictating the necessary extent of resection and subsequent tissue reconstruction. Because tumor resection involving the upper sacrum may be quite destabilizing, other pertinent considerations relate to instrumentation and subsequent tissue reconstruction. The primary aim of this study was to survey the surgical approaches used for managing primary sacral chordoma according to location of lumbosacral spine involvement, including a narrative review of the literature and examination of the authors' institutional case series. METHODS: The authors performed a narrative review of pertinent literature regarding reconstruction and complication avoidance techniques following en bloc resection of primary sacral tumors, supplemented by a contemporary series of 11 cases from their cohort. Relevant surgical anatomy, advances in instrumentation and reconstruction techniques, intraoperative imaging and navigation, soft-tissue reconstruction, and wound complication avoidance are also discussed. RESULTS: The review of the literature identified several surgical approaches used for management of primary sacral chordoma localized to low sacral levels (mid-S2 and below), high sacral levels (involving upper S2 and above), and high sacral levels with lumbar involvement. In the contemporary case series, the majority of cases (8/11) presented as low sacral tumors that did not require instrumentation. A minority required more extensive instrumentation and reconstruction, with 2 tumors involving upper S2 and/or S1 levels and 1 tumor extending into the lower lumbar spine. En bloc resection was successfully achieved in 10 of 11 cases, with a colostomy required in 2 cases due to rectal involvement. All 11 cases underwent musculocutaneous flap wound closure by plastic surgery, with none experiencing wound complications requiring revision. CONCLUSIONS: The modern management of sacral chordoma involves a multidisciplinary team of surgeons and intraoperative technologies to minimize surgical morbidity while optimizing oncological outcomes through en bloc resection. Most cases present with lower sacral tumors not requiring instrumentation, but stabilizing instrumentation and lumbosacral reconstruction are often required in upper sacral and lumbosacral cases. Among efforts to minimize wound-related complications, musculocutaneous flap closure stands out as an evidence-based measure that may mitigate risk.

Assessing the Reliability of Facial Feminization Content on Social Media and Its Impact on the Dissemination of Misinformation.

BACKGROUND: The surge in social media usage has transformed the dissemination and consumption of healthcare information, notably impacting plastic surgery and cosmetic specialties. This study focuses on the influence of social media, particularly Instagram and TikTok, in shaping perceptions of individuals seeking facial feminization (FF) procedures. METHODS: Using the validated DISCERN scale, we assessed the reliability and accuracy of FF content on TikTok and Instagram. The study also analyzed the relationship between content reliability on engagement metrics (likes, comments, views) and the type of content shared (educational, testimonial, promotional). RESULTS: The analysis encompassed 225 TikTok videos and 75 Instagram posts. TikTok content showed 9.33% as "very poor," 66.2% as "poor," 22.6% as "fair," and only 1.33% as "excellent." Similarly, Instagram content demonstrated 14.67% as "very poor" and 69.33% as "poor," with no content rated as "good" or "excellent." Educational content received higher reliability scores on both platforms. TikTok engagement metrics showed lower reliability ratings correlating with more views, comments, and likes. CONCLUSION: The study underscores the critical role of social media in shaping patient perspectives on FF procedures. The prevalence of inaccurate information necessitates a focus on responsible engagement by healthcare professionals, aiming to provide accurate, educational content that aligns with patients' informational needs and ultimately enhances surgical outcomes.

The Impact of a Centralized Plastic Surgery Research Infrastructure on Scholarly Productivity and Output.

Although research and innovation is a key within the field of plastic and reconstructive surgery, the impact of team structure, interpersonal dynamics, and/or standardized infrastructure on scholarly output has been infrequently studied. In this work, we present the formation and implementation of a novel plastic surgery research program that aims to unite previously disparate clinical and translational research efforts at our institution to facilitate critical inquiry. From July 2022 to June 2023, our department launched a pilot research program based on three pillars: (1) formalization of a research curriculum (monthly research meetings for agenda setting and discussion for project honing, formal research leadership for meeting facilitation and workflow regulation), (2) development of a centralized database to compile ongoing research (Google Drive repository to house all ongoing research documents, facilitate real-time editing, and provide resources/templates for assisting in the research process), and (3) bolstering of a core research identity built on mentorship and collaboration (more frequent interactions to shift previously siloed faculty-student mentorship into a robust milieu of intercollaboration). During the first year, we saw an increased number of publications and presentations, as well as robust participation and contribution from faculty, residents, and medical students. Future directions will focus on addressing resource limitation, such as project idea availability and funding, to sustain the success and growth of this novel research infrastructure.

Single Surgeon Comparison of Midline Versus Overlapping Locoregional Flap Closure Following Spinal Instrumentation.

BACKGROUND: Two techniques for paraspinous muscle flap closure of spine surgeries have been described: one with tension-free mobilization of the muscle flaps approximated at the midline and one with perforators more aggressively dissected to allow for overlapping of the flaps. We seek to compare the surgical outcomes in patients who underwent either type of complex spinal closure as no investigation has yet evaluated a superior technique. METHODS: An institutional review board (IRB)-approved retrospective analysis was conducted on all patients who underwent spine surgery followed by locoregional muscle flap complex closure performed by a single plastic surgeon between January 2016 and July 2021. Patients were divided into 2 groups based on which closure method was employed. Odds ratios (ORs) and 95% confidence intervals (CIs) were computed by multivariable logistic regression with Firth's correction. RESULTS: One hundred and 10 patients with similar baseline demographics were included. There were significantly more smokers (15% vs. 0%, P = 0.02) and a significantly greater rate of postoperative radiation (40% vs. 17%, P = 0.009) in the overlapping group. After controlling for smoking and postoperative radiation, the incidence of surgical site infection, skin necrosis, dehiscence, hematoma, and seroma did not differ between the groups. The procedure length per centimeter of closure was shorter in the midline approximation group, although this data fell just short of significance (3.2 vs. 3.8 minutes/cm, P = 0.08). CONCLUSIONS: The present study demonstrates that both the overlapping and midline approximation of muscle flaps are equally safe and effective strategies for locoregional closure of spinal wounds.

Mandible Fractures Undergoing Transfer Rarely Require Acute Intervention.

Study Design: A retrospective review was conducted of all patients with mandibular fractures who were evaluated by plastic surgery at a Level I trauma center between January 1, 2017 and May 1, 2020. Data including demographic characteristics, mechanism of injury, type of presentation (e.g., primary or transfer), treatment plan, and time to intervention were recorded. Objective: Mandibular fractures are common traumatic injuries. Because these injuries are managed by surgical specialists, these patients are often emergently transferred to tertiary care hospitals. This study aims to assess the benefits of emergent transfer in this patient group. Methods: Variables were summarized using descriptive statistics. The relationship with initial disposition was assessed via tests of association, including Student's t-test, Fisher's exact test, or chi-square tests. Significance was set to p values less than 0.05. Multivariate regression analysis was conducted to determine predictors of presentation to outside hospital followed by transfer to our institution. Results: Records from 406 patients with isolated mandibular fractures were evaluated. 145 (36%) were transferred from an outside hospital specifically for specialty evaluation. One patient required intervention in the Emergency Department (ED). Of the 145 patients that were transferred to our facility, eight (5.5%) were admitted for operative management. Patients with open injuries and pediatric patients showed benefit from transfer. Conclusions: Patients are frequently transferred to tertiary care facilities for specialty service evaluation and treatment. However, when isolated mandible fractures were evaluated, only one patient required intervention in the ED. Patients with grossly open fractures and pediatric patients were more frequently admitted specifically for operative management. This practice of acute interfacility transfer represents an unnecessary cost to our health system as isolated mandible fractures can be managed on an outpatient basis. We suggest that pediatric patients and patients with open fractures be transferred for urgent evaluation and management, whereas most patients would be appropriate for outpatient evaluation.

Systematic Review of Prophylactic Plastic Surgery Closure to Prevent Postoperative Wound Complications Following Spine Surgery.

Spinal surgeries are increasingly performed in the United States, but complication rates can be unacceptably high at up to 26%. Consequently, plastic surgeons (PS) are sometimes recruited by spine surgeons (SS) for intraoperative assistance with soft tissue closures. An electronic multidatabase literature search was systematically conducted to determine whether spinal wound closure performed by PS minimizes postoperative wound healing complications when compared to closure by SS (neurosurgical or orthopedic), with the hypothesis that closures by PS minimizes incidence of complications. All published studies involving patients who underwent posterior spinal surgery with closure by PS or SS at index spine surgery were identified. Filtering by exclusion criteria identified 10 studies, 4 of which were comparative in nature and included both closures by PS and SS. Of these 4, none reported significant differences in postoperative outcomes between the groups. Across all studies, PS were involved in cases with higher baseline risk for wound complications and greater comorbidity burden. Closures by PS were significantly more likely to have had prior chemotherapy in 2 of the 4 (50%) studies (P = 0.014, P < 0.001) and radiation in 3 of the 4 (75%) studies (P < 0.001, P < 0.01, P < 0.001). In conclusion, closures by PS are frequently performed in higher risk cases, and use of PS in these closures may normalize the risk of wound complications to that of the normal risk cohort, though the overall level of evidence of the published literature is low.

A Brief Clinical Study: Consecutive Occurences of Frontal Sinus Pneumocele.

Sinus pneumocele is a rare condition marked by pathologic expansion of a paranasal sinus with concomitant bone loss. Here, we describe the case of a 24-year-old male who first presented with a 2×3 cm bony projection of his right medial forehead. Exam and history were notably absent for any skin tethering, prior trauma, inflammation, or neurological symptoms. A computed tomography scan confirmed the prominence was secondary to an enlarged right frontal sinus. The pneumocele was successfully corrected through surgery, but the patient notably developed a similar presentation on the left frontal sinus nearly 1 year later. Clinical findings support a hypothesis of air trapping through mucosal thickening. This second pneumocele was managed similarly.

Spontaneous Reossification Following Craniectomy in a Pediatric Patient.

Spontaneous reossification following a cranial defect is described by only a few case reports. A 6-month-old male with epidural hematoma underwent decompressive craniotomy, subsequently complicated by scalp abscess requiring removal of the bone flap. On serial outpatient follow-up, the patient demonstrated near-complete resolution of cranial defect over the course of 18 months, thus deferring the need for future cranioplasty. Prior articles have identified this occurrence in children and young adults; however, the present case is the first to report of this phenomenon in an infant less than 1 year of age. A brief review of the literature is provided with the proposed physiologic underpinning for the spontaneous reossification observed. While prior studies propose that recranialization is mediated by contact with the dura mater and pericranium, new investigations suggest that calvarial bone repair is also mediated by stem cells from the suture mesenchyme.

The Life Cycle of Orofacial Cleft Operations.

Patients with cleft lip and palate must undergo various surgical interventions at appropriate times to achieve optimal outcomes. While guidelines for the timing of these operations are well known, it has not yet been described if national surgical practice reflects these recommendations. This study evaluates whether orofacial operations are performed in time frames that align with advised timing. Time-to-event analyses were performed using the 2012-2020 Pediatric National Surgical Quality Improvement Program database on the ages at time of orofacial operations. Outliers with an absolute Z-score of 3.29 or greater were excluded. Cleft lip (N=9374) and palate (N=13,735) repairs occurred earliest at mean ages of 200.99±251.12 and 655.08±694.43 days, respectively. Both operations clustered along the later end of recommended timing. 69.0% of lip versus 65.1% of palate repairs were completed within the advised age periods. Cleft lip (N=2850) and palate (N=1641) revisions occurred at a mean age of 7.73±5.02 and 7.00±4.63 years, respectively. Velopharyngeal insufficiency operations (N=3026), not including palate revision, were performed at a delayed mean age of 7.58±3.98 years, with only 27.7% of operations occurring within the recommended time frame. Finally, 75.8% of alveolar bone grafting cases (N=5481) were found to happen within the advised time period, with a mean age of 10.23±2.63 years. This study suggests that, with the exception of VPI procedures, orofacial operations reliably cluster near their recommended age periods. Nevertheless, primary lip repair, palatoplasty, and velopharyngeal insufficiency procedures had a mean age that was delayed based on advised timing.

Early Outcomes of Muscle Flap Closures in Posterior Thoracolumbar Fusions: A Propensity-Matched Cohort Analysis.

BACKGROUND: Plastic surgery closure with muscle flaps after complex spinal reconstruction has become increasingly common. Existing evidence for this practice consists of small, uncontrolled, single-center cohort studies. We aimed to compare 30-day postoperative wound-related complication rates between flap closure and traditional closure after posterior thoracolumbar fusions (PTLFs) for non-infectious, non-oncologic pathologies using a national database. METHODS: We performed a propensity-matched analysis using the 2012-2020 National Surgical Quality Improvement Program dataset to compare 30-day outcomes between PTLFs with flap closure versus traditional closure. RESULTS: A total of 100,799 PTLFs met our inclusion criteria. The use of flap closure with PTLF remained low but more than doubled from 2012 to 2020 (0.38% vs. 0.97%; P = 0.002). A higher proportion of flap closures had higher American Society of Anesthesiologists classifications and higher number of operated spine levels (all P < 0.001). We included 1907 PTLFs (630 for flap closure; 1257 for traditional closure) in the propensity-matched cohort. Unadjusted 30-day wound complication rates were 1.7% for flap and 2.1% for traditional closure (P = 0.76). After adjusting for operative time, wound complication, readmission, reoperation, mortality, and non-wound complication were not associated flap use (all P > 0.05). CONCLUSIONS: Plastic surgery closure was performed in patients with a higher comorbidity burden, suggesting consultation in sicker patients. Although higher rates of wound and non-wound complications were expected for the flap cohort, our propensity-matched cohort analysis of flap closure in PTLFs resulted in non-inferior odds of wound complications compared to traditional closure. Further study is needed to assess long-term complications in prophylactic flap closure in complex spine surgeries.

A Cost-effective, 3D Printed Simulation Model Facilitates Learning of Bilobed and Banner Flaps for Mohs Nasal Reconstruction: A Pilot Study.

SUMMARY: Flap design for Mohs reconstruction is a complex 3-dimensional decision-making process. Simulation offers trainees the chance to practice techniques safely, prior to opportunities in the operating room. To aide in teaching, we developed a high-fidelity, cost-effective model of the face using three-dimensional (3D) printing to simulate flap reconstruction following Mohs surgery. We describe the design of this model and its impact on the comfort and proficiency of trainees.

Craniofacial Trauma from Electronic Scooter Use.

BACKGROUND: In 2018, the City of Providence introduced a program in which electronic scooters were deployed for public use. We aim to characterize the burden of craniofacial injuries associated with these scooters. METHODS: A retrospective review was conducted of all patients consulted to the plastic surgery service for evaluation of craniofacial injury between September 2018 and October 2022. Data pertaining to patient sociodemographics, site and time of injury, and craniofacial trauma were recorded. RESULTS: Twenty-five patients sustaining craniofacial trauma were identified over a four-year period. Most patients required soft tissue repair (64%) and bony fractures were sustained by approximately half of all patients (52%). Admission to ICU was uncommon (16%), and there were no fatalities. CONCLUSIONS: The incidence of craniofacial injury from electronic scooter use is low. However, these injuries may involve extensive surgical reconstruction and ICU admission. We advise the City of Providence to optimize best safety practices and monitoring to minimize risk.

Lateral Canthotomy Revisited: A Refined Surgical Approach for Orbital Access.

The transconjunctival incision is a common and effective approach for establishing surgical exposure to the orbital floor. When access to the lateral orbit is also required, this incision may be extended by an accompanying lateral canthotomy, which releases the tarsal plates from the conjunctiva. Although this approach broadens surgical access through a simple extension, it is often remarked for unpredictable healing patterns and negative aesthetic sequelae, such as rounding of the lateral canthal angle. Traditionally, lateral canthotomy is performed by a transverse incision through a natural skin crease of the lateral palpebral fissure. Herein, we discuss our experience with a less common approach to lateral canthotomy, in which only the inferior crus of the lateral canthal tendon is divided. This approach limits manipulation of delicate orbital anatomy and aims to minimize unsightly scarring while still affording excellent visualization of the lateral orbit and orbital floor.

Plastic Surgery Closure of Complex Spinal Wounds.

Wound breakdown and infection are common complications after complex spine surgery and may occur in up to 40% of high-risk patients. These are challenging scenarios which can result in a prolonged hospital stay, revision surgery, and elevated costs. Reconstructive specialists can do prophylactic closures for high-risk groups to potentially reduce the risk of developing a wound complication. These plastic surgery techniques often involve multilayered closure, with the addition of local muscle and/or fasciocutaneous flaps. The goal of this study was to review the literature for risks associated with wound complications, identification of high-risk patients, and the advantages of using plastic surgery techniques. In addition, we elaborate on the multilayered and flap closure technique for complex spine surgery which is done at our institution.

Operative technique for a combined transcaruncular-transconjunctival approach to double-walled orbital fractures.

Double-walled orbital fractures involving the floor and medial wall are commonly encountered in instances of significant midface trauma. Operative intervention is indicated in the presence of persistent diplopia, significant enophthalmos, or muscle entrapment. Surgical repair of these injuries may be challenging due to large fracture sizes or loss of bony supports. The transconjunctival and transcaruncular approaches have been popularized to reconstruct isolated floor and medial wall fractures, respectively. However, surgical approaches for fractures involving both these walls have not been well described in the literature. In this technical note, we detail a combined transcaruncular-transconjunctival approach that is safe, effective, and aesthetically sensitive.

Re-evaluating the Timing of Surgery after Isolated Orbital Floor Fracture.

Orbital floor fractures are among the most common facial injuries. Although urgent surgical repair may be indicated, most patients require interval follow-up to assess for symptom onset and need for definitive operative intervention. This study aimed to evaluate the time to operative indication after these injuries. Methods: A retrospective review was conducted of all patients with isolated orbital floor fractures at a tertiary academic medical center from June 2015 to April 2019. Patient demographic and clinical data were recorded from the medical record. Time until operative indication was evaluated by the Kaplan-Meier product limit method. Results: Of 307 patients meeting inclusion criteria, 9.8% (30/307) developed indications for repair. Among these, 60% (18/30) were recommended surgery on the day of initial evaluation. Of 137 follow-up patients, 8.8% (12/137) developed operative indications based on clinical evaluation. The median period to decision for surgery was 5 days (range, 1-9). No patients developed symptoms suggesting the need for surgery beyond 9 days after trauma. Conclusions: Our investigation demonstrates that only about 10% of patients presenting with isolated orbital floor fracture develop an indication for surgery. For patients undergoing interval clinical follow-up, we found that patients demonstrated symptoms within 9 days of trauma. No patients demonstrated need for surgery beyond 2 weeks of injury. We believe these findings will assist to establish standards of care and inform clinicians on the appropriate length of follow-up for these injuries.