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1.
Artículo en Inglés | MEDLINE | ID: mdl-33031774

RESUMEN

PURPOSE: To evaluate whether the distance between the mandibular occlusal plane and mandibular foramen predicts inferior alveolar nerve (IAN) position after the sagittal split osteotomy (SSO) when using a low medial horizontal osteotomy (Posnick's modification). METHODS: This was a retrospective cohort study of patients undergoing bilateral SSOs with the medial osteotomy placed at the level of the mandibular occlusal plane. The primary predictor variable was the vertical distance between the mandibular foramen and mandibular occlusal plane. The primary outcome was IAN position after SSO: contained within the proximal segment or freely entering the distal segment. Secondary predictor variables were age, gender, primary diagnosis, and type of surgery. Descriptive, bivariate, and regression statistics were computed. RESULTS: Thirty-one patients underwent 62 SSOs using a low medial cut; the sample's mean age was 19.6 ± 3.0 years, and 16 subjects were female. Twenty-three subjects had a primary diagnosis of craniofacial anomaly, and 26 subjects underwent bimaxillary surgery. The IAN was contained within the proximal segment in 28 SSOs (45.2%). The distance between the mandibular occlusal plane and mandibular foramen was greater in SSOs where the nerve was contained within the proximal segment (6.9 ± 2.5 mm) versus freely entering the distal segment (4.5 ± 2.7 mm, P < .001). A receiver-operator characteristic curve identified a threshold distance of greater than 5 mm as predictive of the IAN being contained within the proximal segment (sensitivity, 0.89; specificity, 0.85; area under the curve, 0.84; P < .001). When the mandibular foramen was greater than 5 mm above the mandibular occlusal plane, there was an increased odds of the IAN being contained within the proximal segment (odds ratio, 48.3; 95% confidence interval, 10.5, 222.8; P < .001). CONCLUSIONS: The distance between the mandibular occlusal plane and mandibular foramen predicts the position of the IAN after SSO when using a low medial horizontal osteotomy.

3.
J Oral Maxillofac Surg ; 78(10): 1813-1819, 2020 Oct.
Artículo en Inglés | MEDLINE | ID: mdl-32540322

RESUMEN

PURPOSE: Sagittal split osteotomy (SSO) of rami with fused cortices or minimal marrow space above the lingula can increase the risk of an unfavorable osteotomy split of the proximal ramus. To reduce the risk of a proximal segment fracture, a recent modification of the SSO places the medial horizontal osteotomy below the lingula. The purpose of the present study was to evaluate the outcomes of SSOs utilizing a low medial horizontal osteotomy in patients with atypical ramus morphologies. PATIENTS AND METHODS: The present study was a prospective series composed of patients with atypical proximal ramus anatomy undergoing SSOs. All patients had undergone bilateral SSO for correction of mandibular deformities. The horizontal ramus osteotomy had been placed at or slightly above the mandibular occlusal plane because of atypical ramus morphology (thin ramus with no appreciable marrow space at or above the lingula and/or narrow retromolar ramus width). The outcome variables were an unfavorable split of the proximal or distal segments, nerve location after SSO (proximal or distal segment), and neurosensory recovery of the inferior alveolar nerve (IAN). RESULTS: The sample included 25 patients who had undergone 50 SSOs using a low medial horizontal osteotomy. Their mean age was 19.6 ± 3.2 years; 14 patients were female. Of the 25 patients, 22 had a primary diagnosis of craniofacial anomaly; 23 had undergone bimaxillary surgery and 6 had received concomitant genioplasty. No unfavorable fractures of the proximal segment occurred. No intraoperative IAN injuries occurred. The IAN was contained within the proximal segment in 52% of the cases. All the patients achieved functional sensory recovery of the IAN bilaterally by 1 year postoperatively. The mean interval to functional sensory recovery was 116 days. CONCLUSIONS: The low medial horizontal osteotomy is an effective technique for reliable execution of SSOs in morphologically atypical mandibles.


Asunto(s)
Mandíbula , Nervio Mandibular , Adolescente , Adulto , Femenino , Mentoplastia , Humanos , Mandíbula/diagnóstico por imagen , Mandíbula/cirugía , Osteotomía , Osteotomía Sagital de Rama Mandibular , Estudios Prospectivos , Adulto Joven
4.
Plast Reconstr Surg ; 145(6): 1073e-1088e, 2020 06.
Artículo en Inglés | MEDLINE | ID: mdl-32459782

RESUMEN

LEARNING OBJECTIVES: After studying this article and viewing the video, the participant should be able to: 1. Compare the relative stability and neurosensory changes following mandible distraction osteogenesis with those after traditional advancement and fixation. 2. Describe the condylar changes that can occur after mandible distraction osteogenesis and list three ways to mitigate these changes. 3. Propose clinical situations where segmental or rotational movements of the midface may allow improved outcomes compared to en bloc linear distraction advancement. 4. Summarize the advantages and risks associated with anterior and posterior cranial distraction osteogenesis compared to traditional one-stage expansion. SUMMARY: Over the past 30 years, distraction forces have been applied to the spectrum of craniofacial osteotomies. It is now time to assess critically the current understanding of distraction in craniofacial surgery, identifying both traditional procedures it has replaced and those it has not. This article provides a review of comparative studies and expert opinion on the current state of craniofacial distraction compared with traditional operations. Through this critical evaluation, the reader will be able to identify when distraction techniques are appropriate, when traditional techniques are more favorable, and what the future of distraction osteogenesis is.


Asunto(s)
Maloclusión de Angle Clase II/cirugía , Mandíbula/cirugía , Avance Mandibular/métodos , Osteogénesis por Distracción/métodos , Predicción , Historia del Siglo XX , Historia del Siglo XXI , Humanos , Avance Mandibular/tendencias , Modelos Animales , Osteogénesis por Distracción/historia , Osteogénesis por Distracción/tendencias , Selección de Paciente
5.
Plast Reconstr Surg ; 145(5): 1262-1265, 2020 05.
Artículo en Inglés | MEDLINE | ID: mdl-32332550

RESUMEN

The Le Fort I osteotomy is a versatile operation for correction of developmental, congenital, and posttraumatic deformities of the lower midface. One of the challenges of the osteotomy is pterygomaxillary separation, with the potential for unfavorable fractures to the orbit/skull base or vascular injury. A modified technique for pterygomaxillary disjunction is the transmucosal tuberosity osteotomy. The authors have used this technique for pterygomaxillary separation in 200 consecutive Le Fort I osteotomies over a 3-year period (2014 to 2017). There were no episodes of unfavorable propagation to the skull base or orbit, oroantral or oronasal fistulae, excessive bleeding/vessel injuries, or vascular insufficiency to the maxilla. The transmucosal tuberosity approach is a reliable and safe method of performing the pterygomaxillary separation during the Le Fort I osteotomy.


Asunto(s)
Maxilar/anomalías , Osteotomía Le Fort/métodos , Humanos , Maxilar/cirugía , Osteotomía Le Fort/efectos adversos , Osteotomía Le Fort/instrumentación , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/etiología
6.
J Oral Maxillofac Surg ; 78(8): 1382-1388, 2020 Aug.
Artículo en Inglés | MEDLINE | ID: mdl-32283076

RESUMEN

PURPOSE: When the inferior alveolar nerve (IAN) is contained within the proximal segment after a mandibular sagittal split osteotomy (SSO), conventional teaching is to release the nerve so that it freely enters the distal segment. However, manipulation of the IAN may cause further injury. The purpose of this study was to measure IAN neurosensory recovery in SSOs when the nerve was not freed from the proximal segment. MATERIALS AND METHODS: This was a prospective split-mouth study of patients undergoing bilateral sagittal split osteotomy (BSSO). The sample was composed of patients who underwent a BSSO in which the IAN was intact bilaterally but freely entering the distal segment on one side (IANDI) and contained within the proximal segment on the other (IANPR). The outcome of interest was time to functional sensory recovery (FSR) of the IAN, measured in days. Descriptive, bivariate, and Kaplan-Meier statistics were computed. P ≤ .05 was considered statistically significant. RESULTS: Twenty patients undergoing 40 SSOs were included as study patients. The sample's mean age was 19.0 ± 2.4 years (range, 15 to 26 years); there were 13 female patients. Of these patients, 15 underwent BSSO whereas 5 underwent BSSO plus genioplasty. The planned mean composite 3-dimensional mandibular movements for IANDI and IANPR were 6.3 ± 2.8 mm (range, 2.5 to 12.3 mm) and 6.3 ± 2.3 mm (range, 2.7 to 10.8 mm), respectively (P = .96). All patients achieved FSR in the bilateral IAN distributions within 1 year of surgery (range, 34 to 284 days). The median times to FSR were 100 days for IANDI and 101 days for IANPR (P = .64). CONCLUSIONS: In patients undergoing SSOs, maintaining the IAN within the proximal segment of the mandible may not affect neurosensory recovery.


Asunto(s)
Traumatismos del Nervio Trigémino/etiología , Adolescente , Adulto , Femenino , Humanos , Mandíbula/cirugía , Nervio Mandibular , Osteotomía , Osteotomía Sagital de Rama Mandibular , Estudios Prospectivos , Adulto Joven
7.
Ann Plast Surg ; 85(5): 546-552, 2020 11.
Artículo en Inglés | MEDLINE | ID: mdl-32187064

RESUMEN

BACKGROUND: Radiation therapy (XRT) induced dermal injury disrupts type I collagen architecture. This impairs cutaneous viscoelasticity, which may contribute to the high rate of complications in expander-based breast reconstruction with adjuvant XRT. The objective of this study was to further elucidate the mechanism of radiation-induced dermal injury and to determine if amifostine (AMF) or deferoxamine (DFO) mitigates type I collagen injury in an irradiated murine model of expander-based breast reconstruction. METHODS: Female Lewis rats (n = 20) were grouped: expander (control), expander-XRT (XRT), expander-XRT-AMF (AMF), and expander-XRT-DFO (DFO). Expanders were surgically placed. All XRT groups received 28 Gy of XRT. The AMF group received AMF 30 minutes before XRT, and the DFO group used a patch for delivery 5 days post-XRT. After a 20-day recovery period, skin was harvested. Atomic force microscopy and Raman spectroscopy were performed to evaluate type I collagen sheet organization and tissue compositional properties, respectively. RESULTS: Type I collagen fibril disorganization was significantly increased in the XRT group compared with the control (83.8% vs 22.4%; P = 0.001). Collagen/matrix ratios were greatly reduced in the XRT group compared with the control group (0.49 ± 0.09 vs 0.66 ± 0.09; P = 0.017). Prophylactic AMF demonstrated a marked reduction in type I collagen fibril disorganization on atomic force microscopy (15.9% vs 83.8%; P = 0.001). In fact, AMF normalized type I collagen organization in irradiated tissues to the level of the nonirradiated control (P = 0.122). Based on Raman spectroscopy, both AMF and DFO demonstrated significant differential protective effects on expanded-irradiated tissues. Collagen/matrix ratios were significantly preserved in the AMF group compared with the XRT group (0.49 ± 0.09 vs 0.69 ± 0.10; P = 0.010). ß-Sheet/α-helix ratios were significantly increased in the DFO group compared with the XRT group (1.76 ± 0.03 vs 1.86 ± 0.06; P = 0.038). CONCLUSIONS: Amifostine resulted in a significant improvement in type I collagen fibril organization and collagen synthesis, whereas DFO mitigated abnormal changes in collagen secondary structure in an irradiated murine model of expander-based breast reconstruction. These therapeutics offer the ability to retain the native microarchitecture of type I collagen after radiation. Amifostine and DFO may offer clinical utility to reduce radiation induced dermal injury, potentially decreasing the high complication rate of expander-based breast reconstruction with adjuvant XRT and improving surgical outcomes.

9.
Plast Reconstr Surg ; 144(3): 696-701, 2019 09.
Artículo en Inglés | MEDLINE | ID: mdl-31461031

RESUMEN

BACKGROUND: Ocular abnormalities in craniosynostosis are a persistent concern for patients and providers, and some surgeons feel that early surgical intervention for synostosis alleviates the progression of ophthalmologic abnormalities. In contradistinction, the authors hypothesize that operating early will have no bearing on postoperative ophthalmologic outcomes. METHODS: Single-suture craniosynostosis patients who underwent surgical correction between 1989 and 2015 were reviewed. Patients with multisuture craniosynostosis, syndromic diagnoses, no preoperative ophthalmology evaluation, and less than 2 years of follow-up were excluded. Logistic regression was used to determine odds of preoperative and postoperative ophthalmologic abnormalities by age, while controlling for patient-level covariates. RESULTS: One hundred seventy-two patients met inclusion criteria. The median age at surgery was 10 months (interquartile range, 7 to 12.9 months). Increasing age at the time of surgery was associated with increased odds of preoperative ophthalmologic diagnoses (OR, 1.06; p = 0.037) but not postoperative diagnoses (OR, 1.00; p = 0.91). Increasing age at surgery was also not associated with increased odds of ophthalmologic diagnoses, regardless of timing (OR, 1.04; p = 0.08). Patients with coronal synostosis (OR, 3.94; p = 0.036) had significantly higher odds of preoperative ophthalmologic diagnoses. Patients with metopic (OR, 5.60; p < 0.001) and coronal (OR, 7.13; p < 0.001) synostosis had significantly higher odds of postoperative ophthalmologic diagnoses. CONCLUSIONS: After reviewing an expansive cohort, associations of both overall and postoperative ophthalmologic diagnoses with age at surgery were not found. The authors' findings thus run counter to the theory that early surgical intervention lessens the likelihood of postoperative ophthalmologic diagnoses and improves ophthalmologic outcomes. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.


Asunto(s)
Craneosinostosis/cirugía , Anomalías del Ojo/cirugía , Oftalmopatías/etiología , Factores de Edad , Craneosinostosis/complicaciones , Femenino , Humanos , Lactante , Modelos Logísticos , Masculino , Estudios Retrospectivos , Factores de Riesgo
10.
J Craniofac Surg ; 30(2): 429-432, 2019.
Artículo en Inglés | MEDLINE | ID: mdl-30640849

RESUMEN

BACKGROUND: A longstanding dictum exists to avoid surgical manipulation of the temporalis muscle out of concern for an exceedingly high rate of muscle atrophy and recurrent temporal hollowing. The authors challenge this surgical myth, considering such advice to be erroneous. The authors hypothesize that elevation of the temporalis muscle, if performed using standard muscle flap principles, will demonstrate excellent results. METHODS: To assess temporalis response to surgical manipulation, the authors reviewed patients who underwent calvarial vault remodeling by the senior author for craniosynostosis between 1988 and 2011. Nonsyndromic patients with single-suture synostosis and 5 years of follow-up were eligible for inclusion. The medical record was used to measure rates of reoperation, recurrent temporal hollowing, and persistent temporalis overcorrection. RESULTS: Of the cohort reviewed, 196 patients met inclusion criteria. Ten patients (5.1%) exhibited recurrent bitemporal constriction. One patient (0.5%) underwent a revision temporalis turnover flap, and 2 patients (1.0%) underwent soft tissue augmentation. The overall reoperation rate was 1.5%. Temporalis overcorrection, in an attempt to prophylactically rectify the expected atrophy after temporalis manipulation, persisted in 11 patients (5.6%). Three of these patients required treatment with steroid injections, Botox injections, or operative muscle debulking. The overall reoperation rate for temporalis overcorrection was 1.5%. CONCLUSIONS: The authors' low reoperation rates for recurrent deformity, in combination with persistent temporalis overcorrection in 5.6% of patients, should dispel the myth that manipulation of the temporalis invariably results in atrophy. The muscle may be surgically manipulated, as long as plastic surgery principles are followed.


Asunto(s)
Craneosinostosis/cirugía , Atrofia Muscular , Complicaciones Posoperatorias , Procedimientos Quirúrgicos Reconstructivos , Reoperación , Músculo Temporal , Femenino , Humanos , Masculino , Persona de Mediana Edad , Atrofia Muscular/etiología , Atrofia Muscular/cirugía , Evaluación de Procesos y Resultados en Atención de Salud , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/patología , Complicaciones Posoperatorias/cirugía , Procedimientos Quirúrgicos Reconstructivos/efectos adversos , Procedimientos Quirúrgicos Reconstructivos/métodos , Reoperación/métodos , Reoperación/estadística & datos numéricos , Estudios Retrospectivos , Colgajos Quirúrgicos/cirugía , Músculo Temporal/patología , Músculo Temporal/cirugía
11.
J Craniofac Surg ; 30(2): 611-617, 2019.
Artículo en Inglés | MEDLINE | ID: mdl-30531286

RESUMEN

Nonvascularized bone grafts (NBGs) represent a practical method of mandibular reconstruction that is precluded in head and neck cancer patients by the destructive effects of radiotherapy. Advances in tissue-engineering may restore NBGs as a viable surgical technique, but expeditious translation demands a small-animal model that approximates clinical practice. This study establishes a murine model of irradiated mandibular reconstruction using a segmental iliac crest NBG for the investigation of imperative bone healing strategies. Twenty-seven male isogenic Lewis rats were divided into 2 groups; control bone graft and irradiated bone graft (XBG). Additional Lewis rats served as graft donors. The XBG group was administered a fractionated dose of 35Gy. All rats underwent reconstruction of a segmental, critical-sized defect of the left hemi-mandible with a 5 mm NBG from the iliac crest, secured by a custom radiolucent plate. Following a 60-day recovery period, hemi-mandibles were evaluated for bony union, bone mineralization, and biomechanical strength (P < 0.05). Bony union rates were significantly reduced in the XBG group (42%) compared with controls (80%). Mandibles in the XBG group further demonstrated substantial radiation injury through significant reductions in all metrics of bone mineralization and biomechanical strength. These observations are consistent with the clinical sequelae of radiotherapy that limit NBGs to nonirradiated patients. This investigation provides a clinically relevant, quantitative model in which innovations in tissue engineering may be evaluated in the setting of radiotherapy to ultimately provide the advantages of NBGs to head and neck cancer patients and reconstructive surgeons.


Asunto(s)
Trasplante Óseo/métodos , Mandíbula/cirugía , Procedimientos Quirúrgicos Reconstructivos/métodos , Animales , Calcificación Fisiológica , Modelos Animales de Enfermedad , Neoplasias de Cabeza y Cuello/cirugía , Masculino , Ratas
12.
Ann Plast Surg ; 81(5): 604-608, 2018 11.
Artículo en Inglés | MEDLINE | ID: mdl-30113984

RESUMEN

BACKGROUND: Breast cancer is most commonly managed with a combination of tumor ablation, radiation, and/or chemotherapy. Despite the oncologic benefit of these treatments, the detrimental effect of radiation on surrounding tissue challenges the attainment of ideal breast reconstruction outcomes. The purpose of this study was to determine the ability of topical deferoxamine (DFO) to reduce cutaneous ulceration and collagen disorganization following radiotherapy in a murine model of expander-based breast reconstruction. METHODS: Female Sprague-Dawley rats (n = 15) were divided into 3 groups: control (expander), XRT (expander + radiation), and DFO (expander + radiation + deferoxamine [DFO]). Expanders were placed in a submusculocutaneous plane in the right upper back and ultimately filled to 15 mL. Radiation was administered via a fractionated dose of 28 Gy. Deferoxamine was delivered topically for 10 days following radiation. After a 20-day recovery period, skin ulceration and dermal type I collagen organization were analyzed. RESULTS: Compared with control, the XRT group demonstrated a significant increase in skin ulceration (3.7% vs 43.3%, P = 0.00) and collagen fibril disorganization (26.3% vs 81.8%, P = 0.00). Compared with the XRT group, treatment with topical DFO resulted in a significant reduction in ulceration (43.3% vs 7.0%, P = 0.00) and fibril disorganization (81.8% vs 15.3%, P = 0.00). There were no statistical differences between the control and DFO groups in skin ulceration or collagen disorganization. CONCLUSIONS: This study suggests topical DFO is capable of reducing skin ulceration and type I collagen fibril disorganization following radiotherapy. This novel application of DFO has potential to enhance expander-based breast reconstruction outcomes and improve quality of life for women suffering the devastating effects of breast cancer.


Asunto(s)
Dorso/cirugía , Deferoxamina/administración & dosificación , Deferoxamina/farmacología , Piel/efectos de los fármacos , Piel/efectos de la radiación , Administración Tópica , Animales , Modelos Animales de Enfermedad , Femenino , Microscopía de Fuerza Atómica , Distribución Aleatoria , Ratas , Ratas Sprague-Dawley , Dispositivos de Expansión Tisular
13.
Cleft Palate Craniofac J ; 55(3): 430-436, 2018 03.
Artículo en Inglés | MEDLINE | ID: mdl-29437520

RESUMEN

BACKGROUND: Submucous cleft palate (SMCP) is the most common form of cleft involving the posterior palate, resulting in variable degrees of velar dysfunction and speech disturbance. Although early surgical intervention is indicated for patients with true cleft palate, the indications for palatoplasty and timing of surgical intervention for patients with SMCP remain controversial. METHODS: Twenty-nine patients with SMCP were retrospectively reviewed. Patients treated with Furlow palatoplasty were dichotomized based on patient age at the time of surgical correction into early speech development and late speech development. Primary outcome measures included standardized assessments of hypernasal resonance and quantitative pre- and postoperative nasometry scores. Patients managed nonoperatively were included for comparison of early and late speech outcomes. RESULTS: Both early and late groups demonstrated improvement in qualitative assessment of hypernasal resonance following Furlow palatoplasty. Early and late groups also had significant improvement in pre- to postoperative nasometry scores from 7.4 to 2.3 SD from norm ( P = .01) and 6.0 to 3.6 SD from norm ( P = .02), respectively. There was no difference in postoperative nasometry scores between early and late groups, 2.3 and 3.6 SD ( P = .12). CONCLUSION: Furlow palatoplasty significantly improves the degree of hypernasality in patients with SMCP based on pre- and postoperative nasometry scores and on qualitative assessment of hypernasality. There were no differences in speech outcomes based on early compared with late operative intervention. Therefore, early palatal repair is not obligatory for optimal speech outcomes in children with SMCP and palatoplasty should be deferred until the emergence of overt velopharyngeal insufficiency.


Asunto(s)
Fisura del Paladar/cirugía , Procedimientos Quirúrgicos Reconstructivos/métodos , Niño , Preescolar , Comorbilidad , Femenino , Humanos , Lactante , Tiempo de Internación/estadística & datos numéricos , Masculino , Michigan , Complicaciones Posoperatorias , Estudios Retrospectivos , Inteligibilidad del Habla , Factores de Tiempo , Resultado del Tratamiento
14.
J Plast Reconstr Aesthet Surg ; 70(7): 865-870, 2017 Jul.
Artículo en Inglés | MEDLINE | ID: mdl-28478892

RESUMEN

BACKGROUND: Implant infections in the setting of breast reconstruction present a significant setback for patients with breast cancer. Traditional management of implant infections is predicated on the operative removal of the implant and delayed replacement. Another option for implant infection management has emerged in which the soft tissue infection is neutralized, the implant is removed, the surgical site is washed out, and a new implant replaced immediately. In this study, we present our findings with the implementation of this technique and an algorithm for choosing which patients are the most appropriate candidates on the basis of a retrospective review. METHODS: A retrospective chart review of patients who underwent operative removal of infected expanders from January 1, 2010 to December 31, 2015 was performed at the University of Michigan by the senior authors. The final reconstructive outcome, time to reconstruction, and infection recurrence were evaluated. RESULTS: Twenty patients with clinical signs of implant infections were identified. Of them, 16 patients with clinical signs of implant infection underwent immediate implant exchange; 15 remained infection free, while 1 patient developed recurrent infection within a month, which was treated with device removal. The mean time to final reconstruction in the 15 infection free patients was 207 days, and the 4 patients who underwent removal without immediate replacement had a 75% rate of non-completion at over 500 days. CONCLUSIONS: Our findings demonstrate that immediate implant exchange safely offers patients the opportunity to remain on a path toward reconstruction. These findings offer support for a paradigm shift in our management of implant infections in breast reconstruction patients who already face challenges associated with breast cancer care.


Asunto(s)
Implantación de Mama/métodos , Implantes de Mama , Remoción de Dispositivos , Infecciones/cirugía , Mamoplastia/efectos adversos , Mamoplastia/métodos , Selección de Paciente , Enfermedad Aguda , Adulto , Anciano , Algoritmos , Femenino , Humanos , Infecciones/etiología , Persona de Mediana Edad , Reoperación , Estudios Retrospectivos , Factores de Tiempo
15.
Eplasty ; 16: e5, 2016.
Artículo en Inglés | MEDLINE | ID: mdl-26816558

RESUMEN

OBJECTIVE: Lumpectomy may result in contour deformities or breast asymmetry in women with breast cancer and macromastia. This study investigates the use of bilateral reduction mammaplasty, with the tumor and margins included within the reduction specimen. METHODS: Twenty-four patients who underwent lumpectomy with immediate bilateral reduction mammaplasty for unilateral breast cancer were included. Patient medical records were reviewed for demographic, oncological, and surgical characteristics. RESULTS: Mean patient age was 57 years, and mean body mass index was 32.2 kg/m(2). Mean tumor size was 1.7 cm. All tumor margins were free of neoplastic involvement. No difference was noted between the ipsilateral and contralateral resection weights (P = .81). Adjuvant radiation therapy was delivered to 21 patients (88%). There were no significant differences in postoperative total (P = .36), major (P = .44), or minor (P = .71) complications between the tumor and nontumor sides. Only 1 patient required additional revision surgery following the initial lumpectomy with bilateral reduction mammaplasty. CONCLUSION: Lumpectomy with bilateral reduction mammaplasty did not compromise surgical margins. Lumpectomy with bilateral reduction mammaplasty may allow for adequate surgical treatment of breast cancer while avoiding significant breast asymmetry in women with macromastia.

16.
J Craniofac Surg ; 23(7 Suppl 1): 1974-6, 2012 Nov.
Artículo en Inglés | MEDLINE | ID: mdl-23154358

RESUMEN

INTRODUCTION: In patients who require additional surgery for velopharyngeal insufficiency (VPI), a higher incidence of obstructive sleep apnea (OSA) may be incurred. Although this phenomenon has been demonstrated with the posterior pharyngeal flap, the effect of dynamic sphincter pharyngoplasty (DSP) on OSA is less clear. The purposes of this case series were to (1) determine the incidence of OSA after DSP, (2) assess the changes in polysomnography after DSP, and (3) identify risk factors for the development of OSA after DSP. Our global hypothesis is that OSA and VPI exist on a continuum and that speech outcomes should not be considered in isolation. METHODS: For a 13-year period, 146 patients with idiopathic VPI, submucous cleft palate, cleft palate only, or cleft lip and palate underwent DSP for VPI. The diagnosis of OSA was defined as the prescription of continuous positive airway pressure therapy by a pediatric sleep medicine physician. The incidence of OSA preoperatively and postoperatively was compared using Fisher exact test. When available, preoperative and postoperative apnea-hypopnea indices (AHIs) were compared using the pairwise, 2-tailed, Student's t-test. Patient factors, such as obesity (body mass index ≥ 95th percentile), the presence of a craniofacial syndrome, surgical history, and a preexisting OSA diagnosis, were noted. A multiple logistic regression was performed to elucidate risk factors for the development of OSA. RESULTS: The average age at surgery was 9.2 years (range, 4-40 y), and the mean follow-up time was 4.5 years (range, 1 mo to 12 y). The incidence of OSA increased after DSP, from 2 to 33 patients (1.4%-22%, respectively; P = 0.05). In 23 patients (16%), both preoperative and postoperative AHIs were available. There was a significant increase in AHI after DSP, from 3.1 to 8.4 episodes per hour of sleep (P = 0.001). Previous tonsillectomy/adenoidectomy was predictive of OSA after DSP (relative risk = 2.4; P = 0.04). CONCLUSIONS: We report an increased incidence of OSA and higher-than-average AHIs postoperatively after DSP. Preoperative tonsillectomy/adenoidectomy predicted the development of OSA after DSP. A high index of suspicion for development of OSA must be maintained in patients who undergo secondary speech operations for VPI. Clinical screening for OSA should be used in this population, with a low threshold for polysomnographic evaluation. The surgeon must be wary that improvements in speech after DSP may change airway dynamics and increase the risk of OSA.


Asunto(s)
Faringe/cirugía , Complicaciones Posoperatorias/epidemiología , Procedimientos Quirúrgicos Reconstructivos/estadística & datos numéricos , Apnea Obstructiva del Sueño/epidemiología , Adenoidectomía/estadística & datos numéricos , Adolescente , Adulto , Índice de Masa Corporal , Niño , Preescolar , Labio Leporino/cirugía , Fisura del Paladar/cirugía , Presión de las Vías Aéreas Positiva Contínua/estadística & datos numéricos , Anomalías Craneofaciales/epidemiología , Femenino , Estudios de Seguimiento , Humanos , Incidencia , Masculino , Michigan/epidemiología , Obesidad/epidemiología , Polisomnografía , Estudios Retrospectivos , Factores de Riesgo , Tonsilectomía/estadística & datos numéricos , Insuficiencia Velofaríngea/cirugía , Adulto Joven
17.
Plast Reconstr Surg ; 127(4): 1612-9, 2011 Apr.
Artículo en Inglés | MEDLINE | ID: mdl-21460667

RESUMEN

BACKGROUND: Distraction advancement has been advocated for treatment of obstructive sleep apnea associated with congenital midface hypoplasia. The purpose of this study was to relate changes in maxillary position to changes in obstructive sleep apnea measures on polysomnography in a consecutive series of patients. METHODS: Among 26 syndromic pediatric patients undergoing Le Fort III distraction over a 5-year period, 15 had documented obstructive sleep apnea with an apnea hypopnea index greater than 5. Linear and angular displacement of key bone landmarks were measured using quantitative computed tomographic scan analysis before and after distraction. Differences of linear and angular movements of maxillary landmarks were tested between those patients with improvement of obstructive sleep apnea (apnea hypopnea index <5) after treatment, and those with no improvement. RESULTS: Mean postoperative apnea hypopnea index was 9.5 (range, 2.1 to 22.7). Eight patients had a decrease in apnea hypopnea index following distraction (improved group) and three additional patients had resolution of symptoms but declined postoperation polysomnography. Four had no improvement or worsening of apnea hypopnea index (no improvement group). Comparison of changes in maxillary position between the improved group and the no improvement group revealed no significant difference in magnitude or direction of linear displacement of key landmarks. Postdistraction change in sella-nasion-point A angle was the only measure significantly (p = 0.02) greater in the improved group. CONCLUSIONS: Based on the authors' comparison of quantitative bone measurements and associated polysomnography changes, an angular increase in sella-nasion-point A angle on presurgical planning of maxillary movement for the treatment of sleep apnea may be more important than absolute linear changes in maxillary position alone.


Asunto(s)
Disostosis Craneofacial/complicaciones , Disostosis Craneofacial/diagnóstico por imagen , Maxilar/cirugía , Osteogénesis por Distracción , Osteotomía Le Fort , Polisomnografía , Apnea Obstructiva del Sueño/cirugía , Tomografía Computarizada por Rayos X , Adolescente , Niño , Preescolar , Disostosis Craneofacial/cirugía , Humanos , Maxilar/diagnóstico por imagen , Apnea Obstructiva del Sueño/etiología , Apnea Obstructiva del Sueño/fisiopatología
18.
Plast Reconstr Surg ; 126(5): 1665-74, 2010 Nov.
Artículo en Inglés | MEDLINE | ID: mdl-21042122

RESUMEN

BACKGROUND: Le Fort III distraction requires generation of bone in the pterygomaxillary region. The authors performed retrospective digital analysis on temporal fine-cut computed tomographic images to quantify both radiographic evidence of pterygomaxillary region bone formation and relative maxillary stability. METHODS: Fifteen patients with syndromic midface hypoplasia were included in the study. The average age of the patients was 8.7 years; 11 had either Crouzon or Apert syndrome. The average displacement of the maxilla during distraction was 16.2 mm (range, 7 to 31 mm). Digital analysis was performed on fine-cut computed tomographic scans before surgery, at device removal, and at annual follow-up. Seven patients also had mid-consolidation computed tomographic scans. Relative maxillary stability and density of radiographic bone in the pterygomaxillary region were calculated between each scan. RESULTS: There was no evidence of clinically significant maxillary relapse, rotation, or growth between the end of consolidation and 1-year follow-up, other than a relatively small 2-mm subnasal maxillary vertical growth. There was an average radiographic ossification of 0.5 mm/mm advancement at the time of device removal, with a 25th percentile value of 0.3 mm/mm. The time during consolidation that each patient reached the 25th percentile of pterygomaxillary region bone density observed in this series of clinically stable advancements ranged from 1.3 to 9.8 weeks (average, 3.7 weeks). CONCLUSIONS: There was high variability in the amount of bone formed in the pterygomaxillary region associated with clinical stability of the advanced Le Fort III segment. These data suggest that a subsection of patients generate the minimal amount of pterygomaxillary region bone formation associated with advancement stability as early as 4 weeks into consolidation.


Asunto(s)
Maxilar/diagnóstico por imagen , Maxilar/cirugía , Anomalías Maxilofaciales/cirugía , Osteogénesis por Distracción , Osteogénesis , Osteotomía Le Fort , Acrocefalosindactilia/diagnóstico por imagen , Acrocefalosindactilia/cirugía , Adolescente , Niño , Preescolar , Disostosis Craneofacial/diagnóstico por imagen , Disostosis Craneofacial/cirugía , Humanos , Anomalías Maxilofaciales/diagnóstico por imagen , Tomografía Computarizada por Rayos X
19.
Neuroreport ; 19(7): 757-60, 2008 May 07.
Artículo en Inglés | MEDLINE | ID: mdl-18418252

RESUMEN

Microglial cells are the innate immune cells of the central nervous system and quickly respond to injury by proliferation, cytokine release, and increased cell surface antigen expression. Thrombin is a multifunctional serine proteinase, which has the capability to activate microglial cells. Here, we report that pharmaceutical-grade thrombin dose-dependently increases the expression of CD40 in N9 microglial cells. This effect is blocked by a thrombin inhibitor, mimicked by thrombin receptor-activating peptide and modified by mitogen-activated protein kinase pathway inhibitors. Thrombin-induced CD40 regulation might play a role in diseases with breakdown of the blood-brain barrier such as multiple sclerosis or stroke.


Asunto(s)
Antígenos CD40/biosíntesis , Microglía/metabolismo , Trombina/metabolismo , Animales , Células Cultivadas , Citometría de Flujo , Sistema de Señalización de MAP Quinasas/fisiología , Ratones
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