The Lawnmower and the Pediatric Lower Extremity: A Catastrophic Combination.

Background: Lower extremity (LE) trauma within the pediatric population may be debilitating and have different implications and etiologies than in adults. Specifically, lawnmower injuries can cause catastrophic sequelae to the lower extremities, often requiring complex reconstruction or resulting in amputation. This study aims to present our experience with pediatric LE lawnmower injuries at one of the busiest level 1 trauma centers in the United States. Methods: An IRB-approved retrospective analysis was performed studying pediatric patients (age <18 years) who experienced LE trauma due to a lawnmower injury over a 5-year period (2012-2017). Patient demographics, perioperative data, and types of reconstruction were reviewed. Univariate analysis of the data was performed to examine trends in exposure and management of pediatric LE lawnmower injuries. Results: Twenty-three patients were identified with pediatric LE lawnmower injuries, of whom 82.6% were male. The patients had a median age of 6 years and a median Injury Severity Score (ISS) of 4. Over one-third (34.8%) of this cohort required immediate amputation. Additionally, 26.1% and 8.7% required local and free flap reconstruction, respectively. In comparison, only 3.6% and 2.3% of all traumatic pediatric LE injuries from the same time frame required local and free flaps, respectively. Conclusions: Lawnmower injuries to the LE can be devastating, causing long-term physical, emotional, and psychosocial consequences for pediatric patients and their families. The data in this study suggest that pediatric LE injuries from lawnmowers more often require complex reconstruction than other traumatic LE injuries. Rapid and effective decision-making by experienced surgeons is necessary to optimize the potential for limb salvage in pediatric LE lawnmower injuries. An algorithm of recommendations on when to transfer these types of injuries to more experienced tertiary centers is provided. Additional resources should be dedicated toward improving public awareness and industrial safety features to help prevent lawnmower injuries in pediatric patients.

Postoperative Radiologic Imaging in Secondary Alveolar Bone Grafting for Cleft Lip and Palate: A Systematic Review and Meta-Analysis.

INTRODUCTION: Radiographs (XRs), computed tomography (CT) scans, and cone-beam CT (CBCT) scans are utilized for assessment of secondary alveolar bone graft (SABG) in patients with cleft lip and palate (CLP). However, the optimal choice for imaging modality remains unclear. This study compares the image fidelity and safety profile for XR, CT, and CBCT in the assessment of patients with CLP who have undergone SABG. METHODS: Articles from MEDLINE and Elsevier Embase were screened. The primary outcome was graft success rate. Secondary outcomes were percent-by-volume of graft maintained and patient safety, defined by radiation exposure. A random effects model was used to calculate the pooled outcomes for each imaging modality. Chi-squared analysis was used to compare pooled outcomes between different imaging modalities. RESULTS: Of the 149 articles identified initially, 14 were included. Computed tomography exhibited a significantly higher image fidelity demonstrated by a lower graft success rate (62.0%) compared with both XR (72.6%, P<0.01) and CBCT (69.8%, P<0.01). Cone-beam CT had the lowest reported percent-by-volume of graft maintained (32.1%). Computed tomography had a higher mean radiation dosage (39.7 milligray) than what has been reported for both XR and CBCT. CONCLUSION: Computed tomography demonstrated lower graft success rates than both XR and CBCT, possibly indicating a higher image fidelity. However, compared with CBCT, CT may have a higher radiation exposure. Randomized trials and longitudinal studies are necessary to perform a direct comparison between CT and CBCT and to correlate the image fidelity of these modalities with clinical outcomes.

Progressive vascular tumor in infant: A case report and literature review of PIK3CA vascular malformation.

PURPOSE: Vascular anomalies are classified as either vascular tumors or vascular malformations. Vascular malformations can be difficult to diagnose and treat in the pediatric population and can masquerade as malignant processes. Understanding the genetics behind vascular malformations can lead to identification of specific mutations which can be treated with targeted immunotherapy. METHODS: Our case presents a pediatric patient with progressively enlarging vascular malformation despite multiple surgical resections and systemic medical treatments who underwent genetic evaluation and was found to have PIK3CA mutation. RESULTS: After identification of PIK3CA mutation, our patient was successfully treated with the p110ɑ-specific inhibitor, alpelisib, with both shrinkage of malformation on follow-up imaging as well as gains in her developmental milestones. CONCLUSION: Progressive vascular malformations in the pediatric population can be hard to diagnose and treat and are thought to arise from somatic mutations. Our case highlights a patient with progressive malformation despite multiple surgical resections who was successfully treated with targeted immunotherapy after proper identification of genetic mutation.

Do Buccal Flaps Improve Velopharyngeal Insufficiency in Conversion Furlow Palatoplasty for Patients with Cleft Palate?

SUMMARY: Velopharyngeal insufficiency (VPI) is a complication following primary palatoplasty that can lead to hypernasality of the voice and other speech problems. The conversion Furlow palatoplasty for VPI can be performed with the addition of buccal flaps to provide additional tissue for palatal repair. In this study, the authors aimed to determine the effectiveness of buccal flaps with conversion Furlow palatoplasty in secondary management of VPI. A retrospective review of patients undergoing surgical repair of VPI between 2016 and 2020 was performed. Patients underwent either conversion Furlow palatoplasty alone (FA) or conversion Furlow palatoplasty with buccal flaps (FB) for VPI after primary straight-line repair of the palate. The authors reviewed medical records to collect demographics, operative information, and preoperative and postoperative speech scores. Of the 77 patients in the study, 16 (21%) had a revision that incorporated buccal flaps. The median age at cleft palate revision surgery was 8.97 years in the FA group and 7.96 years in the FB group ( P = 0.337). In the FA group, four patients (7%) developed a postoperative fistula, compared with zero patients in the FB group. The average time to follow-up after revision surgery was 3.4 years (range, 7 months to 5.9 years). Both cohorts demonstrated a decrease in hypernasality and total parameter scores postoperatively. The use of buccal flaps in revision Furlow palatoplasty could decrease the risk for postoperative complications. The use of data from a larger patient population from multiple institutions is warranted to determine true significance. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

We are moving the needle: Improving racial disparities in immediate breast reconstruction.

BACKGROUND: Although racial disparities in receipt of immediate breast reconstruction (IBR) have been previously reported, prior studies may not have fully assessed the impact of recent advocacy efforts as healthcare disparities gain increased national attention. The aim of this study is to assess more recent racial differences and annual trends in receiving IBR. METHODS: Using the National Surgery Quality Improvement Program database, black or white women over 18 years who underwent mastectomy from 2012 to 2021 were included. IBR was defined by undergoing mastectomy with breast reconstruction during the same anesthetic event. Propensity score analysis was utilized to balance variables between black and white patients. A multivariate logistic regression was performed to determine the effect of race on the odds of receiving IBR. RESULTS: The annual percentage of white patients receiving IBR remained stable at around 50% throughout the study period. The annual percentage of black patients receiving IBR increased from 34% in 2012 to 49% in 2021. Compared with white patients, black patients had lower odds of receiving IBR during the entire study period (odds ratio 0.57, 95% confidence interval 0.49-0.67). When assessing annual trends, black patients were less likely to receive IBR each year from 2012 to 2017. By 2021, both races had similar odds of IBR. CONCLUSIONS: Although racial disparities in IBR have been longstanding, this study demonstrates that the racial gap appears to be closing. This may be because of increased awareness of racial disparities and their impact on patient outcomes.

"Healthcare Disparities in the Care of Children with Craniosynostosis in the United States: A Systematic Review".

BACKGROUND: Healthcare inequity is a pressing concern in pediatric populations with craniofacial conditions. Little is known about the barriers to care affecting children with craniosynostosis. This systematic review investigates disparities impacting care for children with craniosynostosis in the U.S. METHODS: A comprehensive literature search was performed in the following databases from inception to December 2022: Ovid MEDLINE, Ovid EMBASE, and The Cochrane Library. Studies were screened for eligibility by two authors. All original articles that focused on disparities in access, treatment, or outcomes of craniosynostosis surgery were included. Studies describing disparities in other countries, those not written English, and review articles were excluded (Figure 1). RESULTS: An initial database search revealed 607 citations of which 21 met inclusion criteria (Figure 1). All included studies were retrospective reviews of databases or cohorts of patients. The results of our study demonstrate that barriers to access in treatment for craniosynostosis disproportionally affect minority children, children of non-English speaking parents and those of lower socioeconomic status or with Medicaid. Black and Hispanic children, non-English speaking patients, and children without insurance or with Medicaid were more likely to present later for evaluation, ultimately undergoing surgery at an older age. These patients were also more likely to experience complications and require blood transfusions compared to their more privileged, white peers. CONCLUSIONS: There is a discrepancy in treatment received by minority patients, patients with Medicaid, and those who are non-English speaking. Further research is needed to describe the specific barriers that prevent equitable care for these patients.

Evaluation of Helmeting Therapy Duration After Endoscopic Strip Craniectomy for Metopic and Sagittal Craniosynostosis.

INTRODUCTION: Endoscopic strip craniectomy (ESC) is a minimally invasive option for early surgical treatment of metopic (MC) and sagittal craniosynostosis (SC). For ESC, however, the postoperative duration and compliance of helmet therapy are crucial to correct MC and SC asymmetry. The purpose of this study is to assess the period of postoperative band therapy and determine differences, if any, between MC and SC. METHODS: A single-institution retrospective review was performed for patients with MC and SC who underwent ESC from November 2015 to 2019. Patients received preoperative, postoperative, and post-band 3-dimensional imaging. Factors recorded included patient sex, insurance type, number of helmets needed, age at surgery, time of first helmet, and at time of completion of helmet therapy, cephalic index, interfrontal angle, and cranial vault asymmetry index. RESULTS: Patients with SC and MC had ESC surgery at 3.3 and 3.4 months of age, respectively.Patients with SC were found to have completed banding therapy at a younger age (7.88 versus 10.0 mo), with shorter duration (4.17 versus 6.00 mo), and less number of bands (1.54 versus 2.21) than patients with MC. After regression analysis, suture type was found to be a significant predictor of total time in band therapy (P=0.039) with MC requiring a longer duration of banding therapy when compared with SC. CONCLUSIONS: Suture type directly correlates with duration of helmeting therapy for patients, with patients with MC requiring longer periods of postop helmeting and increased number of bands as compared with SC.

Can Craniosynostosis be Diagnosed on Physical Examination? A Retrospective Review.

Craniosynostosis is a developmental craniofacial defect in which one or more sutures of the skull fuse together prematurely. Uncorrected craniosynostosis may have serious complications including elevated intracranial pressure, developmental delay, and blindness. Proper diagnosis of craniosynostosis requires a physical examination of the head with assessment for symmetry and palpation of sutures for prominence. Often, if craniosynostosis is suspected, computed tomography (CT) imaging will be obtained. Recent literature has posited that this is unnecessary. This study aims to address whether physical examination alone is sufficient for the diagnosis and treatment planning of single suture craniosynostosis. Between 2015 and 2022, the Divisions of Pediatric Neurosurgery and Pediatric Plastic Surgery at UTHealth Houston evaluated 140 children under 36 months of age with suspected craniosynostosis by physical examination and subsequently ordered CT imaging for preoperative planning. Twenty-three patients received a clinical diagnosis of multi-sutural or syndromic craniosynostosis that was confirmed by CT. One hundred seventeen patients were diagnosed with single suture craniosynostosis on clinical examination and follow-up CT confirmed suture fusion in 109 (93.2%) patients and identified intracranial anomalies in 7 (6.0%) patients. These patients underwent surgical correction. Eight (6.8%) patients showed no evidence of craniosynostosis on CT imaging. Treatment for patients without fused sutures included molding helmets and observation alone. This evidence suggests that physical examination alone may be inadequate to accurately diagnose single suture synostosis, and surgery without preoperative CT evaluation could lead to unindicated procedures.

It's Hip to Go Home: An Evaluation of Outpatient Alveolar Bone Grafting in Patients With Cleft Palate.

INTRODUCTION: Secondary alveolar bone grafting (ABG) is a common procedure performed at cleft care centers used to fill the alveolar cleft. The advent of techniques such as minimally invasive trephine drill harvest and placement of continuous-infusion pain pumps at the donor site has made outpatient ABG an increasingly feasible and cost-effective procedure. However, enhanced recovery after surgery protocols to maximize pain control and recovery times for this patient population have not been well established. METHODS: A retrospective single-institution review was conducted of pediatric patients with cleft palate who underwent iliac crest bone graft ABG at a large urban academic children's hospital from 2017 to 2022. Patient age, alveolar cleft repair laterality, pain scores, surgery duration, hospital LOS, readmissions, and re-operations within 30 days were examined. RESULTS: Fifty-four patients met our inclusion criteria. Fifty patients (92.6%) received a pain pump during the operation. The median duration of surgery and LOS in the post-anesthesia care unit were 1.28 and 1.75 hours, respectively. Fifty-two patients (96.3%) were discharged on the same day as their surgery whereas 2 patients (3.7%) stayed in the hospital overnight. The median pain score at the time of discharge was 0 (interquartile range 0, 0). There were 6 (11.1%) minor complications including 5 pain pump malfunctions and 1 recipient site wound breakdown. There was 1 readmission (1.9%) for development of a surgical site infection at the hip and no re-operations within 30 days of surgery. CONCLUSION: The described outpatient ABG protocol demonstrates effective postoperative pain control, short hospital LOS, and few complications requiring hospital readmission or reoperation.

Defining the Incidence of the Impostor Phenomenon in Academic Plastic Surgery: A Multi-Institutional Survey Study.

BACKGROUND: Impostor phenomenon occurs when high-achieving individuals have persistent self-doubt despite objective measures of competence and success, and has been associated with professional burnout and attenuated career advancement in medical specialties. This study aimed to define the incidence and severity of the impostor phenomenon in academic plastic surgery. METHODS: A cross-sectional survey containing the Clance Impostor Phenomenon Scale (0-100; higher scores indicating greater severity of impostor phenomenon) was distributed to residents and faculty from 12 academic plastic surgery institutions across the United States. Generalized linear regression was used to assess demographic and academic predictors of impostor scores. RESULTS: From a total of 136 resident and faculty respondents (response rate, 37.5%), the mean impostor score was 64 (SD 14), indicating frequent impostor phenomenon characteristics. On univariate analysis, mean impostor scores varied by gender (Female: 67.3 vs. Male: 62.0; p=0.03) and academic position (Residents: 66.5 vs. Attendings: 61.6; p=0.03), but did not vary by race/ethnicity, post-graduate year of training among residents, or academic rank, years in practice, or fellowship training among faculty (all p>0.05). After multivariable adjustment, female gender was the only factor associated with higher impostor scores among plastic surgery residents and faculty (Estimate 2.3; 95% Confidence Interval 0.03-4.6; p=0.049). CONCLUSION: The prevalence of the impostor phenomenon may be high among residents and faculty in academic plastic surgery. Impostor characteristics appear to be tied more to intrinsic characteristics, including gender, rather than years in residency or practice. Further research is needed to understand the influence of impostor characteristics on career advancement in plastic surgery.

The Limit Is Zero: A Prospective Evaluation of Ketorolac in Patients Undergoing Primary Palatoplasty to Reduce Narcotic Utilization.

BACKGROUND: Patients undergoing primary palatoplasty rely on narcotics for pain control, but narcotics can lead to sedation and respiratory depression. Recent research into Enhanced Recovery After Surgery (ERAS) pathways utilizing multimodal pain therapy has yielded promising results for patients undergoing palatoplasty in terms of decreased hospital length of stay (LOS), increased oral intake, and decreased narcotic usage. Despite the potential benefit of ketorolac after palatoplasty, there is a paucity of data regarding its use. METHODS: A single-center cohort study of patients undergoing primary palatoplasty was performed using 2 cohorts: a retrospective cohort treated with our institution's prior ERAS protocol from 2016 to 2018 and a prospective group of patients who also received ketorolac (ERAS+K) postoperatively from 2020 to 2022. RESULTS: A total of 85 patients (57 ERAS and 28 ERAS+K) were included. Compared with the ERAS group, the ERAS+K cohort had significantly decreased LOS (31.8 versus 55 h, P =0.02), decreased morphine milligram equivalents administered at 24 hours (1.5 versus 2.5, P =0.003), 48 hours (0 versus 1.5, P <0.001), and total inpatient morphine milligram equivalents (1.9 versus 3.8, P =0.001). The ERAS+K group also had a significant decrease in the prescribed narcotic rate (32.1% versus 61.4%, P =0.006). No bleeding issues, blood transfusions, or reoperations were noted in either cohort. CONCLUSIONS: This study illustrates many potential benefits of using ketorolac as a pain management adjunct in combination with a multimodal pain regimen. Our results demonstrated favorable outcomes, including decreased narcotic usage and LOS as well as increased hourly oral intake, without increasing bleeding complications.

Monkeypox Presenting as a Hand Consult in the Emergency Department: Two Case Reports.

The ongoing outbreak of the monkeypox virus (now referred to as "mpox") was deemed a public health emergency by the World Health Organization in 2022. The United States now reports the highest number of mpox cases, with 29 980 cases and 21 deaths as of January 11, 2023. The most common presenting symptom is a pruritic, vesicular rash that commonly involves the hands. While covering hand call, our division has encountered 2 cases of mpox in the emergency department for which the chief complaint was a hand lesion. Because hand surgeons will be called upon to make an initial diagnosis, the purpose of these case reports is to describe the presentation, disease course, treatment, and outcomes of these mpox patients. These patients had both uncontrolled HIV as well as other sexually transmitted disease. Symptoms included painful vesicular hand lesions with ulceration and eventual central necrosis, followed by similar lesions on the face, trunk, and genital area. Diagnosis was made using nucleic acid amplification testing through polymerase chain reaction. The patients were treated with restoration of immunity through control of HIV as well as treatment of all secondary bacterial infections. One patient died in the hospital, and the other survived without any long-term defects.

Characterization of Regional Morphological Changes in Sagittal Craniosynostosis Following Endoscopic Strip Craniectomy With Post-operative Helmeting: Predictors for Success.

BACKGROUND: Sagittal craniosynostosis (SC) restricts craniofacial growth perpendicular to the sagittal plane resulting in scaphocephaly. The cranium grows in the anterior-posterior dimension causing disproportionate changes, which can be corrected with either cranial vault reconstruction (CVR) or endoscopic strip craniectomy (ESC) combined with post-operative helmet therapy. ESC is performed at an earlier age, and studies demonstrate benefits in risk profile and morbidity compared to CVR, with comparable results if the post-operative banding protocol is strictly upheld. We aim to identify predictors of successful outcome and, using three-dimensional (3D) imaging, assess cranial changes following ESC with post-banding therapy. MATERIALS AND METHODS: A single institution retrospective review was performed from 2015-19 for patients with SC who underwent ESC. Patients received immediate post-operative 3D photogrammetry for helmet therapy planning and implementation as well as post-therapy 3D imaging. Using these 3D images, the cephalic index (CI) for study patients was calculated before and after helmet therapy. In addition, Deformetrica™ was used to measure volume and shape changes of pre-defined anatomic skull regions (frontal, parietal, temporal, & occipital) based on the pre- and post-therapy 3D imaging results. Fourteen institutional raters evaluated the pre- and post-therapy 3D imaging in order to determine the success of the helmeting therapy. RESULTS: Twenty-one SC patients met our inclusion criteria. Using 3D photogrammetry, 14 raters at our institution rated 16 of the 21 patients to have had successful helmet therapy. There was a significant difference in CI following helmet therapy with both groups, but there was no significant difference in CI between the "successful" and "unsuccessful" groups. Furthermore, the comparative analysis demonstrated that the parietal region had a significantly higher change in mean RMS distance when compared to the frontal or occipital regions. CONCLUSION: For patients with SC, 3D photogrammetry may be able to objectively recognize nuanced findings not readily detectable when using CI alone. The greatest changes in volume were observed in the parietal region, which falls in line with treatment goals for SC. Patients deemed to have unsuccessful outcomes were found to be older at time of surgery and initiation of helmet therapy. This suggests that early diagnosis and management for SC may increase the likelihood of success.

Repeat Buccal Flaps Successfully Reduce Hypernasality in a Patient with Cleft Palate.

Surgical intervention can contribute to the development of velopharyngeal insufficiency (VPI) leading to hypernasality and regurgitation. In this case, a patient with a history of bilateral buccal flaps used for her primary CP repair presented to clinic with hypernasality and VPI as assessed by speech exam and imaging. She underwent repeat bilateral buccal flap palatal lengthening with division of the pedicles 3 months later. Three months after her division, her hypernasality score improved from moderate to mild and her posterior gap decreased. This study concluded buccal flaps can be used a second time for patients needing palatal revisions for VPI.

Is the Message Clear? Evaluation of Readability Levels for Cleft Lip, Cleft Palate, and Craniofacial Websites.

Web-based health information is the leading source of medical knowledge for patients and families. The American Medical Association (AMA) and US Department of Health and Human Services recommend reading material be at or below a sixth-grade reading level. This study aimed to evaluate and compare the readability of the most popularly searched cleft lip and/or palate (CL/P) and other craniofacial syndrome (CFS) websites.Google searches for "cleft lip," "cleft palate," and "craniofacial syndromes" were performed to identify the top 40 websites in an incognito window with the location set to the United States. Flesch Reading Ease Score (FRES) was used to determine ease of reading from 0 (most difficult) to 100 (greatest ease of reading) and Flesch-Kincaid Reading Grade (FKGL) for website content and compared between websites using an FRES of 80 to 90 and FKGL of 6.0 to 6.9 for a sixth-grade reading level.Readability was low for all sites with 6 CL/P websites and no CFS websites at or below a sixth-grade reading level. CL/P websites had FRES readability scores of 58.5 ± 12.3 and were at a 9.4 ± 2.3 grade level. CFS websites had readability scores on the FRES of 39.8 ± 13.1 and were at a 10.8 ± 1.8 grade level.Web-based information related to CL/P and CFS is on average several grade levels above the recommended sixth-grade reading level. Online information for CL/P and CFS may need to be revised to improve understanding for the public and families.

Dual-Innervated Free Gracilis Muscle Transfer for Facial Reanimation in Children.

BACKGROUND: Facial palsy may have deleterious effects for pediatric patients. The most common reconstruction is 2-stage free gracilis muscle transfer (FGMT) after cross-face nerve graft (CFNG). This requires a prolonged period from time of surgery to smile. New techniques using both a CFNG and motor nerve to masseter (MNM) as dual power sources in a single-stage surgery have been described in adults. Here, we examine our experience with this technique in children. METHODS: A retrospective study was performed examining patients who underwent dual-innervated single-stage FGMT at 2 pediatric hospitals from 2016 to 2019. Demographics, etiology, perioperative characteristics, time to mandibular and emotional smile, and Sunnybrook scores were recorded. RESULTS: Five patients met inclusion criteria with a mean age of 11.8 (range, 8-20). Two patients had congenital facial palsy while 3 had acquired facial palsy. Four patients (80%) received dual end-to-end neural coaptations of the CFNG and MNM to the obturator nerve. One (20%) had end-to-side coaptation of the CFNG to the obturator nerve and end-to-end of the MNM to the obturator nerve. The average time to mandibular smile was 103 ± 15.4 days. The average time to emotional smile was 245 ± 48.1 days. The preoperative Sunnybrook scale was 32 ± 7.5 and improved to 55.3 ± 20.6 at 8 months postoperatively. CONCLUSIONS: Dual-innervated FGMT is effective for facial reanimation in children with unilateral facial palsy. Patients can harness a stronger motor source (MNM) and the component of an emotional stimulus (CFNG). This approach may be the new criterion standard pediatric facial reanimation.

Incidence of Readmission Following Pediatric Hand Surgery: An Analysis of 6600 Patients.

Background: Quality in surgical outcomes is frequently assessed by the 30-day readmission rate. There are limited data available in the published literature regarding readmission rates following pediatric hand surgery. This study aims to identify factors associated with an increased risk of readmission following hand surgery in a pediatric population. Methods: The 2012-2017 National Surgical Quality Improvement Project - Pediatric (NSQIP-P) databases were queried for pediatric patients who underwent procedures with hand-specific current procedural terminology (CPT) codes. The primary outcome was readmission. Results: A total of 6600 pediatric patients were identified and included in the analysis. There were 45 patients who were readmitted in the study cohort, giving an overall readmission rate of 0.68%. The median time to readmission was 12 (IQR 5-20) days. On univariate analysis, factors associated with readmission included younger age, smaller size, prematurity, higher American Society of Anesthesiologists (ASA) class, inpatient admission at index operation, and longer anesthesia and operative times. Complex syndactyly repair was also associated with higher readmission rates. On multivariate analysis, ASA class 3 or 4 and inpatient surgery remained significant predictors of readmission. Conclusions: Overall, pediatric hand surgery is associated with a very low risk of 30-day readmission. Higher ASA class and inpatient surgery increase patients' risk for readmission. In particular, complex syndactyly repair is associated with a higher risk of readmission than other hand procedures. This information is useful in surgical planning and preoperative counseling of parents.

Anterior Cranial Base Reconstruction in Complex Craniomaxillofacial Trauma: An Algorithmic Approach and Single-Surgeon's Experience.

Management of traumatic skull base fractures and associated complications pose a unique reconstructive challenge. The goals of skull base reconstruction include structural support for the brain and orbit, separation of the central nervous system from the aerodigestive tract, volume to decrease dead space, and restoration of the three-dimensional appearance of the face and cranium with bone and soft tissues. An open bicoronal approach is the most commonly used technique for craniofacial disassembly of the bifrontal region, with evacuation of intracranial hemorrhage and dural repair performed prior to reconstruction. Depending on the defect size and underlying patient and operative factors, reconstruction may involve bony reconstruction using autografts, allografts, or prosthetics in addition to soft tissue reconstruction using vascularized local or distant tissues. The vast majority of traumatic anterior cranial fossa (ACF) injuries resulting in smaller defects of the cranial base itself can be successfully reconstructed using local pedicled pericranial or galeal flaps. Compared with historical nonvascularized ACF reconstructive options, vascularized reconstruction using pericranial and/or galeal flaps has decreased the rate of cerebrospinal fluid (CSF) leak from 25 to 6.5%. We review the existing literature on this uncommon entity and present our case series of n = 6 patients undergoing traumatic reconstruction of the ACF at an urban Level 1 trauma center from 2016 to 2018. There were no postoperative CSF leaks, mucoceles, episodes of meningitis, or deaths during the study follow-up period. In conclusion, use of pericranial, galeal, and free flaps, as indicated, can provide reliable and durable reconstruction of a wide variety of injuries.

Forecasting the flap: predictors for pediatric lower extremity trauma reconstruction.

BACKGROUND: Predicting the need for post-traumatic reconstruction of lower extremity injuries remains a challenge. Due to the larger volume of cases in adults than in children, the majority of the medical literature has focused on adult lower extremity reconstruction. This study evaluates predictive risk factors associated with the need for free flap reconstruction in pediatric patients following lower extremity trauma. METHODS: An IRB-approved retrospective chart analysis over a 5-year period (January 1, 2012 to December 31, 2017) was performed, including all pediatric patients (<18 years old) diagnosed with one or more lower extremity wounds. Patient demographics, trauma information, and operative information were reviewed. The statistical analysis consisted of univariate and multivariate regression models to identify predictor variables associated with free flap reconstruction. RESULTS: In total, 1,821 patients were identified who fit our search criteria, of whom 41 patients (2.25%) required free flap reconstruction, 65 patients (3.57%) required local flap reconstruction, and 19 patients (1.04%) required skin graft reconstruction. We determined that older age (odds ratio [OR], 1.134; P =0.002), all-terrain vehicle accidents (OR, 6.698; P<0.001), and trauma team activation (OR, 2.443; P=0.034) were associated with the need for free flap reconstruction following lower extremity trauma in our pediatric population. CONCLUSIONS: Our study demonstrates a higher likelihood of free flap reconstruction in older pediatric patients, those involved in all-terrain vehicle accidents, and cases involving activation of the trauma team. This information can be implemented to help develop an early risk calculator that defines the need for complex lower extremity reconstruction in the pediatric population.

Back to the Beginning: An Algorithmic Approach to Neonatal Myelomeningocele Repair.

INTRODUCTION: Myelomeningoceles are formed by prenatal failure of neural tube closure and can cause hydrocephalus, motor abnormalities, and developmental delay. Although small defects are amenable to primary closure, larger defects often require complex reconstruction. Our goal was to identify factors associated with postoperative soft tissue complications and develop a systematic approach for myelomeningocele closure. METHODS: A retrospective review was performed at the Children's Memorial Hermann Hospital from January 2013 to January 2019. Patients were identified using International Classification of Diseases, Ninth Revision/Tenth Revision , codes for myelomeningocele. Cohorts were stratified by reconstruction type and defect location. Primary outcomes were incidence of complications including cerebrospinal fluid leak, superficial and deep infection, and wound dehiscence. In addition, we developed an algorithm to standardize closure approach for patients with myelomeningoceles. RESULTS: A total of 172 patients with myelomeningocele were identified with 73 patients undergoing postnatal repair. Overall, 72% of defects were >5 cm. Defects were in the lumbar (9%), sacral (8%), and junctional (83%) regions. Overall, 30.1% patients underwent lumbar myofascial repair with 39.7% requiring fasciocutaneous flaps. Larger defects (>5 cm) were more likely to be closed with complex fasciocutaneous flaps (82.8% vs 66.0%, P = 0.11). No significant differences were observed in complication rates. CONCLUSIONS: In this series, patients with larger myelomeningoceles appear to benefit from complex flap closure. We propose a 5-layer closure for patients with myelomeningocele including the routine use of a myofascial layer. Cutaneous closure technique should be tailored based on specific defect characteristics as outlined in our algorithm. This approach streamlines myelomeningocele repair while optimizing outcomes and decreasing downstream complications.