Computed Tomography in Radiation Oncology During the Coronavirus Disease 2019 Pandemic.

During the coronavirus disease 2019 (COVID-19) pandemic, cancer centers must implement effective measures to protect patients and staff from infection with the novel coronavirus. A critical component of this effort is the timely identification of patients undergoing treatment who have COVID-19. Limitations on testing make such efforts challenging. However, the specialty of radiation oncology is unique in its use of computed tomography (CT) imaging for image guidance, and these CT studies have the potential to identify patients with COVID-19 even before they develop symptoms. Several organizations have developed published guidelines for radiologists to identify characteristic findings of COVID-19 on thoracic CT scans. The present article describes these recommendations in order to educate radiation oncologists on how to identify potential cases of COVID-19 and empower physicians in our field to optimally protect patients and staff.

Emergency Magnetic Resonance Imaging of Musculoskeletal Trauma.

Musculoskeletal (MSK) trauma is commonly encountered in the emergency department. Computed tomography and radiography are the main forms of imaging assessment, but the use of magnetic resonance (MR) imaging has become more common in the emergency room (ER) setting for evaluation of low-velocity/sports-related injury and high-velocity injury. The superior soft tissue contrast and detail provided by MR imaging gives clinicians a powerful tool in the management of acute MSK injury in the ER. This article provides an overview of techniques and considerations when using MR imaging in the evaluation of some of the common injuries seen in the ER setting.

Ellis-van Creveld Syndrome with Sagittal Craniosynostosis.

Ellis-van Creveld syndrome (EVC) is a rare disorder (the incidence is estimated at around 7/1,000,000) characterized by the clinical tetrad of chondrodystrophy, polydactyly, ectodermal dysplasia, and cardiac anomalies. Sagittal synostosis is characterized by a dolichocephalic head shape resulting from premature fusion of the sagittal suture. Both are rare disorders, which have never been reported together. We present a case of EVC and sagittal synostosis. We report the clinical features of a Hispanic boy with EVC and sagittal craniosynostosis who underwent cranial vault remodeling. The presentation of this patient is gone over in detail. A never before reported case of EVC and sagittal synostosis is presented in detail.

Osseous Scaphotrapezial Coalition.

Osseous scaphotrapezial coalition is one of the rarest forms of carpal coalition of the hand. Often discovered incidentally, pain and functional limitation have not been reported. Carpal coalitions occurring across the carpal rows are thought to occur as a result of some insult or congenital anomaly. Isolated scaphotrapezial coalition calls into question the traditional thinking that fusion between the proximal and distal carpal rows must be acquired or associated with congenital syndromes.

Treatment effects of dexmedetomidine and ketamine on postoperative analgesia after cleft palate repair.

Primary cleft palate repair may result in significant pain in the immediate postoperative period, which can lead to vigorous crying resulting in wound dehiscence and pulmonary complications. Effective pain control with opioids is the mainstay but administration on the floor has to be countered with the complications associated with their use, chiefly respiratory depression and sedation. We retrospectively examined the efficacies of intraoperative administration of intravenous (IV) dexmedetomidine (DEX) and ketamine (KET) to prevent early postoperative pain in children undergoing primary cleft palate repair and compared the results against relevant literature. The Texas Children's Hospital anesthesia database was queried to identify children undergoing a palatal surgery from December 2011 to December 2012. Inclusion criteria permitted completed primary palatal surgery without major complications and intraoperative administration of DEX or KET. The control group (CTRL) received no additional drug. A comprehensive literature review was performed. A total of 71 pediatric patients underwent palatal surgery during the study period with 46 patients qualifying for analysis. Although results were not significant, consistent trends were observed with regards to lower opioid requirements during the first 24 hours for both medications compared with the CTRL. KET also had shorter time to discharge. The literature review resulted in several studies supporting decreased postoperative pain end points for both DEX and KET. In our sample, DEX and KET reduced postoperative opioid requirements. KET seems to have the added benefit of a shorter hospital stay. These finding are supported in the literature. With further investigation, the addition of these drugs may serve to provide improved pain relief without over sedation in patients undergoing cleft palate repair.

The Delay Phenomenon: A Compilation of Knowledge across Specialties.

Objective The purpose of this article is to review and integrate the available literature in different fields to gain a better understanding of the basic physiology and optimize vascular delay as a reconstructive surgery technique. Methods A broad search of the literature was performed using the Medline database. Two queries were performed using "vascular delay," a search expected to yield perspectives from the field of plastic and reconstructive surgery, and "ischemic preconditioning," (IPC) which was expected to yield research on the same topic in other fields. Results The combined searches yielded a total of 1824 abstracts. The "vascular delay" query yielded 76 articles from 1984 to 2011. The "ischemic preconditioning" query yielded 6534 articles, ranging from 1980 to 2012. The abstracts were screened for those from other specialties in addition to reconstructive surgery, analyzed potential or current uses of vascular delay in practice, or provided developments in understanding the pathophysiology of vascular delay. 70 articles were identified that met inclusion criteria and were applicable to vascular delay or ischemic preconditioning. Conclusion An understanding of IPC's implementation and mechanisms in other fields has beneficial implications for the field of reconstructive surgery in the context of the delay phenomenon. Despite an incomplete model of IPC's pathways, the anti-oxidative, anti-apoptotic and anti-inflammatory benefits of IPC are well recognized. The activation of angiogenic genes through IPC could allow for complex flap design, even in poorly vascularized regions. IPC's promotion of angiogenesis and reduction of endothelial dysfunction remain most applicable to reconstructive surgery in reducing graft-related complications and flap failure.

A novel quantitative method for evaluating surgical outcomes in craniosynostosis: pilot analysis for metopic synostosis.

Objective assessment of head shape has been an elusive goal in the management of craniosynostosis patients. Clinical judgment, craniometric indices, and computed tomography scans are the primary means through which a surgeon assesses this patient population. The purpose of this study was to examine and discuss the utility of the STARscanner for evaluation of surgical outcomes in metopic synostosis patients. A retrospective chart review of patients with metopic synostosis who underwent fronto-orbital advancement with pre- and postoperative STARscanner imaging at Texas Children's Hospital was performed. Two patients were identified and evaluation and discussion of the data produced by the STARscanner was undertaken. A novel symmetry index created by the authors, called the anterior-posterior volume ratio (APVR), was discussed for use in metopic synostosis patients. The postoperative growth metrics demonstrated an interval increase compared with the preoperative data. The anterior symmetry ratio, posterior symmetry ratio, overall symmetry ratio, cranial vault volumes, cranial vault asymmetry index, and cephalic ratio were not found to be useful in evaluating resolution of dysmorphology after fronto-orbital advancement in metopic synostosis. The APVR does not characterize dysmorphology, but may help show degree of expansion of the anterior cranial vault after fronto-orbital advancement. The STARscanner imaging device does not appear to have significant utility in characterizing head shape for surgical outcomes assessment in metopic synostosis. The minor utility of this device may be that it is a safe and fast way to derive growth parameters for both short-term and long-term follow-up of cranial vault remodeling.

Local foreign-body reaction to commercial biodegradable implants: an in vivo animal study.

Biodegradable plates have been used extensively in fracture fixation since the 1960s. They rarely cause stress-protection atrophy or problems requiring secondary plate removal, common complications seen with metallic plates. However, aseptic foreign-body reactions have been reported, sometimes years after the original implantation. Both inadequate polymer degradation and debris accumulation have been implicated as causes. The current generation of commercial biodegradable plates is formulated to minimize this complication by altering the ratio of polylactic and polyglycolic acids. This in vivo study compares the degree of local foreign-body reaction of two commercially available resorbable plates in rabbits. Two types of biodegradable plates were examined: poly(D/L)lactide acid (PDLLA) and polylactide-co-glycolide acid (PLGA). Each plate was placed into a periosteal pericalvarial pocket created beneath the anterior or posterior scalp of a rabbit. Humane killing occurred at 3, 6, and 12 months postoperatively. Foreign-body reaction was evaluated histologically. The PDLLA plates demonstrated marked local foreign-body reactions within the implant capsule as early as 3 months after implantation, with presence of inflammatory cells and granulomatous giant cells in close association with the implant material. All local foreign-body reactions were subclinical with no corresponding tissue swelling requiring drainage. PLGA plates did not demonstrate any signs of inflammatory reactions. In addition, the PLGA plates did not appear to resorb or integrate at 12 months. Neither PDLLA nor PLGA plates demonstrated inflammation of the soft tissue or adjacent bone outside the implant capsule. In our study, the PDLLA plates demonstrated histological evidence of foreign-body reaction that is confined within the implant capsule, which was not seen with the PLGA plates. This finding may be attributable to the lack of significant resorption seen in the PLGA plates. Both PDLLA and PLGA plates were biocompatible with the rabbit tissue environment and should be considered for continued use in craniofacial, maxillofacial, and orthopedic reconstruction.

Less is more in the nonoperative management of complete brachial artery transection after supracondylar humeral fracture.

Supracondylar humeral fractures are the most common fracture of the elbow in children. Despite it being a familiar problem faced by surgeons, there are aspects of its management that remain controversial. Specifically, management of these fractures that result in a pink or perfused hand that remains pulseless after acceptable reduction is expectedly controversial. We present a patient with a supracondylar humeral fracture and loss of pulse. The patient was found to have complete brachial artery transection but maintained a pink and well-perfused hand. It was determined to forgo arterial reconstruction because of concerns of worsening ischemia by damage to the collateral circulation. Despite no arterial reconstruction, the patient had a successful outcome. Therefore, this report highlights that arterial reconstruction may not be required, even in cases of severe brachial artery injury.

Management of pediatric mandible fractures.

When determining the optimal treatment strategy for a pediatric mandible fracture, planning must factor in the patient's age, anatomy, stage of dental development, fracture site, and ability to cooperate with the proposed treatment plan. Careful consideration must be given to the possibility of long-term growth disturbance with various fracture locations and types of treatment. This article reviews the current principles of the management of pediatric mandibular fractures.

Bilateral macrodystrophia lipomatosa with syndactyly: a case report and literature review.

Macrodystrophia lipomatosa is a rare, non-hereditary form of congenital local gigantism characterised by enlargement and hypertrophy of all mesenchymal tissue components with a disproportionate increase in adipose tissue. This form of macrodactyly has been reported in association with other anomalies including polydactyly, brachydactyly, syndactyly, and symphalangism. We describe a previously unreported case of bilateral upper extremity macrodystrophia lipomatosa with syndactyly in a 23-month-old boy. In this report, we emphasise the importance of establishing a diagnosis with imaging and review the described surgical approaches to treating this difficult condition.

Breast reduction in adolescents: indication, timing, and a review of the literature.

BACKGROUND: Adolescent breast hypertrophy can have long-term negative medical and psychological impacts. In select patients, breast reduction surgery is the best treatment. Unfortunately, many in the general and medical communities hold certain misconceptions regarding the indications and timing of this procedure. Several etiologies of adolescent breast hypertrophy, including juvenile gigantomastia, adolescent macromastia, and obesity-related breast hypertrophy, complicate the issue. It is our hope that this paper will clarify these misconceptions through a combined retrospective and literature review. METHODS: A retrospective review was conducted looking at adolescent females (≤18 years old) who had undergone bilateral breast reduction surgery. Their preoperative comorbidities, BMI, reduction volume, postoperative complications, and subjective satisfaction were recorded. In addition, a literature review was completed. RESULTS: 34 patients underwent bilateral breast reduction surgery. The average BMI was 29.5 kg/m(2). The average volume resected during bilateral breast reductions was 1820.9 g. Postoperative complications include dehiscence (9%), infection (3%), and poor scarring (6%). There were no cases of recurrence or need for repeat operation. Self-reported patient satisfaction was 97%. All patients described significant improvements in self body-image and participation in social activities. The literature review yielded 25 relevant reported articles, 24 of which are case studies. CONCLUSION: Reduction mammaplasty is safe and effective. It is the preferred treatment method for breast hypertrophy in the adolescent female and may be the only way to alleviate the increased social, psychological, and physical strain caused by this condition.

Craniofrontonasal dysplasia: variability of the frontonasal suture and implications for treatment.

Craniofrontonasal dysplasia's (CFND's) phenotypic range includes hypertelorism, coronal craniosynostosis, frontonasal dysplasia, and digital anomalies. The variable expression is paradoxical for an X-linked syndrome because hemizygous males are less affected than heterozygous females. We describe a case of CFND due to a c.30>T EFNB1 gene mutation. In place of the typical craniosynostosis found in CFND, she presented with a superiorly displaced nasion and an anomalously positioned frontonasal suture. This report reveals an unreported malformation in CFND and its surgical implications.

Frontonasal and fibrous dysplasia in a patient with unilateral cleft lip and palate.

Frontonasal dysplasia is a rare entity. It has characteristic physical deformities: hypertelorism, broad nasal root, median facial cleft of the upper lip or palate, clefting of the nasal alae, poorly formed nasal tip, cranium bifidum occultum, and a widow's peak hairline. Fibrous dysplasia is a benign bone tumor in which normal bone is replaced by fibrous, poorly formed osseus tissues. We present a patient with frontonasal dysplasia who desired correction of her hypertelorism. Incidentally, fibrous dysplasia was found in her left orbit complicating surgical correction. In addition, the patient has velopharyngeal insufficiency and a class III malocclusion. The interplay of all these craniofacial defects makes the sequencing and timing of surgery important in this unique patient.

Predictors of post-mastectomy reconstruction in an underserved population.

OBJECTIVE: Past studies found insurance status, race, comorbidities and hospital setting influence the likelihood and timing of post-mastectomy breast reconstruction (BR). We evaluated these factors at a public hospital serving a predominantly minority and uninsured population. METHODS: Women who underwent mastectomy and/or BR from 2005 to 2011 were reviewed. The association between patients' characteristics and receipt of BR and timing (immediate BR vs. delayed BR) were analyzed. The 5-year overall BR rate was estimated with the Kaplan-Meier method. RESULTS: The analysis included 387 patients. 130 received BR. 85 (65%) received immediate BR and 25 (19%) underwent microsurgical repair. The total complication rate was 25%. The 5 yr overall BR rate was 43% (95% CI: 36%-51%). Univariate factors positively associated with overall BR included younger age, non-smoker, lower BMI, no comorbidities, no neoadjuvant chemotherapy requirement, lower AJCC stage and negative lymph nodes. Younger age, no comorbidities, neoadjuvant chemotherapy, higher AJCC stage, and positive lymph nodes were positively associated with delayed breast reconstruction compared to immediate BR. Multivariate regression models show patient of younger age (p<0.001), BMI less than 30 (p<0.01), negative lymph nodes (p<0.03) and no neoadjuvant chemotherapy requirement (p<0.01) are more likely to have BR overall: young patients (p<0.02) are more likely to have delayed BR. Race and insurance type were not significantly associated with BR or timing of BR given the patient population. CONCLUSION: At a public hospital, serving a largely uninsured population, post-mastectomy rates of immediate BR and overall BR within 5 yrs are 22% and 43%, respectively. Overall complication rates were low and a substantial fraction of post-mastectomy patients received microsurgical BR. Contrary to previous studies, race and insurance status were not found to be the primary drivers of post-mastectomy reconstruction.

Treatment of mandibular angle fractures with a matrix strut miniplate.

New innovative techniques and more efficacious hardware allowing rapid and reliable fixation have resulted in better mandibular angle fracture management. This article presents follow-up data to our previous report, "Treatment of mandibular angle fracture with a matrix miniplate: a preliminary report," regarding the safety and efficacy of the 2.0 matrix strut miniplate in clinical practice. Mandibular angle fractures repaired with a single 2.0 matrix strut miniplate, using an intraoral approach, were selected for chart review over a 10-year period. Demographics including patient information, fracture etiology, site of fracture, treatment, surgical duration, and follow-up were collected. Complications were recorded along with the method of treatment. The significance (P = 0.05) of association between demographic and clinical factors with surgical complications was examined using Fisher exact tests. Thirty-four patients with mandibular angle fractures underwent matrix miniplate fixation via an intraoral approach. These patients were followed up for a mean follow-up period of 12 months. Four patients developed complications: 2 with infection requiring hardware removal and external fixation (5.9%), 1 infection treated with incision and drainage (2.9%), and 1 nonunion (2.9%). The matrix strut miniplate offers surgeons another tool to successfully accomplish mandibular fixation expediently while minimizing additional risk to patients. This system adds superior stability without negatively impacting other aspects of care and should be strongly considered for angle fixation.

Implant-associated anaplastic large cell lymphoma of the breast: Insight into a poorly understood disease.

Implant-associated anaplastic large cell lymphoma (ALCL) is the subject of much debate in the field of plastic surgery. Only a few published cases have been reported and the rarity of the disease may make proving causality exceedingly difficult. Despite this, it is of utmost importance that full attention be devoted to this subject to ensure the safety and well-being of patients. The authors report one new case of implant-associated ALCL that recently presented to their institution. Implant-associated ALCL is a poorly understood disease. It should likely be considered its own clinical entity and categorized into two subtypes: one presenting as a seroma and the other as a distinct mass or masses. When reported, only textured implants have been associated with ALCL. The United States Food and Drug Administration and American Society of Plastic Surgeons have initiated a registry and have collected critical data to gain further understanding of this disease.

Le lymphome anaplasique à grandes cellules (LAGC) associé à un implant mammaire suscite d'abondants débats en chirurgie plastique. Seuls quelques cas publiés ont été signalés et, en raison de la rareté de la maladie, il est très difficile d'en prouver la causalité. Pourtant, il est capital de se pencher sérieusement sur le sujet afin de garantir la sécurité et le bien-être des patients. Les auteurs rendent compte d'un récent cas de LAGC associé à un implant mammaire au sein de leur établissement. Le LAGC associé à un implant mammaire est une maladie mal comprise. Il faudrait probablement le considérer comme une entité clinique distincte et le classer en deux sous-types: l'une se manifestant sous forme de sérome et l'autre, sous forme de masse(s) distincte(s). Seuls les implants texturés s'y associent. La Food and Drug Administration des États-Unis et l'American Society of Plastic Surgeons ont créé un registre et colligé des données essentielles pour mieux comprendre cette maladie.

Frontal sinus fractures: a conservative shift.

This article reflects on the changing management of frontal sinus fractures. Severity of these injuries has decreased tremendously since the universal adoption of seat belts and air bags. Recently, there has been a shift from aggressive surgical management to more conservative management strategies, some forgoing surgery all together. New technologies, such as bioabsorbable plates and endoscopic sinus surgery, are leading the way in improved surgical management strategies and offer promising alternatives to the more traditional approaches.

A Prospective Study of Strut versus Miniplate for Fractures of Mandibular Angle.

This prospective randomized clinical trial compared the treatment outcomes of strut plate and Champy miniplate in fixation of mandibular angle fractures. Patients with mandibular angle fracture were consented and enrolled into this study. Exclusion criteria include patients with severely comminuted fractures. The patients were randomly assigned to receive the strut plate or Champy miniplate for angle fracture fixation. Patient demographics, fracture characteristics, operative and postoperative outcomes were collected prospectively. Statistical analysis was performed to evaluate the significance of the outcome. A total of 18 patients were included in this study and randomly assigned to receive either the strut plate or Champy miniplate. Out of which five patients were excluded postoperatively due to complex fracture resulting in postoperative maxillomandibular fixation. The final enrollment was 13 patients, N = 6 (strut) and N = 7 (Champy). There was no statistically significant difference in the pretreatment variables. Nine of these patients had other associated facial fractures, including parasymphyseal and subcondylar fractures. Most of the (11) patients had sufficient follow-up after surgery. Both groups exhibited successful clinical unions of the mandibular angle fractures. The complications associated with the mandibular angle were 20% in the strut plate group and 16.7% in the Champy group. One patient in the strut plate group had a parasymphyseal infection, requiring hardware removal. The strut plate demonstrated comparable surgical outcome as the Champy miniplate. It is a safe and effective alternative for management of mandibular angle fracture.