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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.

2.
Arch Plast Surg ; 47(5): 483-486, 2020 Sep.
Artículo en Inglés | MEDLINE | ID: mdl-32971601

RESUMEN

Midline clefts of the upper lip are rare, and it is therefore important that surgeons have access to a methodical approach for when these presentations are encountered. We adapted principles of the anatomic subunit approximation for unilateral cleft lip, to the repair of midline clefts. The overt use of anatomic landmarks to define the repair results in a design that inherently adjusts to varying degrees of clefts and can accommodate asymmetries. The "measure twice, cut once" style is an advantage to new surgeons and to surgeons who seldom encounter this presentation. We describe the details of surgical repair in the context of a patient with Pai syndrome and associated nasal hamartomas that resulted in nasolabial asymmetry. This is the first report of surgical outcome following treatment of Pai syndrome and includes early and 5-year follow-up. The system of repair that we describe is applicable to both symmetric and asymmetric midline clefts.

3.
Ann Surg ; 2020 Sep 15.
Artículo en Inglés | MEDLINE | ID: mdl-32941269

RESUMEN

OBJECTIVE: In this study, the extent of racial diversity in images of breast-related plastic surgery published literature was investigated to better understand disparities that exist in breast surgery. BACKGROUND: The lack of racial diversity in images of skin color in surgery literature can perpetuate implicit bias and stereotypes. Implicit bias can affect the way patients are evaluated, diagnosed, and treated. The visual aspects of plastic surgery make a lack of diversity in imagery especially impactful on patient care and outcomes. METHODS: Published medical images and graphics depicting human skin were analyzed across four major plastic surgery journals. Up to four years were chosen a priori to evaluate from each journal and represented the initial year of color image publication, the year of study initiation (2016), and representative years for a given decade (2000 and 2010). Images and graphics were tabulated, rated by Fitzpatrick scale and categorized into "white" or "non-white". Data were evaluated with pair-wise and linear regression statistics. RESULTS: Of the 2774 images and 353 graphics that met inclusion criteria, only 184 (8.18%) images and 9 graphics (6.34%) depicted non-white skin. Temporal analysis showed that there is an increased diversity of images published since 2010 with 0% of images being non-white prior to and 7.3%-10.3% after 2010. International and multi-national authors tended to publish more non-white images. CONCLUSIONS: There is insufficient racial diversity visually represented in the breast-related plastic surgery literature with a small degree of progress made towards more equitable imagery over time. Increasing awareness of image content, and the need for equitable visual representation may allow for improved racial diversity in surgical literature.

5.
Plast Reconstr Surg Glob Open ; 7(12): e2563, 2019 Dec.
Artículo en Inglés | MEDLINE | ID: mdl-32042543

RESUMEN

Background: Racial disparities exist in the accessibility, delivery, and quality of healthcare. Clinical images are central to plastic surgery, but choice of images in the literature is susceptible to implicit biases. The objective of this study was to determine if published images reflect the racial demographic of patients. Methods: A search for color photographs and rendered graphics depicting human skin was completed in 6 plastic surgery journals and the New England Journal of Medicine Images in Clinical Medicine for each decade between 1992 and 2017. For each article, images were categorized as white or nonwhite based on Fitzpatrick Scale (1-3 versus 4-6). Additionally, the authors' geographic region was documented. Proportional data and average number of nonwhite images per article were compared. Regression analyses were performed to assess the correlation of time and geographic region on nonwhite images. Results: In total, 24,209 color photographs and 1,671 color graphics were analyzed. In plastic surgery journals, 22% of photographs were nonwhite and the average number of photographs per article with white skin was 5.4 compared with 1.6 with nonwhite skin (P < 0.0001). There was a significant increase in nonwhite photographs over time (r = 0.086, P < 0.001) and association of nonwhite photographs with international authors (r = 0.12, P < 0.001). Conclusions: Roughly 60%-70% of the world population and 30% of US cosmetic patients are nonwhite. Images in plastic surgery literature reflect neither racial demographics by global region nor the patient population seeking surgery. To advance equitable care, images should better represent the racial composition of the populations served.

6.
J Craniofac Surg ; 29(3): 547-552, 2018 May.
Artículo en Inglés | MEDLINE | ID: mdl-29438208

RESUMEN

BACKGROUND: Cranial vault reconstruction (CVR) is the gold standard in the operative treatment of craniosynostosis. Full thickness osseous defects (FTOD) of the calvaria have been observed in 5% to 15% patients after CVR, with higher rates cited in the fronto-orbital advancement (FOA) subset. Particulate bone graft (PBG) harvested manually has been shown to decrease FTOD after FOA from 24% to 5.5%. The authors used a modified technique using a powered craniotome, with the hypothesis that the technique would also improve outcomes. METHODS: A retrospective review was performed of patients who underwent CVR for craniosynostosis between 2004 and 2014. Patient demographics, diagnosis, age, operative details, and postoperative care were reviewed in detail. Categorical, nonparametric variables were compared by Fisher exact tests. RESULTS: A total of 135 patients met inclusion criteria. The most common diagnoses were metopic (n = 41), sagittal (n = 33), and unilateral coronal craniosynostosis (n = 31); 65% (n = 88) underwent FOA, 29% (n = 39) underwent single-stage total vault reconstruction, and 6% (n = 8) had a posterior vault reconstruction. CVR was performed without PBG in 95 patients and with PBG in 40 patients. Without PBG, FTOD were discovered on clinical examination in 18% of patients (n=17): 11 presented with subcentimeter defects, while 6 had larger defects requiring revision cranioplasty (6% operative revision rate). Among those receiving PBG, 1 patient presented a subcentimeter FTOD (2.5% FTOD incidence and 0% operative revision rate). CONCLUSION: Particulate bone graft harvested with a powered device decreases the rate of FTOD and reoperation rate after CVR for craniosynostosis.


Asunto(s)
Trasplante Óseo/métodos , Craneosinostosis/cirugía , Craneotomía/instrumentación , Procedimientos Quirúrgicos Reconstructivos/métodos , Cráneo/cirugía , Trasplante Óseo/instrumentación , Preescolar , Femenino , Humanos , Lactante , Masculino , Complicaciones Posoperatorias/prevención & control , Procedimientos Quirúrgicos Reconstructivos/instrumentación , Reoperación , Estudios Retrospectivos , Cráneo/patología
7.
J Pediatr ; 186: 165-171.e2, 2017 07.
Artículo en Inglés | MEDLINE | ID: mdl-28456388

RESUMEN

OBJECTIVE: To assess the impact of age at referral on treatment options in craniosynostosis and to identify risk factors for referral delays in this population. STUDY DESIGN: A retrospective cohort study was performed on patients with an abnormal head shape diagnosis treated at a single academic medical center between January 1, 2004 and January 1, 2014. Newly diagnosed patients with craniosynostosis were identified and referral patterns were examined. A multivariate logistic regression model was used to identify risk factors associated with the range of ages at initial referral. RESULTS: A total of 477 patients were evaluated at our institution, 197 of whom were subsequently diagnosed with craniosynostosis. The median age at initial appointment was 5.6 months (mean 8.2 months). Only 28% of children were referred within 3 months of birth. Patients referred within 3 months of birth were less likely to have had preappointment imaging than those patients referred slightly later (OR 2.53, CI 1.07-5.98, P = .035). Several variables were associated with referral after 12 months of age including multiple suture involvement (OR 4.21, CI 1.06-16.68, P = .041), minority race (OR 4.96, CI 1.91-12.9, P ≤ .0001), and referral by a nonpediatrician (OR 6.9, CI 1.73-27.49, P = .006). CONCLUSIONS: Obtaining imaging before referral to a specialist for abnormal head shape was associated with a delay in evaluation and potentially increases radiation exposure and limits treatment options in patients with craniosynostosis. In addition, children from minority groups, children referred from someone other than a pediatrician's office, and those with multiple suture craniosynostosis are at increased risk of delayed referral. Further studies into the cause of these delays are warranted.


Asunto(s)
Craneosinostosis/diagnóstico , Craneosinostosis/terapia , Derivación y Consulta , Especialidades Quirúrgicas , Factores de Edad , Diagnóstico Tardío , Femenino , Humanos , Lactante , Modelos Logísticos , Masculino , Estudios Retrospectivos , Factores de Riesgo , Tiempo de Tratamiento
8.
Plast Reconstr Surg ; 138(6): 1275-1285, 2016 Dec.
Artículo en Inglés | MEDLINE | ID: mdl-27537228

RESUMEN

BACKGROUND: The aesthetic aspects of the cleft lip nasal deformity have been appreciated for over a century, but the functional implications have remained largely underappreciated or misunderstood. This study describes the frequency and severity of nasal obstructive symptoms among children with cleft lip and/or cleft palate, addressing the hypotheses that age, cleft type, and severity are associated with the development of nasal obstructive symptoms. METHODS: Children with nonsyndromic cleft lip and/or cleft palate and a comparison group of unaffected children born from 1997 to 2003 were identified through the North Carolina Birth Defects Monitoring Program and birth certificates. Nasal airway obstruction was measured using the validated Nasal Obstruction Symptom Evaluation scale. RESULTS: The survey was completed by parental proxy for 176 children with cleft lip and/or cleft palate and 333 unaffected children. Nasal obstructive symptoms were more frequently reported in cleft lip with cleft palate compared with unaffected children (p < 0.0001); children who had isolated cleft lip with or without alveolus and isolated cleft palate were not statistically different from unaffected children. Patients with unilateral cleft lip with cleft palate were found to be more severely affected than bilateral cases. Nasal obstruction was observed in early childhood, although severity worsened in adolescence. CONCLUSIONS: This population-based study reports a high prevalence of nasal obstructive symptoms in children with cleft lip and/or cleft palate based on type and severity of the cleft. The authors encourage cleft teams to consider using this or similar screening methods to identify which children may benefit from functional rhinoplasty. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, I.


Asunto(s)
Labio Leporino/complicaciones , Fisura del Paladar/complicaciones , Obstrucción Nasal/etiología , Adolescente , Factores de Edad , Estudios de Casos y Controles , Niño , Labio Leporino/cirugía , Fisura del Paladar/cirugía , Estudios Transversales , Femenino , Encuestas Epidemiológicas , Humanos , Masculino , Obstrucción Nasal/diagnóstico , Obstrucción Nasal/epidemiología , Obstrucción Nasal/cirugía , Prevalencia , Rinoplastia , Índice de Severidad de la Enfermedad
9.
J Clin Sleep Med ; 10(11): 1231-2, 2014 Nov 15.
Artículo en Inglés | MEDLINE | ID: mdl-25325591

RESUMEN

OBJECTIVE: We discuss the use of levothyroxine for excessive daytime sleepiness (EDS) and prolonged nocturnal sleep time in a euthyroid patient with narcolepsy. METHODS: After failure of first-line narcolepsy treatments, a 48-year-old female began levothyroxine (25 mcg/day). After 12 weeks of treatment, the patient was evaluated for improvement in total sleep time and subjective daytime sleepiness assessed by Epworth Sleepiness Scale (ESS). RESULTS: At baseline, ESS score was 16 and total sleep time averaged 16 h/day. After 12 weeks, ESS was 13 and reported total sleep time was 13 h/day. CONCLUSIONS: Levothyroxine improved EDS and total sleep time in a euthyroid patient with narcolepsy without cataplexy after 12 weeks without side effects.


Asunto(s)
Narcolepsia/diagnóstico , Narcolepsia/tratamiento farmacológico , Sueño/efectos de los fármacos , Tiroxina/administración & dosificación , Catalepsia , Trastornos de Somnolencia Excesiva/diagnóstico , Trastornos de Somnolencia Excesiva/tratamiento farmacológico , Relación Dosis-Respuesta a Droga , Esquema de Medicación , Femenino , Estudios de Seguimiento , Humanos , Persona de Mediana Edad , Polisomnografía/métodos , Valores de Referencia , Índice de Severidad de la Enfermedad , Sueño/fisiología , Pruebas de Función de la Tiroides , Glándula Tiroides/fisiología , Factores de Tiempo , Resultado del Tratamiento
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