Robotic-Assisted Peripheral Nerve Surgery: A Systematic Review.

BACKGROUND: Robotic-assisted techniques are a tremendous revolution in modern surgery, and the advantages and indications were well discussed in different specialties. However, the use of robotic technique in plastic and reconstructive surgery is still very limited, especially in the field of peripheral nerve reconstruction. This study aims to identify current clinical applications for peripheral nerve reconstruction, and to evaluate the advantages and disadvantages to establish potential uses in the future. METHODS: A review was conducted in the literatures from PubMed focusing on currently published robotic peripheral nerve intervention techniques. Eligible studies included related animal model, cadaveric and human studies. Reviews on robotic microsurgical technique unrelated to peripheral nerve intervention and non-English articles were excluded. The differences of wound assessment and nerve management between robotic-assisted and conventional approach were compared. RESULTS: Total 19 studies including preclinical experimental researches and clinical reports were listed and classified into brachial plexus reconstruction, peripheral nerve tumors management, peripheral nerve decompression or repair, peripheral nerve harvesting, and sympathetic trunk reconstruction. There were three animal studies, four cadaveric studies, eight clinical series, and four studies demonstrating clinical, animal, or cadaveric studies simultaneously. In total 53 clinical cases, only 20 (37.7%) cases were successfully approached with minimal invasive and intervened robotically; 17 (32.1%) cases underwent conventional approach and the nerves were intervened robotically; 12 (22.6%) cases converted to open approach but still intervened the nerve by robot; and 4 (7.5%) cases failed to approach robotically and converted to open surgery entirely. CONCLUSION: Robotic-assisted surgery is still in the early stage in peripheral nerve surgery. We believe the use of the robotic system in this field will develop to become popular in the future, especially in the fields that need cooperation with other specialties to provide the solutions for challenging circumstances.

International Microsurgery Club: An Effective Online Collaboration System.

BACKGROUND: This study aimed to determine if International Microsurgery Club (IMC) is an effective online resource for microsurgeons worldwide, in providing an avenue for timely group discussions and advice regarding complicated cases, and an avenue for collaboration and information sharing. METHODS: All posts on the IMC Facebook group from member 1 to 8,000 were analyzed according to inclusion criteria and categorized into three categories-case discussion, question, and information sharing. Posts were retrospectively analyzed for number of responses, time of responses, number of "likes," number of treatment options, time of day, and demographics of authors and responders. RESULTS: A retrospective analysis of 531 cases showed an average response rate of 75.7% within 1 hour and as membership grew. The response rate stabilized averaging between 72.5 and 78% across all times of the day. An average of 11.8 microsurgeons was involved per case discussion, and 5.7 treatment options were provided per case. CONCLUSION: IMC is shown to be an effective resource to allow microsurgeons to access timely advice from other microsurgeons without time and distance limitation, and to have interactive group discussions on complicated cases.

Aesthetic restoration of fronto-orbital deformity with prefabricated implant utilizing modeling clay and rapid-prototyping technology.

Skeletal deformity in the fronto-orbital region resulting from various problems can have significant aesthetic concerns. Restoring an aesthetically acceptable appearance relies most importantly on the restoration of a precise skeletal contour. Current surgical options for depression deformities or partial-thickness defects range from extensive corrective osteotomies to less complicated methods of onlay grafting with autogenous or alloplastic materials. Both methods have difficulties in providing a symmetric and smooth contour for predictable and reliable cosmetic results. Alloplastic implants provide another effective alternative and the success of the skeletal contouring correlates directly with the accuracy of the implant sculpture. Prefabricated methylmethacrylate implants, with the aid of modeling clay, computer imaging, and modern rapid-prototyping technologies, fits the depression deformity well and balances the skeletal contour. It provides plastic surgeons greater precision in customizing the implant, which ensures better predictability and reliability of cosmetic outcomes.

Facial nerve palsy after sagittal split ramus osteotomy of the mandible: mechanism and outcomes.

PURPOSE: Facial nerve palsy after sagittal split ramus osteotomy of the mandible (SSRO) is a rare, but serious, complication. The aim of the present study was to evaluate the incidence of this complication, the possible causative mechanisms, its subsequent management, and eventual outcomes. PATIENTS AND METHODS: All patients who underwent SSRO of the mandible at the Craniofacial Center, Chang Gung Memorial Hospital, Taiwan, from 1981 to 2008 were included in the present study. The patients reported as having postoperative facial nerve paralysis were identified and reviewed. RESULTS: A total of 3,105 patients had undergone bilateral SSRO (6,210 sagittal splits). Of these 3,105 patients, 6 were reported as having unilateral facial nerve palsy postoperatively, for an incidence of 0.1%. One case was diagnosed as Bell's palsy. None of the patients with postoperative facial nerve palsy required surgical intervention, but all received physical therapy and medications. Complete recovery was obtained without sequela in all but 1 patient, who had incomplete frontal branch recovery. CONCLUSIONS: Most facial nerve palsies that occur after SSRO of the mandible result from neurapraxia or axonotmesis, possibly from nerve compression or traction. Complete recovery can be expected in most cases, and conservative management without surgical exploration is recommended.

Surgical repair for macrostomia: significance of Z-plasty limb directions.

The objective of this study was to determine whether the direction of Z-plasty limbs incorporated into the surgical repair for macrostomia had a significant influence on the quality of the resultant scar. A total of 41 patients who underwent macrostomia repair by means of the same technique, and who had a follow up period of at least 2 years, were retrospectively reviewed through postoperative photographs and medical records. Quality of scar, lip symmetry, and commissure shape and thickness were recorded. Our results showed that a more favorable scar would be achieved in the medial limb of the Z-plasty if it was planned parallel to relaxed skin tension lines (P < 0.05). An unfavorable scar would be more likely if the medial limb of the Z-plasty was made in a horizontal direction or perpendicular to relaxed skin tension lines (P < 0.05). The quality of scar in both the central and lateral limbs of the Z-plasty was not significantly influenced by their direction.

Surgical management of Binder's syndrome: lessons learned.

Maxillonasal dysplasia, commonly known as Binder's syndrome, is unmistakably characterized by midfacial hypoplasia and a retruded flat nose. The condition is variably expressed, and reconstruction must be tailored to the individual. Controversy still exists over the optimal age for surgery and the ideal treatment strategy. In a review of 24 patients with Binder's syndrome treated at the Chang Gung Craniofacial Centre over a period of 17 years, the authors examine the evolution of their experience treating patients with this condition. Maxillary osteotomies were rarely required and were reserved only for patients with severe and symptomatic class 3 malocclusion. Effective augmentation of the skeletal deficiencies in the midface was achieved with onlay bone or cartilage grafts. Nasal augmentation was performed with bone or cartilage grafts to the dorsum, columella, and tip. Cartilage is preferred over bone as graft material because it retains its volume and is less prone to resorption. Silastic implants can be a useful adjunct to cartilage in cases for which donor availability is limited. To minimize the risk of infection and extrusion, however, silastic implants are always limited to the nasal dorsum and always used in conjunction with cartilage grafts to the columella and tip. The authors prefer to defer surgery until midfacial growth is nearly complete, when the patient is in his or her mid-teenage years. Earlier surgery is indicated if the condition presents a significant psychological strain to the patient. In such cases, a silastic nasal implant can be used as a temporary corrective measure.

Undertreatment of osteoporosis following hip fracture: a retrospective, observational study in Singapore.

Undertreatment of osteoporosis after hip fracture increases the risk of death, disability, recurrent osteoporotic fractures, and financial burden. Only half were compliant with osteoporosis medications. Elderly patients were less persistent and compliant to treatment. Denosumab was associated with a higher proportion of days covered by osteoporosis medications than oral bisphosphonates. PURPOSE: The aim of this study was to identify factors that contributed to the initiation of osteoporosis medications following hip fracture as well as the compliance and persistence to osteoporosis medications. METHODS: Clinical data of 532 patients older than 50 years old admitted for surgical fixation of hip fractures were reviewed. Three hundred forty-seven had sufficient data for analysis after excluding patients with non-fragility fractures. Prescription for any osteoporosis medication in the year following hip fracture as well as compliance to treatment was evaluated. RESULTS: Only 40.3% of patients were prescribed with osteoporosis medication within 1 year post-hip fracture. Females (p = 0.020) performing dual-energy x-ray absorptiometry scan (p < 0.001) and 25 hydroxyvitamin D levels testing post-hip fracture (p < 0.027) were independent determinants of increased likelihood of being prescribed with osteoporosis medication. Patients with proportion of days covered (PDC) ≥ 0.8 (or 80% of days covered in a year) were defined as compliant. Overall, only 49.7% of the patients were compliant with osteoporosis medications. Elderly patients aged 70-79 years (p = 0.002) and males (p = 0.017) were less persistent with osteoporosis treatment when compared with patients aged < 69 years and females. The compliance was poorer in patients aged 70-79 years (p = 0.026) as compared with those under 69 years of age. Statistically significant difference (p = 0.032) was observed between mean PDC of oral bisphosphonates (0.66) and denosumab (0.83). Only 39.3% of patients were persistent with treatment at 1 year. CONCLUSION: Our findings demonstrate the urgent need to increase awareness through a structured protocol of osteoporosis treatment. A multi-disciplinary Fracture Liaison Service should be set up to ensure compliance to osteoporosis medication post-hip fracture.

Strategies for achieving long-term effective outcome in cleft missions: the Noordhoff Craniofacial Foundation and Chang Gung Memorial Hospital.

The Noordhoff Craniofacial Foundation and Chang Gung Memorial Hospital have partnered to deliver cleft programs to developing nations still in need of adequate cleft care. The lessons learnt through the development of the Chang Gung Cleft and Craniofacial Center from humble beginnings to its current international standing have enabled insights into devising key strategies for achieving long-lasting and compounding outcome in cleft missions. Close collaboration with local governing and health authorities, as well as establishment of ongoing support from charitable organizations that share similar philosophies, is an essential component to creating growth and sustainability of a cleft program. Identification of local "seed" physicians and key personnel, and their subsequent training at a major cleft center, is pivotal to the establishment of local cleft centers and cleft foundations that would ultimately empower local health care providers' autonomy in delivering the highest standard of care to patients with cleft in their own country.

Invasive Pneumococcal Disease Associated with Fanconi-Like Syndrome.

Acquired causes of Fanconi syndrome in adults are usually due to drugs, toxins or paraproteinaemias. Infectious causes are rarely described. We report a case of invasive pneumococcal disease in a patient who developed a Fanconi-like syndrome during the course of her illness. This patient presented with multiple electrolyte derangements consisting predominantly of hypokalaemia, hypomagnesaemia and hypophosphataemia during hospitalization for invasive pneumococcal disease with possible Austrian syndrome. Further evaluation revealed significant urinary losses of these electrolytes, uric acid and ß2-microglobulin. Together with evidence of hypouricaemia, this is suggestive of proximal renal tubulopathy, and hence a Fanconi-like syndrome. The patient's clinical condition and biochemical anomalies improved following pneumococcus treatment. LEARNING POINTS: Suspect Fanconi syndrome when there are multiple electrolyte derangements consisting of hypokalaemia, hypomagnesaemia and hypophosphataemia.Recognise the common causes of Fanconi syndrome and appreciate that infections such as legionellosis, leptospirosis and pneumococcal disease can potentially result in Fanconi syndrome.The management of Fanconi syndrome is generally supportive and involves treating the underlying cause.

Tips for Making a Successful Online Microsurgery Educational Platform: The Experience of International Microsurgery Club.

The presence of online learning resources has grown tremendously in recent years. They provide powerful and yet easily accessible means of learning and sharing knowledge. Online learning resources now encompass all aspects of medicine, and microsurgery is no exception. International Microsurgery Club is a closed, invitation-only group based on the Facebook social media platform. It was initiated on May 6, 2016, with the primary objectives of providing a convenient forum for discussing challenging cases, sharing valuable resources, and providing opportunities for research collaboration. The membership of International Microsurgery Club has grown to over 8700 at 2 years' existence, and continues to expand. International Microsurgery Club has become one of the largest online platforms for global microsurgeons. Here, the authors share their experience on how to establish a successful online platform for medical education.

Total pharyngolaryngectomy for squamous cell carcinoma of the hypopharynx: a review.

OBJECTIVES: To evaluate our experience with total pharyngolaryngectomy in the treatment of hypopharyngeal squamous cell carcinoma. STUDY DESIGN: Retrospective analysis of consecutively treated patients in an academic otolaryngology, head and neck department. METHODS: One hundred eighty patients who had total pharyngolaryngectomy performed for hypopharyngeal carcinoma were included in this study. Patients with a history of previous head and neck cancer were excluded. Clinicopathologic parameters were recorded and survival calculated using the Kaplan-Meier method. RESULTS: One hundred sixty-two (90%) of the patients were male, and the patients had a mean age of 62 years. The majority (91%) of patients had advanced overall clinical stage disease (stage 3,4). Thirty-one (17.8%) and 43 (24%) patients developed locoregional and metastatic disease recurrence, respectively. The 2- and 5-year disease-specific survival rates were 72% and 52%, respectively. Advanced nodal stage, perineural invasion, lymphovascular invasion, and positive margins were predictors of poor survival on univariate analysis, and lymphovascular invasion was an independent prognostic factor on multivariate analysis. CONCLUSION: Surgery and postoperative radiotherapy remains the treatment against which other modalities should be compared for advanced stage hypopharyngeal squamous cell carcinoma.

Patient satisfaction after zygoma and mandible reduction surgery: an outcome assessment.

An ovoid and slender face is considered attractive in Oriental culture, and facial bony contouring is frequently performed in Asian countries to achieve this desired facial profile. Despite their popularity, critical analyses of patients' satisfaction after facial-bone contouring surgery is lacking in the current literature. Questionnaires were sent to 90 patients who had undergone zygoma and/or mandibular contouring by a single surgeon at the Craniofacial Center, Chang Gung Memorial Hospital, Taiwan. The number of patients who had mandibular angle reduction and zygoma reduction were 78 and 36, respectively. The questionnaire contained 20 questions, concerning aesthetic and surgical results, psychosocial benefits and general outcome. Medical records were also reviewed for correlation with the questionnaire findings. The survey response rate was 52.2% (47 patients). A total of 95.7% were satisfied with the symmetry of their face after surgery, and 97.9% felt that there was improvement in their final facial appearance. As many as 61.7% could not feel an objectionable new jaw line or bony step and 66.0% could not detect any visible deformity. A total of 87.2% could not detect bony regrowth after surgery. Complication after surgery was experienced by 17.0% of patients, but all of these recovered without long-term consequences. All patients noted a positive psychosocial influence, and 97.9% of patients said that they would undergo the same surgery again under similar circumstances and would recommend the same surgery to friends. The majority of patients with square face seeking facial bone contouring surgery are satisfied with their final appearance. Of equal importance is the ability for this type of surgery to have a positive influence on the patient's psychosocial environment.

Customised fabricated implants after previous failed cranioplasty.

Reconstruction of cranial defects can be reasonably considered a failure if an aesthetically obvious cranial contour deformity persists after surgery. Such unsatisfactory outcome often results from variable resorption of bone grafts or infection, requiring removal of implant. In considering further treatment for such failed cases, the use of alloplastic implants is frequently warned as imprudent due to their theoretically increased potential for infection; however, the validity of such caution has never been substantiated. We describe a user-friendly, time- and cost-effective method of producing prefabricated methyl methacrylate implants for the reconstruction of cranial defects, using readily available computer-aided design and computer-aided manufacture facilities. This method was carried out in 31 patients who presented with persistent cranial defects after previously failed cranioplasty. The efficacy of this technique and the clinical outcome of the patients in this series were analysed. All implants produced a precise fit, with a reduction in operating time and satisfactory cosmesis having been achieved. Infection that required removal of implant occurred in three patients (9.7%), and one patient developed a dural tear, requiring repair. Customised fabricated alloplastic implants provide a safe, accurate and efficient way of restoring normal cranial contours in patients with cranial defects who have had previous failed cranioplasties.

Negative pressure manoeuvre in microtia reconstruction with autologous rib cartilage.

In microtia reconstruction, maintaining a healthy contact between the skin and the fabricated cartilage framework is essential to attaining a smooth and accentuated contour of the reconstructed auricle. Conventional means to achieve this include bolster sutures and continuous suction drains, both of which have associated shortcomings. A new dressing method was developed and applied in 10 consecutive patients who underwent the first of a two-stage microtia reconstruction using the Nagata technique. A small catheter was introduced into the space between the skin and the cartilage framework. Negative pressure was applied through the catheter, drawing the skin onto the cartilage framework. This evens out the skin, accentuates the contour of the framework and concurrently eliminates potential dead space. Skin contact on the framework is maintained whilst the catheter is removed and an occlusive transparent dressing is applied to the ear. Of the 10 cases in which this manoeuvre was performed, one had to be converted to the bolster suture technique due to a persistent air leak from the wound. Overall results of the nine cases in which this technique was carried out successfully demonstrate smooth skin contour and excellent definition of the fabricated framework. This negative pressure manoeuvre provides a simple, safe and consistent approach to achieving a smooth and accentuated contour in auricular reconstruction.

A new method for the second-stage auricular projection of the Nagata method: ultra-delicate split-thickness skin graft in continuity with full-thickness skin.

BACKGROUND: Staged auricular reconstruction remains mainstream among the various techniques of microtia reconstruction using autogenous costal cartilage. The initial stage involves fabrication and implantation of the cartilage framework, followed by projection of the reconstructed auricle in the second stage. During the projection stage, the line of incision is usually made close to the helical rim, from the superoanterior margin of the helical rim to the region of the lobule. Generally, a fascial flap is raised and covered over a cartilage block to project the auricle, and a skin graft is inset over the raw surface of the newly created postauricular sulcus. METHODS: The authors developed a new refinement for the second-stage auricular projection, whereby the skin cover for the raw surface over the posterior aspect of the auricle and the postauricular sulcus is an ultra-delicate split-thickness skin graft raised in continuity with the full-thickness skin over the anterior aspect of the auricle. RESULTS: Incorporation of this new technique has minimized the visibility of suture lines and improved the appearance of the superior otobasion. In addition, the dimension of the skin cover required can be designed with greater precision. Postoperative outcomes using this new technique for auricular projection have been more than satisfactory. CONCLUSION: More favorable results that carry less surgical stigma can now be achieved in auricular reconstruction using this new modification of Nagata's two-stage method.