Migraine Surgery: An All or Nothing Phenomenon? Prospective Evaluation of Surgical Outcomes.

OBJECTIVE: A detailed analysis of outcomes after migraine surgery suggests an anatomic etiology of pain, such as peripheral nerve compression, in select patients. BACKGROUND: Historically, surgeons have not played a role in the treatment of migraine. However, a subgroup of patients with extracranial anatomic triggers appear to benefit from surgical intervention. Traditionally, the determination of success or failure of migraine surgery is based on whether there is greater or less than 50% improvement of the migraine headache index (MHI) after surgery. However, in this study, patients either did not respond to treatment (≤5%) or improved completely (≥80%). Detailed analysis is provided of this surprising finding. METHODS: Subjects completed a prospective migraine questionnaire preoperatively as well as at 3 and 12 months postoperatively. RESULTS: All variables improved significantly from baseline. Interestingly, in 83% of patients, the MHI improved either ≥80% or ≤5%, suggesting a more binary distribution. Only 17% of indices fell in the intermediate (5% to 80%) range. Moreover, 69% of patients had ≥80% improvement resulting in a mean improvement of 96% in this group. The remaining 14% had ≤5% improvement, with an average improvement of 0%. CONCLUSION: Migraine surgery remains controversial. Traditional conservative therapy targets the central theory of migraine propagation. This study again prospectively demonstrates the efficacy of surgical trigger site deactivation in migraine patients. Patients either failed to improve or improved after surgery, with few intermediate outcomes. The binary distribution of data lends further support to an anatomic etiology of pain, that is, peripheral nerve compression, in select patients.

Cleft Lip Standardized Patient Examinations: The Role in Plastic Surgery Resident Education.

BACKGROUND: Our institution has incorporated the use of objective structured clinical examinations (OSCE) in our residency curriculum. The OSCE provides trainee education and evaluation while addressing the six Accreditation Council for Graduate Medical Education (ACGME) core competencies required within training programs. We report our program's experience with the first cleft OSCE ever conducted. METHODS: A validated method for administration of OSCEs currently used at our medical school was utilized for residents in postgraduate years (PGYs) 3 through 6. The video-recorded patient encounter involved a 1-month-old newborn with a unilateral cleft lip and palate and used standardized patient actors as parents. A post-encounter written exam assessed medical knowledge. A questionnaire regarding the utility of the exercise was administered to residents after the OSCE. Results were evaluated using analysis of variance (P < .05). RESULTS: There was a positive correlation with increasing level of training in terms of medical knowledge (P < .04). Residents in PGY-3 and PGY-4 demonstrated lower understanding of the surgical markings and details of the lip repair compared with those in PGY-5 and PGY-6 (P < .03). All residents performed similarly on evaluation of the remaining ACGME core competencies. All residents agreed that this was a realistic and useful encounter. CONCLUSION: Results of our cleft OSCE demonstrate that medical knowledge regarding the evaluation, management, and surgical repair of patients is less in midlevel residents. All residents expressed an interest in earlier exposure to pediatric patients in the training period. Although a cleft OSCE does not replace clinical rotations, it is a valuable adjunct to training and evaluation of trainees, particularly for junior residents.

Canonical and non-canonical aryl hydrocarbon receptor signaling pathways.

Decades of research on the Aryl hydrocarbon Receptor (AhR) has unveiled its involvement in the toxicity of halogenated and polycyclic aromatic hydrocarbons, and a myriad of normal physiological processes. The molecular dissection of AhR biology has centered on a canonical signaling pathway in an effort to mechanistically reconcile the diverse pathophysiological effects of exposure to environmental pollutants. As a consequence, we now know that canonical signaling can explain many but not all of the AhR-mediated effects. Here we describe recent findings that point to non-canonical signaling pathways, and focus on a novel AhR interaction with the Krüppel-like Factor 6 protein responsible for previously un-recognized epigenetic changes in the chromatin affecting gene expression.

Rhinoplasty Education Using a Standardized Patient Encounter.

BACKGROUND: Comprehensive aesthetic surgery training continues to be a challenge for residency programs. Our residency program developed a rhinoplasty-based objective structured clinical examination (OSCE) based upon validated methods as part of the residency education curriculum. We report our experience with the rhinoplasty-based OSCE and offer guidance to its incorporation within residency programs. METHODS: The encounter involved resident evaluation and operative planning for a standardized patient desiring a rhinoplasty procedure. Validated OSCE methods currently used at our medical school were implemented. Residents were evaluated on appropriate history taking, physical examination, and explanation to the patient of treatment options. Examination results were evaluated using analysis of variance (statistical significance P<0.05). RESULTS: Twelve residents completed the rhinoplasty OSCE. Medical knowledge assessment showed increasing performance with clinical year, 50% versus 84% for postgraduate year 3 and 6, respectively (P<0.005). Systems-based practice scores showed that all residents incorrectly submitted forms for billing and operative scheduling. All residents confirmed that the OSCE realistically represents an actual patient encounter. All faculty confirmed the utility of evaluating resident performance during the OSCE as a useful assessment tool for determining the Next Accreditation System Milestone level. CONCLUSIONS: Aesthetic surgery training for residents will require innovative methods for education. Our examination showed a program-educational weakness in billing/coding, an area that will be improved upon by topic-specific lectures. A thoroughly developed OSCE can provide a realistic educational opportunity to improve residents' performance on the nonoperative aspects of rhinoplasty and should be considered as an adjunct to resident education.

Clinical Significance of Internal Mammary Lymph Node Biopsy during Microsurgical Breast Reconstruction: Review of 264 Cases.

BACKGROUND: Despite the knowledge of alternate lymphatic draining patterns of the breast, routine evaluation of the internal mammary lymph node basin is still not considered standard of care. The advent of microsurgical breast reconstruction using the internal mammary vessels as recipients, however, has allowed sampling of internal mammary lymph nodes with technical ease, thus revisiting their role in breast cancer management. In the present study, the authors reviewed their experience with this practice. METHODS: A retrospective analysis of patients who underwent internal mammary lymph node biopsy at the time of autologous breast reconstruction using the internal mammary vessels between 2004 and 2012 was performed. Parameters of interest included patient age, timing of reconstruction (immediate versus delayed), disease stage, and pathologic findings of internal mammary lymph nodes. RESULTS: A total of 264 autologous breast reconstructions using the internal mammary vessels were performed in 204 patients with a median age of 44.5 years. The majority of reconstructions were immediate [n = 211 (79.9 percent)]. Seventy-two percent of patients had either stage I [72 patients (35.3 percent)] or stage II disease [75 patients (36.8 percent)]. Six patients were found to have internal mammary lymph node metastasis. Stage migration and alteration in adjuvant therapy occurred in all patients. CONCLUSION: Internal mammary lymph node sampling at the time of autologous breast reconstruction using the internal mammary system should become routine practice, as the morbidity associated with internal mammary lymph node harvest is low and the impact in cases of nodal involvement is quite substantial. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Facelift combined with simultaneous fractional laser resurfacing: Outcomes and complications.

BACKGROUND: The combination of simultaneous surgical rhytidectomy with ablative resurfacing has been a controversial procedure due to the concern of postoperative wound healing. Traditional ablative resurfacing lasers are believed to have higher rates of complications, leading to delayed healing and skin flap loss when combined with face rhytidectomy surgeries. With the development of fractionated ablative laser therapy, there has been increased interest in combining these two procedures. The objective of this study is to evaluate the clinical outcomes of patients undergoing simultaneous full-face rhytidectomy in combination with fractionated ablative skin resurfacing. METHODS: A retrospective chart analysis was performed for all patients who had a combined procedure of facelift and ablative fractional laser resurfacing from 2008 to 2013 by the senior author (SKS). Postoperative recovery and complications were recorded. The surgical technique used for performing the facelift was an extended supraplatysmal dissection with SMAS plication. Fraxel Re:Pair 10,600-nm fractional carbon dioxide laser was used to perform an ablative resurfacing including the elevated skin flaps. RESULTS: A total of 86 patients were included. Average age was 60.01 years (range of 45-78 years). Longest follow up was five years. The average size of the elevated skin flaps was 100 cm(2). Average skin type was a Fitzpatrick type 2. All patients had complete re-epithelialization by one week after their procedure. Four patients (4.6%) experienced acne outbreaks. Four patients (4.6%) had facial erythema that persisted greater than two weeks. Of these four patients, all resolved by five weeks postoperatively. There was no delayed wound healing or skin flap loss observed. CONCLUSION: Our results indicate that simultaneous rhytidectomy with fractionated ablative laser resurfacing does not cause an increase in wound healing or skin loss. Due to improved patient outcomes with combining these procedures, we believe that this can be increasingly offered as a safe combination.

Cardiac transplant outcomes in pediatric patients with pre-formed anti-human leukocyte antigen antibodies and/or positive retrospective crossmatch.

BACKGROUND: Children undergoing heart transplantation who have preformed anti-human leucocyte antigen (HLA) panel reactive antibodies (PRA) or positive retrospective crossmatch (XM) may be at increased risk for rejection and graft failure. We assessed outcomes of transplant recipients with either positive PRA before transplant or positive retrospective XM. METHODS: A review of 148 heart transplant patients between 1990 and 2006 was undertaken, identifying transplants in patients with pre-transplant PRA > 1% and/or a positive XM. Demographic information and detailed post-transplant outcomes including episodes of rejection, infection, and graft failure were recorded. RESULTS: There were 11 PRA positive (PRA+) transplants, 135 PRA negative (PRA-) transplants, and no PRA data on 2. There were 14 XM+ transplants, 115 XM- transplants, and no XM data on 19. Kaplan-Meier graft survival was better in XM- than XM+ patients (p < 0.015), but not different between PRA+ and PRA- Groups. Timing of first rejection and number of rejection episodes were not different between XM+ and XM- Groups or between PRA+ and PRA- Groups. Infections were not different between PRA or XM Groups. Four patients were PRA+/XM- (all PRA, 1%-10%), 7 were PRA-/XM+, and 7 were PRA+/XM+ (6 of 7 PRA >10%). CONCLUSIONS: Pediatric heart transplant patients whose retrospective XM is positive are at significantly increased risk for graft failure. Elevated pre-transplant PRA may not predict increased risk of graft failure, although markedly positive PRA (>10%) predicts a positive retrospective XM. Improved treatment for pediatric transplant patients with a positive retrospective XM is needed.