Long-Term Outcomes After External Maxillary Distraction Surgery in Patients With Down Syndrome.

BACKGROUND: Patients with Down syndrome have severe facial deformities that can precipitate functional consequences and social stigmatization. Craniofacial surgical intervention can play a role in improving these symptoms and patient quality of life. The objective of this study was to investigate the long-term outcomes of distraction osteogenesis and orthognathic surgical intervention in patients with Down syndrome. MATERIALS AND METHODS: Charts of 3 patients with Down syndrome who were treated with external maxillary distraction osteogenesis were retrospectively reviewed. The patients' caregivers were prospectively interviewed between 10 and 15 years after surgery to determine surgical stability, long-term function, and quality of life status. RESULTS: All patients and their caregivers reported excellent results with improvements in function and quality of life. Facial skeletal changes have been stable over time. The cephalometric analysis demonstrated significant maxillary advancement in all 3 patients and mandibular changes to correct mandibular prognathism and asymmetry in the patient who underwent finishing orthognathic surgery. CONCLUSIONS: External maxillary distraction osteogenesis and orthognathic surgery may be considered in select patients with Down syndrome as part of their multidisciplinary health care. These interventions can result in long-term improvements in patient function and quality of life.

The Association Between H-Index and Publication of Plastic Surgery Meeting Presenters From 2014 to 2017.

BACKGROUND: Plastic surgery is a competitive specialty that values research productivity among members of the field. The Hirsch index has been shown to measure a researcher's scientific impact. This study sought to determine whether an association exists between H-indices and the probability of and speed to publication. METHODS: Using Scopus, Google Scholar, PubMed, and the Plastic Surgery the Meeting (PSTM) website, first author (FAHi) and senior author (SAHi) H-indices (n = 1048) from Plastic Surgery the Meeting (PSTM) abstracts from 2014 to 2017 were collected. Whether or not an abstract was ultimately published in a peer-reviewed journal was noted. If published, number of days between PSTM presentation and publication date were recorded. Logistic regression model was used for statistical analysis. RESULTS: In total, 592 out of 1048 total abstracts were published as manuscripts. FAHi and SAHi had significant positive correlations with odds of publication. Both FAHi and SAHi showed positive correlation with the odds of abstract publication (P < 0.001 and P = 0.033). Impact of FAHi on likelihood of publication was greater than that of SAHi. The correlation between FAHi and SAHi with the number of days until abstract publication was not significant (P = 0.333 and P = 0.856). For abstracts published before the PSTM presentation date (15.9% of published), only FAHi (P = 0.008) showed positive correlation of publication before presentation. CONCLUSIONS: The Hirsch index provides an objective method for evaluating the probability that an abstract will lead to manuscript publication, in addition to its traditional application in gauging the impact of research. The findings of this study support that both FAHi and SAHi have a positive, direct correlation with the probability of publication.

Alloplastic Temporomandibular Joint Reconstruction Following Recurrent Ameloblastoma Resection.

ABSTRACT: Ameloblastomas are benign tumors that most commonly affecting the mandible. The current standard of treatment for ameloblastomas is resection followed by reconstruction that has historically been accomplished through the use of a microsurgical vascularized flaps taken from the iliac crest or fibula. Alloplastic reconstruction methods have gained popularity over recent years with success reported in the reconstruction of many pathologies, including ankylosis, condylar fracture, neoplasia involving extensive resection, severe inflammatory/degenerative temporomandibular joint (TMJ) disease, and congenital TMJ abnormalities. The authors present a patient who successfully underwent ameloblastoma resection and TMJ reconstruction with a custom TMJ Concepts alloplastic implant. The authors also present a review of the literature on alloplastic TMJ reconstruction following ameloblastoma resection. To our knowledge, this is the second report in the literature on the use of a TMJ Concepts implant after ameloblastoma resection.

The Most Disruptive Publications in Craniofacial Surgery (1954-2014).

BACKGROUND: Emphasis on the quantification and qualification of scientific literature has increased over recent years. The newly validated disruption score is a bibliometric measure that identifies groundbreaking research that eclipses prior research in a specific field of study. MATERIALS AND METHODS: The 100 most disruptive craniofacial surgery publications were identified through query of the 4 top craniofacial journals and 10 of the most prominent Plastic and Reconstructive Surgery journals, looking at craniofacial specific publications. RESULTS: Presented is the compilation and analysis of the 100 most disruptive publications in the field of craniofacial surgery compared to the 100 most cited publications between 1954 and 2014. Plastic and Reconstructive Surgery had the most papers in the top 100 (n = 56) followed by Journal of Oral and Maxillofacial Surgery (n = 22), and British Journal of Surgery (n = 12). The correlation coefficient between disruption scores and citation counts was -0.001 and -0.07 among all papers, and the top 100 most disruptive papers, respectively. For craniofacial journals, Journal of Craniofacial Surgery had the highest average disruption score for all published papers. The most common decade represented in the top 100 was the 1980's (n = 32) and the least common was the 2000's (n = 14). Randomized controlled trials did not comprise a large amount of either the most disruptive (n = 1) or most cited (n = 2) lists. CONCLUSIONS: This is the first use of disruption index score to describe craniofacial surgery research. The disruption score can help recognize paradigm shifts and innovative research in this unique surgical subspecialty.

Beyond Mastectomy: The Incidence of Subsequent Aesthetic Procedures after Mastectomy with and without Breast Reconstruction.

Background: Mastectomy poses significant challenges to a woman's body image and psychological well-being, and breast reconstruction plays a pivotal role in postoperative quality of life. Following breast reconstruction, many patients choose to have subsequent aesthetic procedures. Data on the prevalence of such subsequent aesthetic interventions are lacking in the literature. The aim of this study was to analyze trends in aesthetic procedures in patients following mastectomy with and without breast reconstruction. Methods: The PearlDiver database was queried within its capabilities for patients who underwent mastectomy with and without breast reconstruction, and a variety of aesthetic procedures after mastectomy. Aesthetic procedure rates were compared between cohorts. Results: We identified 365,525 mastectomy patients: 282,815 without reconstruction and 82,710 with reconstruction. In total, 609 patients with reconstruction and 329 without underwent subsequent aesthetic procedures. The rate of aesthetic procedures was higher in the reconstruction group (0.7%) compared with the nonreconstruction group (0.1%; P < 0.001). Conclusions: Patients who chose to have breast reconstruction after mastectomy underwent significantly more subsequent aesthetic procedures compared with those who chose mastectomy alone. Our findings provide insights on the prevalence of aesthetic procedures in postmastectomy patients, highlighting the potentially longitudinal nature of the reconstructive and aesthetic journey beyond the index oncologic procedure. Further research is needed to address motivations for such procedures as well as patient-reported outcomes and satisfaction.

Gal - T Knockout Porcine Nerve Xenografts Support Axonal Regeneration in a Rodent Sciatic Nerve Model.

BACKGROUND: Nerve xenografts harvested from transgenic α1,3-galactosyltransferase knockout (GalT-KO) pigs lack the epitope responsible for hyperacute rejection in pig-to-primate transplants. It is unknown whether these cold preserved nerve grafts support axonal regeneration in another species during and after immunosuppression. In this study, we compare outcomes between autografts and cold preserved xenografts in a rat sciatic model of nerve gap repair. METHODS: Fifty male Lewis rats had a 1 cm sciatic nerve defect repaired using either: autograft and suture (n=10); 1-week or 4-week cold preserved xenograft and suture (n=10 per group); 1-week or 4-week cold preserved xenograft and photochemical tissue bonding using a human amnion wrap (PTB/HAM) (n=10 per group). Rats with xenografts were given tacrolimus until 4 months post-operatively. At 4 and 7 months, rats were euthanized and nerve sections harvested. Monthly sciatic functional index (SFI) scores were calculated. RESULTS: All groups showed increases in SFI scores by 4 and 7 months. The autograft suture group had the highest axon density at 4 and 7 months. The largest decrease in axon density from 4 to 7 months was in the 1-week cold preserved PTB/HAM group. The only significant difference between group SFI scores occurred at 5 months, when both 1-week cold preserved groups had significantly lower scores than the 4-week cold preserved suture group. CONCLUSIONS: Our results in the rat sciatic model suggest that GalT-KO nerve xenografts may be viable alternatives to autografts and demonstrate the need for further studies of long-gap repair and comparison with acellular nerve allografts. CLINICAL RELEVANCE: This proof-of-concept study in the rat sciatic model demonstrates that cold preserved GalT-KO porcine xenografts support axonal regeneration, as well as axonal viability following immunosuppression withdrawal. These results further suggest a role for both cold preservation and photochemical tissue bonding in modulating the immunological response at the nerve repair site.

Safety and Efficacy of Extended Postdischarge Venous Thromboembolism Prophylaxis in Microsurgical Breast Reconstruction.

Discharging patients on extended postoperative venous thromboembolism (VTE) prophylaxis is trending in microsurgical breast reconstruction (MBR). This study investigated contemporary bleeding and thromboembolic complications after MBR and reported postdischarge enoxaparin outcomes. Methods: The PearlDiver database was queried for MBR patients who did not receive postdischarge VTE prophylaxis (cohort 1) and MBR patients discharged with enoxaparin for at least 14 days (cohort 2), then queried for hematoma, deep venous thrombosis (DVT), and/or pulmonary embolism. Concurrently, a systematic review was undertaken to identify studies investigating VTE with postoperative chemoprophylaxis. Results: In total, 13,541 patients in cohort 1 and 786 patients in cohort 2 were identified. The incidence of hematoma, DVT, and pulmonary embolism were 3.51%, 1.01%, 0.55% in cohort 1, and 3.31%, 2.93%, and 1.78% in cohort 2, respectively. There was no significant difference in hematoma between these two cohorts (P = 0.767); however, a significantly lower rate of DVT (P < 0.001) and pulmonary embolism (P < 0.001) occurred in cohort 1. Ten studies met systematic review inclusion. Only three studies reported significantly lower VTE rates with postoperative chemoprophylaxis. Seven studies found no difference in bleeding risk. Conclusions: This is the first study utilizing a national database and a systematic review to investigate extended postoperative enoxaparin in MBR. Overall, rates of DVT/PE seem to be declining compared with previous literature. The results of this study suggest that there remains a lack of evidence supporting extended postoperative chemoprophylaxis, although the therapy appears safe in that it does not increase bleeding risk.

Trigger Site Deactivation Surgery for Headaches is Associated with Decreased Postoperative Medication Use.

Patients with chronic headaches suffer debilitating pain, which often leads to the use of numerous medications. Trigger site deactivation surgery has emerged as an effective treatment for select headache patients. This study aims to describe the preoperative and postoperative medication use among patients undergoing trigger site deactivation. METHODS: One-hundred sixty patients undergoing trigger site deactivation surgery between September 2012 and November 2017 were prospectively enrolled. Information on medication use, including type, dose, and frequency of use, was collected. Follow-up surveys were sent to all patients 12 months postoperatively. RESULTS: One-hundred twenty-nine patients met the inclusion criteria. At the time of screening, 96% of patients described taking prescription medication for their headache pain. The type of medication varied among patients but included preventative in 55%, abortive in 52%, rescue in 54%, and antiemetic in 18%. Thirty-one percent of patients reported using opioid medication for their headache pain. At 12 months postoperatively, 68% of patients reported decreased prescription medication use. Patients reported a 67% decrease in the number of days they took medication. Twenty-three percent stopped medications altogether. Fifty percent of patients reported that their migraine medication helped them more compared with preoperatively. CONCLUSIONS: Trigger site deactivation surgery has been associated with improvements in headache symptoms. We now show that it is also associated with a significant decrease in medication use.

Muscle Fascia Changes in Patients with Occipital Neuralgia, Headache, or Migraine.

SUMMARY: In an ongoing effort to understand the pathogenesis of occipital neuralgia/headache/migraine, it is critical to describe the anatomical/tissue changes encountered during surgery. Greater occipital nerve anatomical studies mainly focus on the greater occipital nerve course through muscle/fascial planes and interaction with the occipital vessels. However, structural soft-tissue changes have not been described in detail. Anecdotally, trapezius fascia is thickened at the greater occipital nerve trigger site. This study further investigates this observation. Patients undergoing greater occipital nerve decompression surgery were enrolled prospectively in this observational study (n = 92). Tissue changes were recorded intraoperatively. The resulting data were examined. Trapezius fascia was more than 3 mm thick and appeared fibrotic in 86 patients (94 percent), whereas semispinalis muscle appeared normal in all subjects. The greater occipital nerve was macroscopically abnormal, defined as edematous, flattened, and discolored in 29 cases (32 percent). The occipital artery interacted significantly with the greater occipital nerve in 88 percent of cases. The authors conclude that the tissue structure is abnormal in patients undergoing greater occipital nerve decompression surgery. This is the first study that describes the prevalence of thickened and fibrotic appearing trapezius fascia at the occipital trigger site, a phenomenon encountered in the vast majority of patients (94 percent). This structural anomaly has a resemblance to thickened fascial tissues seen in other nerve compression syndromes, and could be related to microtrauma/overuse or actual trauma in the head and neck region.

Dislocation of the metacarpophalangeal joint of the index finger requiring open reduction due to the presence of an intra-articular sesamoid bone.

Complex dislocation of the metacarpophalangeal joint of the index finger is rare and often requires surgical intervention. Here, we present a case of an index finger metacarpophalangeal joint dislocation requiring open reduction due to obstruction by a displaced volar plate and the intra-articular entrapment of a sesamoid bone. Surgical approach was performed dorsally, allowing easy visualization of the volar plate and sesamoid bone as well as minimizing risk to the radial digital nerve to the index finger. Postoperatively, the patient reported good functional return despite the delay in definitive management.

The Relationship of Psychiatric Comorbidities and Their Impact on Trigger Site Deactivation Surgery for Headaches.

BACKGROUND: Patients seeking trigger site deactivation surgery for headaches often have debilitating symptoms that can affect their functional and mental health. Although prior studies have shown a strong correlation between psychiatric variables and chronic headaches, their associations in patients undergoing surgery have not been fully elucidated. This study aims to analyze psychiatric comorbidities and their impact on patients undergoing trigger site deactivation surgery for headaches. METHODS: One hundred forty-two patients were prospectively enrolled. Patients were asked to complete the Patient Health Questionnaire-2 and Migraine Headache Index surveys preoperatively and at 12 months postoperatively. Data on psychiatric comorbidities were collected by means of both survey and retrospective chart review. RESULTS: Preoperatively, 38 percent of patients self-reported a diagnosis of depression, and 45 percent of patients met Patient Health Questionnaire-2 criteria for likely major depressive disorder (Patient Health Questionnaire-2 score of ≥3). Twenty-seven percent of patients reported a diagnosis of generalized anxiety disorder. Patients with depression and anxiety reported more severe headache symptoms at baseline. At 1 year postoperatively, patients with these conditions had successful surgical outcomes comparable to those of patients without these conditions. Patients also reported a significant decrease in their Patient Health Questionnaire-2 score, with 22 percent of patients meeting criteria suggestive of depression, compared to 45 percent preoperatively. CONCLUSIONS: There is a high prevalence of depression and anxiety in patients undergoing trigger site deactivation surgery. Patients with these comorbid conditions achieve successful surgical outcomes comparable to those of the general surgical headache population. Furthermore, trigger site deactivation surgery is associated with a significant decrease in depressive symptoms.

The 100 Most-disruptive Articles in Plastic and Reconstructive Surgery and Sub-specialties (1954-2014).

Alternative bibliometrics have recently been the subject of significantly increased interest. The disruption index is a new bibliometric that was recently applied to surgery and urology and identifies papers that shift paradigms and eclipse previous research in a given field. METHODS: The 100 most-disruptive publications in the 14 most prominent plastic and reconstructive surgery and subspecialty journals were identified. RESULTS: We present the 100 most-disruptive studies as well as the 100 most-cited studies for comparison in n=14 of the most popular plastic and reconstructive surgery (and subspecialty) journals between 1954 and 2014. The 100 most-disruptive publications in these journals were more disruptive than 99.8% of all PubMed papers. Plastic and Reconstructive Surgery (PRS) had the most papers in the top 100 (n=64) followed by British Journal of Plastic Surgery (currently Journal of Plastic, Reconstructive & Aesthetic Surgery, n=15), and Journal of Oral and Maxillofacial Surgery (n=7). PRS had 9 of the top 10 papers. However, Clinics in Plastic Surgery had the highest average disruption score for all its published papers (0.0029). The correlation coefficient linking disruption scores and citation counts was 0.01 and 0.11, respectively. The most common decade represented in the top 100 was the 1980's (n=31) and the least common was the 2000's (n=9). CONCLUSIONS: This is the first application of the disruption index to plastic and reconstructive surgery. The disruption score provides a unique ability to identify research that has shifted paradigms and driven the innovation that defines our specialty.

Medical device related pressure ulcer of the lip in a patient with COVID-19: Case report and review of the literature.

Pressure ulcers of the lip constitute a rare entity faced by plastic surgeons and there is a relatively paucity of data regarding optimal management. In this study we present one case of upper lip pressure ulcer related to prone intubation for respiratory distress due to SARS-CoV-2 infection, treated with surgical excision and reconstruction. We also performed a review of the literature to identify other studies on pressure lip ulcers. Six studies were considered relevant. Conservative management constitutes the most common method of treatment; however, little is known about the aesthetic, and functional morbidity related to either surgical or non-surgical treatments.

Patient Pain Sketches Can Predict Surgical Outcomes in Trigger-Site Deactivation Surgery for Headaches.

BACKGROUND: Patient selection for headache surgery is an important variable to ensure successful outcomes. In the authors' experience, a valuable method to visualize pain/trigger sites is to ask patients to draw their pain. The authors have found that there are pathognomonic pain patterns for each site, and typically do not operate on patients with atypical pain sketches, as they believe such patients are poor surgical candidates. However, a small subset of these atypical patients undergo surgery based on other strong clinical findings. In this study, the authors attempt to quantify this clinical experience. METHODS: Patients were prospectively enrolled and completed pain sketches at screening. One hundred six diagrams were analyzed/categorized by two independent, blinded reviewers as follows: (1) typical (pain over nerve distribution, expected radiation); (2) intermediate (pain over nerve distribution, atypical radiation); or (3) atypical (pain outside of normal nerve distribution, atypical radiation). Preoperative and postoperative Migraine Headache Index was compared between subgroups using unpaired t tests. RESULTS: Migraine Headache Index improvement was 73 ± 38 percent in the typical group, 78 ± 30 percent in the intermediate group, and 30 ± 40 percent in the atypical group. There was a significant difference in Migraine Headache Index between the typical and atypical groups (p = 0.03) and between the intermediate and atypical groups (p < 0.01). The chance of achieving Migraine Headache Index improvement greater than 30 percent in the atypical group was 20 percent. CONCLUSIONS: Patient pain sketches classified as atypical (facial pain, atypical pain point origin, diffuse pain) can predict poor outcomes in headache surgery. As the authors continue to develop patient selection criteria for headache surgery, patient sketches should be considered as an effective, cheap, and simple-to-interpret tool for selecting candidates for surgery.

The Efficacy of Surgical Treatment for Headaches in Patients with Prior Head or Neck Trauma.

BACKGROUND: Patients undergoing trigger-site deactivation surgery for headaches report a high prevalence (approximately 37 percent) of prior head or neck injury. Traditional medical treatment often fails to treat these posttraumatic patients. It is unclear whether surgery mirrors these poor outcomes. This study aims to describe the characteristics of posttraumatic headache surgery patients and compare their postoperative results to those of patients without a history of head or neck injury. METHODS: One hundred forty-two patients undergoing trigger-site deactivation surgery were prospectively enrolled. Patients were requested to complete a preoperative questionnaire on headache history, including the Migraine Headache Index and information on prior head or neck injury. Follow-up surveys were requested at approximately 12 months postoperatively. RESULTS: Seventy patients (49 percent) reported a history of head or neck injury, and 41 (29 percent) classified the injury as the precipitating event leading to their headache onset. Patients with a precipitating event were significantly less likely to report a family history of migraine. There was no significant difference in mean preoperative Migraine Headache Index between cohorts. At 12 months postoperatively, there was no significant difference in Migraine Headache Index reduction between groups. The proportion of patients who experienced at least a 50 and 80 percent improvement in Migraine Headache Index per group, respectively, was 83 and 67 percent (atraumatic), 76 and 68 percent (posttraumatic), and 71 and 63 percent (precipitating event). CONCLUSIONS: This study suggests that surgical outcomes in posttraumatic headache patients are comparable to those without injury. Trigger-site deactivation surgery candidates with a history of injury can therefore expect similar outcomes as reported for patients overall. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, II.

Migraine Surgery at the Frontal Trigger Site: An Analysis of Intraoperative Anatomy.

BACKGROUND: The development of migraine headaches may involve the entrapment of peripheral craniofacial nerves at specific sites. Cadaveric studies in the general population have confirmed potential compression points of the supraorbital and supratrochlear nerves at the frontal trigger site. The authors' aim was to describe the intraoperative anatomy of the supraorbital and supratrochlear nerves at the level of the supraorbital bony rim in patients undergoing frontal migraine surgery and to investigate associated pain. METHODS: PATIENTS: scheduled for frontal-site surgery were enrolled prospectively. The senior author (W.G.A.) evaluated intraoperative anatomy and recorded variables using a detailed form and operative report. The resulting data were analyzed. RESULTS: One hundred eighteen sites among 61 patients were included. The supraorbital nerve traversed a notch in 49 percent, a foramen in 41 percent, a notch plus a foramen in 9.3 percent, and neither a notch nor a foramen in one site. The senior author noted macroscopic nerve compression at 74 percent of sites. Reasons included a tight foramen in 24 percent, a notch with a tight band in 34 percent, and supraorbital and supratrochlear nerves emerging by means of the same notch in 7.6 percent or by means of the same foramen in 4.2 percent. Preoperative pain at a site was significantly associated with nerve compression by a foramen. CONCLUSIONS: The intraoperative anatomy and cause of nerve compression at the frontal trigger site vary greatly among patients. The authors report a supraorbital nerve foramen prevalence of 50.3 percent, which is greater than in previous cadaver studies of the general population. Lastly, the presence of pain at a specific site is associated with macroscopic nerve compression.

Lumbar Spondylolysis and Spondylolisthesis in Down Syndrome: A Cross-sectional Study at One Institution.

STUDY DESIGN: Retrospective cross-sectional study. OBJECTIVES: To describe lumbar spondylolysis and spondylolisthesis and establish their prevalence in individuals with Down syndrome. SUMMARY OF BACKGROUND DATA: Orthopedic problems in Down syndrome are variable and numerous. Lumbar spondylolysis and spondylolisthesis may be common conditions in Down syndrome. However, there has been a paucity of data on the association of these conditions in the published literature. METHODS: A retrospective review of 110 patients with Down syndrome seen at a single institution from 2000 through 2012 was performed. Medical records, X-rays, and physician dictations were carefully reviewed to establish a detailed database of the study population. RESULTS: Of the 110 patients in the study, 20 exhibited spondylolysis (unilateral, n = 11; bilateral, n = 9), whereas 38 had lumbar spondylolisthesis (isthmic, n = 9; dysplastic, n = 2; degenerative, n = 27). No gender difference was noted (p ≥ .7732). Fifteen patients reported low back pain (LBP) and/or leg pain. There was no significant association between LBP, leg pain, and spondylolysis (p = .9232). Both of these symptoms were highly predictive of lumbar spondylolisthesis, however (p = .0006). No significant findings were noted in pelvic parameters (pelvic incidence, sacral slope, pelvic tilt, or lumbar lordosis) in this study. CONCLUSIONS: The prevalence of spondylolysis and spondylolisthesis in individuals with Down syndrome may be as high as 18.7% and 32.7%, respectively, significantly higher than in the non-Downs population. Etiopathogenesis of these conditions in Down syndrome does not appear to be related to pelvic parameters. Low back pain and leg pain may be more predictive of spondylolisthesis in Down syndrome than in the general population. Therefore, it is recommended that individuals with Down syndrome and LBP and/or leg pain be evaluated for lumbar spondylolisthesis.