Quantifying Sagittal Lip Changes in Patients with Bilateral Cleft Lip Post Abbe Flap Reconstruction.

OBJECTIVES: To objectively quantify results of sagittal lip changes following Abbe flap reconstruction in patients with bilateral cleft lip. DESIGN: Retrospective, observational study. SETTING: Single institution, 8-year retrospective review. PATIENTS/PARTICIPANTS: In total, 17 patients with bilateral cleft lip that underwent Abbe flap reconstruction were included in this study. INTERVENTION: Patients had lateral photographs taken prior to Abbe flap reconstruction and at least 8 months post-Abbe flap. MAIN OUTCOME MEASUREMENTS: Vegter's index, Sushner's S2 line and Burstone's B line reference lines were used for evaluation of sagittal lip changes. Wilcoxon signed rank tests were used in analysis. RESULTS: The mean pre-Abbe flap upper to lower lip ratio, defined as Vegter's Lip Index, was 0.906 compared to a mean of 0.946 following Abbe flap reconstruction. The mean upper to lower lip ratio for Sushner's S2 and Burstone's B line exhibited an increase in upper lip sagittal projection from -0.164 to 1.459 and 0.259 to 0.957, respectively (P < 0.001). CONCLUSIONS: This study quantifies sagittal changes to upper and lower lip position after Abbe flap reconstruction. These findings may aid in operative planning and patient/caregiver expectations during counseling.

Abbe Flap Division Before Two Weeks' Time: Harmful or Advantageous?

INTRODUCTION: The Abbe flap is a standard intervention to treat upper lip deformities in patients with bilateral cleft lip. This two-stage procedure requires a 2 to 3-week period in which the superior and inferior lips remain connected. This study evaluates the safety of Abbe flap division and inset prior to 14 days' time. MATERIALS AND METHODS: A single institution, 8-year review of all patients with a bilateral cleft lip who underwent Abbe flap reconstruction was performed. Patients were classified into two groups: those whom division was performed 14 days or later and those with division earlier than 14 days. RESULTS: A total of 26 patients were identified. Patients who underwent Abbe flap division in less than 14 days (n = 10) demonstrated an average time to division of 9.7 days (range 7-13 days) with no evidence of flap loss, wound breakdown or infection. Patients who underwent Abbe flap division within 14 days or more (n = 16) demonstrated an average time to division of 15 days with four minor complications and no flap loss. CONCLUSION: Dividing the Abbe flap after the first postoperative week appears to be safe and without additional risk to flap loss or wound breakdown. A shorter time to Abbe flap division may decrease the burden of care on patients and their caregivers.

Global Prevalence and Burden of Orofacial Clefts: A Systematic Analysis for the Global Burden of Disease Study 2019.

Orofacial clefts, in particular cleft lip and cleft palate, are among the most common congenital anomalies. Despite guidelines recommending early surgical correction, a global backlog of untreated patients persists. This has made orofacial clefts an attractive target for global cleft care initiatives. The most recent global burden of orofacial clefts was estimated to be 529,758.92 disability-adjusted life years (95% uncertainty interval: 362,492.88-798,419.69 disability-adjusted life years), whereas the global prevalence of orofacial clefts was estimated to be 4.6 million (95% uncertainty interval: 3.8-5.7 million). An inverse relationship exists between the Sociodemographic Index and the burden of orofacial clefts. Sub-Saharan Africa, Middle East/North Africa, and South Asia are the regions carrying the most significant burden of orofacial clefts. This manuscript provides updated estimates of the global burden and prevalence of orofacial clefts, acting as a guide to direct future investments, resources, and initiatives from individuals and organizations engaged in global cleft care delivery with the goal of building sustainable cleft care capacity where it is needed the most.

Hyperbaric Oxygen Therapy for Threatened Nipple-Sparing Mastectomy Flaps: An Adjunct for Flap Salvage.

BACKGROUND: Nipple-sparing mastectomy (NSM) is emerging as the standard of care for treatment of breast cancer because of its oncologic safety and superior aesthetic outcomes. However, ischemia or necrosis of the skin flap and/or nipple-areola complex remain frequent complications. Hyperbaric oxygen therapy (HBOT) has emerged as a potential adjunct for flap salvage, although it is not currently a widely accepted practice. Here we review our institution's experience using a protocol of HBOT in patients with signs of flap ischemia or necrosis after NSM. METHODS: Retrospective review identified all patients treated with HBOT at our institution's hyperbaric and wound care center because of signs of ischemia after NSM. Treatment parameters consisted of 90-minute dives at 2.0 atmosphere once or twice daily. Patients unable to tolerate dives were considered a treatment failure, whereas those lost to follow-up were excluded from analysis. Patient demographics, surgical characteristics, and treatment indications were recorded. Primary outcomes assessed were flap salvage (no operative revision), need for revision procedures, and treatment complications. RESULTS: A total of 17 patients and 25 breasts met the inclusion criteria. The mean ± SD time to initiation of HBOT was 9.47 ± 12.7 days. The mean ± SD age was 46.7 ± 10.4 years, and mean ± SD follow-up time was 36.5 ± 25.6 days. Indications for NSM included invasive cancer (41.2%), carcinoma in situ (29.4%), and breast cancer prophylaxis (29.4%). Initial reconstruction included tissue-expander placement (47.1%), autologous reconstruction with deep inferior epigastric flaps (29.4%), and direct-to-implant reconstruction (23.5%). Hyperbaric oxygen therapy indications included ischemia or venous congestion for 15 breasts (60.0%) and partial thickness necrosis for 10 breasts (40.0%). Flap salvage was achieved in 22 of 25 breasts (88.0%). Reoperation was required for 3 breasts (12.0%). Hyperbaric oxygen therapy-related complications were observed in 4 patients (23.5%), which included 3 patients with mild ear pain and 1 patient with severe sinus pressure leading to treatment abortion. CONCLUSIONS: Nipple-sparing mastectomy is an invaluable tool for breast and plastic surgeons to achieve oncologic and cosmetic goals. However, ischemia or necrosis of the nipple-areola complex or mastectomy skin flap remains frequent complications. Hyperbaric oxygen therapy has emerged as a possible intervention for threatened flaps. Our results demonstrate the utility of HBOT in this population to achieve excellent NSM flap salvage rates.

LeFort III/I for Beckwith-Wiedemann Syndrome: A Case Report.

This case presents a facially mature patient with Beckwith-Wiedemann Syndrome (BWS) who presented with severe class III malocclusion. Computed tomography imaging revealed an anterior crossbite of 19 mm and a narrow pharyngeal airway at the level of the tongue base precluding mandibular setback surgery. The patient was indicated for a LeFort III combined with a LeFort I advancement, each of 10 mm, for a 20 mm combined advancement. Stable, functional occlusion was achieved without airway compromise. This novel use of the combined LeFort III/I can restore stable class I occlusion in patients with BWS at risk for tongue base airway compromise.

Reawakening Neuritis of the Median Nerve after Carpal Tunnel Release: Defining and Predicting Patients at Risk.

BACKGROUND: Patients with long-standing carpal tunnel symptoms may develop transient and, paradoxically, worsened neuropathic pain immediately following release. The authors have termed this "reawakening phenomenon." The purpose of this study was to compare the characteristics of patients with this phenomenon to those with a standard postoperative course. METHODS: A retrospective chart review was performed on all patients who underwent carpal tunnel release at a single institution between January of 2012 to December of 2017. Patients demonstrating increased neuropathic pain in the median nerve distribution postoperatively without evidence of complex regional pain syndrome were included. A comparison cohort was composed of the remaining patients identified. Demographic data, medical history, carpal tunnel history, and electromyogram and nerve conduction study findings were recorded. RESULTS: A total of 640 patients were identified; 440 met criteria. Seventeen patients were found to have symptoms consistent with median nerve reawakening phenomenon. The reawakening cohort was older (71.1 versus 56.8 years), more likely to have evidence of thenar muscle atrophy (58.8 percent versus 13.48 percent), and more likely to have fibrillations and sharp waves on electrodiagnostic studies. Although not statistically significant, they also had a longer duration of symptoms (4.9 versus 2.9 years). Of those patients with reawakening phenomenon, 14 had resolution of their symptoms at an average period of 4.4 months. Three remaining patients who were subjectively symptomatic had normal or improved postoperative electromyogram and nerve conduction studies. CONCLUSIONS: Reawakening of the median nerve has not been previously described but occurs in 3.9 percent of hands following routine carpal tunnel release. Preoperative counseling of patients at high risk for reawakening phenomenon is recommended. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

Violence Depicted in Superhero-Based Films Stratified by Protagonist/Antagonist and Gender.

The objective of this study was to describe and quantify acts of violence depicted in a select number of superhero-based films, further stratified by protagonist/antagonist characters and gender. A total of 10 superhero-based films released in 2015-2016 were analyzed by five independent reviewers. The average number of acts of violence associated with protagonist and antagonist characters for all included films was 22.7 and 17.5 mean events per hour, respectively (p=0.019). The average number of acts of violence associated with male and female characters for all included films was 33.4 and 6.5 mean events per hour, respectively (p<0.001). The most common acts of violence for all major characters were "fighting", "use of a lethal weapon", "bullying/intimidation/torture", "destruction of property", and "murder" (14.9, 11.4, 3.5, 3.4, and 2.4 mean events per hour, respectively). Based on our sample of superhero-based films, acts of violence were associated more with protagonist characters and male characters.