Skeletal and Dental Habilitation of Residual Alveolar and Maxillary Clefts.

ABSTRACT: Management of residual clefts of the alveolus and maxilla requires the coordinated effort of multiple members of the craniofacial team including surgeon, orthodontist, and when teeth are hypoplastic or absent, the prosthodontist to achieve complete habilitation. Such cooperation among specialists begins early in the patient's life and continues through completion of care.Although numerous publications on this topic exist, few present definitive multidisciplinary reconstructive outcomes with longterm results. In this review paper, the authors present our comprehensive, multidisciplinary protocols, experience, and techniques as they have evolved with over 35 years of practice at our Craniofacial Center.Details of our updated protocols for each intervention and procedure, including our current thoughts on appropriate timing, follow up and advantages from the incorporation of current technologies are discussed. Close cooperation among specialists at all stages of care, the use of evolving technology, and adherence to, and modification where indicated, of time honored team protocols enables us to consistently achieve successful functional and esthetic outcomes, while minimizing complications.

Cleft Skeletal Asymmetry: Asymmetry Index, Classification and Application.

OBJECTIVE: To quantitatively measure the extent of 3D asymmetry of the facial skeleton in patients with unilateral cleft lip and palate (UCLP) using an asymmetry index (AI) approach, and to illustrate the applicability of the index in guiding and measuring treatment outcome. METHOD: Two groups of subjects between the ages of 15 and 20 who had archived CBCT scan were included in this study. Twenty-five patients with complete UCLP were compared with 50 age-matched noncleft subjects. The CBCT scans were segmented and landmarked for 3D anthropometric analysis. An AI was calculated as a quantitative measure of the extent of facial skeletal asymmetry. RESULTS: For the control group, the AI ranged from 0.72 ± 0.47 at A point to 4.77 ± 1.59 at Gonion. The degree of asymmetry increased with the increasing laterality of the landmark from the midsagittal plane. In the UCLP group, the values of AI significantly increased compared to the control group at nearly all measured landmarks. The extent of the asymmetry to involve the upper, middle, and lower facial skeleton varied widely with the individual patient with UCLP. CONCLUSION: The asymmetry index is capable of capturing the 3D facial asymmetry of subjects with UCLP and as a basis for classification of the extent of the asymmetry. We found the index to be applicable in surgical planning and in measuring the outcome in improving the symmetry in patients who have undergone orthognathic surgery.

Impact of Abdominal Lipectomy on Post-Sleeve Gastrectomy Surgery Weight Loss.

BACKGROUND: Abdominal lipectomy after bariatric surgery is recommended because of residual excess skin resulting in difficulty with maintaining hygiene, recurrent infections, and functional impairment, interfering with daily activities. There is a dearth of literature examining weight loss outcomes in patients undergoing abdominal lipectomy post sleeve gastrectomy (SG). The purpose of this study was to examine whether post-SG patients who received abdominal lipectomy achieved greater percent excess weight loss (%EWL) than post-SG patients who did not receive abdominal lipectomy. METHODS: Retrospective study of patients who underwent minimally invasive SG at the University of Illinois Hospital and Health Sciences System from March 2008 to June 2015 was conducted. The cohort was divided into 2 groups: patients who underwent abdominal lipectomy after SG (PS-SG) and patients who underwent SG alone (SG). Demographics, comorbidities, and %EWL were examined. RESULTS: Twenty-nine patients were included in the PS-SG group versus 287 patients in the SG group. Significant differences were found in %EWL at 24 (P < 0.0001), 36 (P < 0.005), and more than 36 months (P < 0.005) follow-up between groups, with a greater %EWL in patients in the PS-SG group versus the SG group. CONCLUSIONS: This preliminary study revealed that patients in the PS-SG group achieved greater %EWL than patients with SG alone. Although larger studies are needed, this study supports using abdominal lipectomy as an adjunctive procedure to assist with long-term weight loss as part of the overall treatment of bariatric surgery patients.

Gender Confirmation Surgery: Guiding Principles.

BACKGROUND: At this time, no formal training or educational programs exist for surgeons or surgery residents interested in performing gender confirmation surgeries. AIM: To propose guiding principles designed to aid with the development of formal surgical training programs focused on gender confirmation surgery. METHODS: We use expert opinion to provide a "first of its kind" framework for training surgeons to care for transgender and gender nonconforming individuals. OUTCOMES: We describe a multidisciplinary treatment model that describes an educational philosophy and the institution of quality parameters. RESULTS: This article represents the first step in the development of a structured educational program for surgical training in gender confirmation procedures. CLINICAL IMPLICATIONS: The World Professional Association for Transgender Health Board of Directors unanimously approved this article as the framework for surgical training. STRENGTHS AND LIMITATIONS: This article builds a framework for surgical training. It is designed to provide concepts that will likely be modified over time and based on additional data and evidence gathered through outcome measurements. CONCLUSION: We present an initial step in the formation of educational and technical guidelines for training surgeons in gender confirmation procedures. Schechter LS, D'Arpa S, Cohen MN, et al. Gender Confirmation Surgery: Guiding Principles. J Sex Med 2017;14:852-856.

Transcaruncular approach to the isolated medial orbital wall fracture: technical perspective and cadaveric dissection.

With technologic progress in imaging for patients with trauma, isolated medial orbital wall fractures have become an increasingly appreciated injury. Given that these injuries may cause deformity and functional deficit, reconstruction is warranted in some cases. Surgical approaches to the medial orbit have evolved, and there are particular benefits of the transcaruncular approach. This approach was used to reconstruct isolated medial orbital wall fractures for 9 patients over a 33-month period. A cadaver dissection demonstrating the approach combined with skull images is presented to illustrate anatomic details and technical points of the dissection.

A matched cohort study of superomedial pedicle vertical scar breast reduction (100 breasts) and traditional inferior pedicle Wise-pattern reduction (100 breasts): an outcomes study over 3 years.

BACKGROUND: The superomedial pedicle vertical scar breast reduction is gaining popularity for its round, projecting breast and shorter incision when compared with the traditional Wise-pattern reduction using an inferior pedicle. However, there is a paucity of large-volume institutional outcomes studies identifying how this technique fares against more traditional methods of reduction. METHODS: A retrospective review of a prospectively maintained database of bilateral breast reductions over a 3-year period was performed. One hundred superomedial breast reductions (50 patients) were matched to 100 inferior pedicle breast reductions (50 patients). Matching was implemented based on age (±3 years) and size of reduction (±200 g). Patient demographics, size of reduction, nipple-areola complex sensitivity, minor and major postoperative complications, and symptomatic relief were assessed. Statistical analysis was performed with SAS Version 9.2. RESULTS: Two hundred twelve patients underwent 424 bilateral breast reductions between January of 2009 and June of 2012 at a single institution. Mean volume of tissue reduced was 815 g per breast (range, 200 to 2068 g) and 840 g per breast (range, 250 to 2014 g), respectively. All patients achieved symptomatic relief. No statistical difference in major or minor complications was seen between the two cohorts. No statistical difference in major or minor complications was seen between the two cohorts. No significant difference in complications was seen between small- and large-volume reductions. CONCLUSION: Superomedial pedicle vertical scar breast reduction is a novel, alternative mammaplasty technique with excellent functional and aesthetic outcomes which can be used for a wide range of macromastia without a significant difference in complication rates when compared with traditional Wise pattern inferior pedicle reduction mammaplasty. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

The management of postoperative nausea and vomiting: current thoughts and protocols.

UNLABELLED: The postoperative course of surgical patients can have a tremendous impact on the surgical outcome and on patient satisfaction. One of the most significant issues is postoperative nausea and vomiting (PONV) which, despite being a common side effect of general anesthesia, has received little attention in the plastic surgery literature. The incidence and potential consequences of PONV are frequently underestimated and consequently the need for prophylaxis is often overlooked. There are significant consequences to this seemingly minor morbidity that extend beyond patient discomfort and dissatisfaction. In addition to being considered a significant undesirable outcome by patients, severe cases of PONV may result in postoperative complications and unplanned hospital admissions. In this article we overview the mechanism, pathophysiology, and risk factors for PONV and provide a comprehensive algorithmic approach to its management. LEVEL OF EVIDENCE V: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Complications of pediatric facial fractures.

Pediatric facial fractures account for only 5% of all facial fractures, with even a much lower incidence in children younger than 5 years (1%-1.5%). The evolution of principles in the management of pediatric facial fractures and the differences in management between adult and pediatric patients have been well documented in the literature. Pediatric facial fracture management presents unique challenges because it might affect growth in the area specific to the trauma segment. Children are, in several ways, at a regenerative advantage: greater osteogenic potential, faster healing rate, primary dentition that is thereby temporary, and the capacity for significant dental compensation. Perhaps because of this, complications such as infection, malunion, nonunion, and postinjury malocclusion are relatively rare compared with the adult population. In this article, we will focus on different approaches to complications that arise after pediatric fracture management.

Free microsurgical and pedicled flaps for oncological mandibular reconstruction: technical aspects and evaluation of patient comorbidities.

Oncologic mandibular reconstruction has changed significantly over the years and continues to evolve with the introduction of newer technologies and techniques. Patient demographic, reconstructive, and complication data were obtained from a prospectively maintained clinical database of patients who underwent head and neck reconstruction at our institution. The free fibular flap is now considered the gold standard for mandibular reconstruction. However, in patients with multiple comorbidities, lengthy procedures may be less optimal and pedicled flaps, with specific modifications, can yield reasonable outcomes. Technical aspects and comorbidity profiles are examined in the oncological mandibular reconstruction cohort.

Use of virtual surgery and stereolithography-guided osteotomy for mandibular reconstruction with the free fibula.

UNLABELLED: Fibular osteotomy remains a challenging aspect of mandibular microsurgical reconstruction, dependent largely on surgeon experience, intraoperative judgment, and technical speed. Virtual surgical planning and stereolithographic modeling is a relatively new technique that can allow for reduction in the learning curve associated with neomandible contouring, enhanced levels of accuracy, and acceleration of a time-consuming intraoperative step. The authors present a video (narrated and edited from planning sessions and intraoperative use of technique to illustrate the technology) and describe their favorable results. Five patients underwent composite resection of the mandible and free fibula osteocutaneous reconstruction over a 6-month period (December of 2009 to June of 2010) at a single institution using a virtual planning session and stereolithographic modeling. Outcomes assessed included technical accuracy, aesthetic contour, and functional outcomes. All patients achieved negative margins with cutting guide-directed resection. Use of this technique eliminated the need for intraoperative measurement and yielded fibular segments with excellent apposition and faithful duplication of the preoperative plan. Minimal adjustments were needed for inset. Flap survival was 100 percent. All patients have maintained preoperative occlusion and a symmetric mandibular contour on Panorex study, three-dimensional computed tomography, and clinical examination. Accuracy of the reconstructed contour was confirmed using computed tomographic image overlay. This virtual surgical planning technique combined with stereolithographic model-guided osteotomy is the mainstay of the authors' approach to fibular osteotomy when dealing with patients requiring mandibular reconstruction. The authors feel this technology facilitates realization of technical accuracy, aesthetic contour, and functional outcomes and may be particularly useful if free fibular mandibular reconstruction is performed less frequently. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.