Surgical Treatment of Nonsyndromic Unicoronal Craniosynostosis.

PURPOSE: Unicoronal synostosis (UCS) remains one of the most difficult craniofacial conditions to treat. This review attempts to consolidate all existing literature from the past 25 years that has investigated surgical treatment of nonsyndromic UCS. Additional attention is paid to specific areas of controversy regarding surgical management and evaluation of UCS: outcomes of fronto-orbital advancement (FOA) versus endoscopic strip craniectomy (ESC), emergence of spring-associated cranioplasty for craniosynostosis, and morphologic assessment metrics. METHODS: A literature search from 1992 to 2017 was performed with a defined search strategy and manual screening process. About 24 studies were included in the final review. RESULTS: There is inconsistency among studies in measuring outcomes. Despite wide utilization, FOA produces mixed results, especially when looking at long-term outcomes. Preliminary data suggest advantages to using ESC over FOA with regard to facial symmetry, postoperative strabismus, and operating time. Distraction osteogenesis has long been utilized in Asia and is now being actively studied in the United States. Data on spring-assisted cranioplasty are lacking. Long-term results at skeletal maturity for many of these techniques are lacking. DISCUSSION: Despite some promising results, methods of measurement are inconsistent and long-term data are lacking. All future research in this area would benefit from consistent and standardized reporting of data, including perioperative statistics and reproducible 3-dimensional computed tomography craniofacial measurements. Additionally, no definitive recommendations can be made until data at skeletal maturity are studied, and all studies would benefit from long-term follow-up data.

A Three-Dimensional Study of Midfacial Changes Following Le Fort II Distraction With Zygomatic Repositioning in Syndromic Patients.

Le Fort II distraction with zygomatic repositioning introduced the ability to restore central midfacial height and convexity independent of changes in orbital morphology. This study analyzes midfacial and orbital morphology before and after Le Fort II distraction with zygomatic repositioning.All patients who underwent Le Fort II Distraction with zygomatic repositioning between 2013 and 2015 were included. Two- and 3-dimensional measurements were made using 3dMD Vultus software to assess canthal tilt, nasolabial angle, ratio of midfacial to lower facial height, and absolute change in nasal length. Presence of an open bite and Angle classification were assessed before and after surgery.Four patients underwent segmental midface advancement using Le Fort II distraction with zygomatic repositioning. Associated diagnoses included Apert syndrome, Goldenhar syndrome, and achondroplasia. Changes in facial dimensions included: 3.19° improvement in canthal tilt (range -4.7° to 8.4°), 9° change in nasolabial angle (range -1.0° to 19°), and 0.69 cm increase in absolute nasal length (range 0.2-0.94 cm). Mean ratio of midfacial to lower facial height was 0.79 preoperatively and 0.89 postoperatively. Preoperatively, all patients demonstrated Angle class III with 3 of 4 patients demonstrating anterior open bite. All achieved closure of open bite and demonstrated class I or II occlusion. No complications were observed.Le Fort II distraction with zygomatic repositioning resulted in normalization of midfacial soft tissue landmarks. This form of advancement demonstrates the ability to selectively improve midfacial height and canthal tilt while restoring normal occlusion.

Interrater reliability of a phenotypic assessment tool for the ear morphology in microtia.

The Elements of Morphology Standard Terminology working group published standardized definitions for external ear morphology. The primary objective of our study was to use these descriptions to evaluate the interrater reliability for specific features associated with microtia. We invited six raters from three different subspecialities to rate 100 ear photographs on 32 features. We calculated overall and within specialty and professional experience intraclass correlation coefficients (ICC) and 95% confidence intervals. A total of 600 possible observations were recorded for each feature. The overall interrater reliability ranged from 0.04 (95% CI: 0.00-0.14) for the width of the antihelix inferior crus to 0.93 (95% CI: 0.91-0.95) for the presence of the inferior crux of the antihelix. The reliability for quantitative characteristics such as length or width of an ear structure was generally lower than the reliability for qualitative characteristics (e.g., presence or absence of an ear structure). Categories with very poor interrater reliability included anti-helix inferior crux width (0.04, 95% CI: 0.00-0.14), crux helix extension (0.17, 95% CI 0.00-0.37), and shape of the incisura (0.14, 95% CI: 0.01-0.27). There were no significant differences in reliability estimates by specialty or professional experience for most variables. Our study showed that it is feasible to systematically characterize many of structures of the ear that are affected in microtia. We incorporated these descriptions into a standardized phenotypic assessment tool (PAT-Microtia) that might be used in multicenter research studies to identify sub-phenotypes for future studies of microtia.

An assessment of the risks and benefits of immediate autologous breast reconstruction in patients undergoing postmastectomy radiation therapy.

BACKGROUND: The utility of immediate autologous breast reconstruction in patients likely to undergo radiation therapy remains controversial. The purpose of this study was to perform a quantitative outcomes assessment of patients undergoing immediate free-flap breast reconstruction and postmastectomy radiation therapy (PMRT). METHODS: A retrospective chart review was performed of patients undergoing free-flap breast reconstruction by the senior authors (L.C.W. and J.M.S.) between 2005 and 2009. The treatment group included patients who underwent immediate free-flap breast reconstruction and received PMRT. The control group consisted of patients undergoing immediate breast reconstruction without PMRT. Variables assessed included postoperative complications and revision surgery. RESULTS: Four hundred seven women underwent immediate free-flap breast reconstruction for a total of 655 flaps. In the cohort that underwent unilateral reconstruction, there was a higher incidence of volume loss (28.26% vs 4.42%, P < 0.0001) and fat necrosis (19.57% vs 3.54%, P = 0.002) in the PMRT group. In the cohort that underwent bilateral reconstruction, there was a higher rate of volume loss for those in the PMRT group (19.75% vs 1.0%, P < 0.0001). However, for both patients who underwent unilateral reconstruction and those who underwent bilateral reconstruction, the PMRT group underwent similar rates of revision surgery. The cohort that underwent bilateral reconstruction experienced a higher incidence of volume loss in radiated perforator flaps (39%) vs muscle-sparing free transverse rectus abdominis myocutaneous flaps (12%; P = 0.013). CONCLUSIONS: Postmastectomy radiation therapy can result in volume loss and fat necrosis, yet there are no increases in other complications or revision procedures. The deleterious effects of PMRT do not preclude the decision for immediate autologous reconstruction.

Does conventional posterior vault remodeling alter endocranial morphology in patients with true lambdoid synostosis?

BACKGROUND: True lambdoid synostosis (TLS) produces a consistent morphology that includes occipital flattening, an ipsilateral occipitomastoid prominence, and a mild contralateral hemifacial deficiency that minimally improves with surgery. Prior studies have demonstrated that dysmorphic middle and posterior cranial fossae contribute to the craniofacial scoliosis characteristic of TLS. We hypothesize that these endocranial features remain after surgery, causing the persistent hemifacial deficiency seen in these patients. METHODS: Three-dimensional anthropometric measurements were made on preoperative and postoperative CT scans of patients with TLS (n = 5). Quantitative analysis was performed on the middle cranial fossa area (MCF), anterior cranial fossa area (ACF), posterior fossa deflection angle (PFA), petrous ridge angle (PRA), temperomandibular joint (TMJ) angle, and external auditory meatus angle. The results were analyzed using a 2-tailed t test. RESULTS: Preoperative CT scans were obtained at a mean age of 1.05 years. Patients underwent posterior vault remodeling at a mean age of 1.33 years. Postoperative CT scans were obtained a mean age of 3.14 years. Following surgery, patients with TLS demonstrated an unchanged PFA (P = 0.76) with deviation toward the affected suture. The ACF remained symmetrical (P = 0.212), and the contralateral MCF remained enlarged relative to the ipsilateral side (P = 0.003). The contralateral middle fossa became more retrodisplaced (P = 0.021). The ipsilateral PRA remained unchanged (P = 0.95). Ear position also remained asymmetrical (P = 0.037). The position of the TMJ was not statistically different between sides before (P = 0.24) or after surgery (P = 0.07). CONCLUSIONS: Traditional cranioplasty effectively restores calvarial shape, but does not significantly alter the dysmorphic features seen in the endocranium of patients with TLS.

The Use of Validated Visual Scales in Plastic Surgery: Where Are We Now?

BACKGROUND: The assessment of the human body, whether for aesthetic or reconstructive purposes, is an inherently visual endeavor. Ideally, reproducible, prompt, and cost-effective systems of visual evaluation would exist that can provide validated assessments of the aesthetic endpoints of treatment. One method to accomplish a standardization of the appreciation of visual endpoints is the use of visual scales. The goal of this systematic review is to summarize and evaluate the use of validated visual scales within aesthetic medicine, dermatology, and plastic and reconstructive surgery. METHODS: A literature search was performed with a defined search strategy and extensive manual screening process. The Medical Outcomes Trust guidelines for visual scales in medicine were used, with special attention paid to each study's validation metrics. The review process identified 44 publications with validation data of sufficient quality from an initial survey of 27,745 articles. All rating scales based on imaging other than standardized clinical photographs were excluded. RESULTS: The review demonstrates that validated visual assessment in plastic surgery is incomplete. Within specific subfields of aesthetic medicine and dermatology, many of the ( n = 20) facial aging scales were well-validated and demonstrated high reliability. Publications ( n = 8) focused on the evaluation of facial clefts demonstrated heterogeneity in the methods of validation and in overall reliability. Within the areas of breast surgery ( n = 9), body contouring ( n = 2), and scarring ( n = 5), the scales were variable in the methods used and the validation procedures were diverse. Scales using a visual guide tended to have better interrater (kappa = 0.75) and intrarater reliability (kappa = 0.78), regardless of the specific area of interest. CONCLUSIONS: The fields of aesthetic medicine, and aesthetic and reconstructive plastic surgery require assessment of visual states over time and between many observers. For these reasons, the development of validated and reliable methods of visual assessment are critical. Until recently, the use of these tools has been limited by their time-consuming nature and cost.

Validation of Ideal Breast Characteristics With Breast Augmentation Patients.

Background: Breast augmentation procedures are one of the most commonly performed aesthetic procedures in the United States. Little work has focused on the general public's overall perception of the ideal breast or has validated them with patient photographs. Objectives: To validate crowdsourced perceptions of breasts with their alignment to the aesthetics of breast augmentation patients. Methods: A prospective cross-sectional study was performed using participants enrolled through the AmazonMechanical Turk crowdsourcing platform (Amazon Web Services, Amazon, Seattle, WA) to obtain participant opinions ofhow closely patient breasts aligned with previously obtained results of 4 ideal breast characteristics. Outcomes were reported based on the correlation between breast attractiveness and alignment to ideal breast characteristics, both before and after breast implant procedures. Results: 2306 responses from 737 participants reported patient photograph alignment with ideal breast projection proportion (1.0) as having the highest correlation to opinions of heightened aesthetic beauty (R = 0.98, P < 0.001), and ideal nipple direction (front) as having the lowest correlation to aesthetic beauty (R = 0.90, P < 0.001). Younger age groups (18-24) and participants with a high school diploma or less rated patients as less attractive, while married and wealthy individuals reported higher attraction levels. Conclusions: Crowdsourcing can be a useful tool for aesthetic surgery preferences and has helped reveal key takeaways. The importance of the 4 breast characteristics has been validated, with alignment to all 4 characteristics tested having a high correlation to preferences. Differences in preference across demographic groups are a topic to further investigate.

Public Perception of Ideal Breast Shape.

BACKGROUND: In the past decade, there has been a dramatic increase in trends related to body-shaping procedures. According to the American Society of Plastic Surgeons, nearly 300,000 breast augmentation procedures were conducted in 2019. Learning the ideal shape of a breast and which esthetics lead to public perception of the most attractive breast is beneficial to properly performing these procedures. OBJECTIVES: The authors aimed to quantify the public's perception of attraction to breast shape by measuring public opinion for various esthetic elements of breast anatomy and linking this to various demographic factors. METHODS: Survey responses were collected from 1000 users of Amazon Mechanical Turk to collect demographic data and ask users to rank preferences for randomized image panels of breast proportions. RESULTS: 960 responses were used for analysis. A majority of respondents were male (60%), with a plurality being 25 to 34 years old (49.3%). The most notable preferences between all groups were breast projection proportion and nipple direction, with preferences of 1.0 and frontal nipple direction, respectively. Breast width to shoulder width ratio also had a clear preference among the crowd, with 105% being the preferred percentage, and the 25 to 34 age group having a very strong preference for this. CONCLUSIONS: The authors used a crowdsourcing survey technique with randomized image panels to analyze ideal breast preference using images of various anatomical traits of the female breast. It was concluded that crowdsourcing can be a favorable technique for learning ideal overall preferences for specific anatomy.

Crowd-Sourced Reliability of an Assessment of Lower Facial Aging Using a Validated Visual Scale.

Reliable and valid assessments of the visual endpoints of aesthetic surgery procedures are needed. Currently, most assessments are based on the opinion of patients and their plastic surgeons. The objective of this research was to analyze the reliability of crowdworkers assessing de-identified photographs using a validated scale that depicts lower facial aging. METHODS: Twenty photographs of the facial nasolabial region of various non-identifiable faces were obtained for which various degrees of facial aging were present. Independent crowds of 100 crowd workers were tasked with assessing the degree of aging using a photograph numeric scale. Independent groups of crowdworkers were surveyed at 4 different times (weekday daytime, weekday nighttime, weekend daytime, weekend nighttime), once a week for 2 weeks. RESULTS: Crowds assessing midface region photographs had an overall correlation of R = 0.979 (weekday daytime R = 0.991; weekday nighttime R = 0.985; weekend daytime R = 0.997; weekend nighttime R = 0.985). Bland-Altman test for test-retest agreement showed a normal distribution of assessments over the various times tested, with the differences in the majority of photographs being within 1 SD of the average difference in ratings. CONCLUSIONS: Crowd assessments of facial aging in de-identified photographs displayed very strong concordance with each other, regardless of time of day or week. This shows promise toward obtaining reliable assessments of pre and postoperative results for aesthetic surgery procedures. More work must be done to quantify the reliability of assessments for other pretreatment states or the corresponding results following treatment.

Three-dimensional changes in head shape after extended sagittal strip craniectomy with wedge ostectomies and helmet therapy.

OBJECTIVE Outcome studies for sagittal strip craniectomy have largely relied on the 2D measure of the cephalic index (CI) as the primary indicator of head shape. The goal of this study was to measure the 2D and 3D changes in head shape that occur after sagittal strip craniectomy and postoperative helmet therapy. METHODS The authors performed a retrospective review of patients treated with sagittal strip craniectomy at their institution between January 2012 and October 2015. Inclusion criteria were as follows: 1) isolated sagittal synostosis; 2) age at surgery < 200 days; and 3) helmet management by a single orthotist. The CI was calculated from 3D images. Color maps and dot maps were generated from 3D images to demonstrate the regional differences in the magnitude of change in head shape over time. RESULTS Twenty-one patients met the study inclusion criteria. The mean CI was 71.9 (range 63.0-77.9) preoperatively and 81.1 (range 73.0-89.8) at the end of treatment. The mean time to stabilization of the CI after surgery was 57.2 ± 32.7 days. The mean maximum distances between the surfaces of the preoperative and 1-week postoperative and between the surfaces of the preoperative and end-of-treatment 3D images were 13.0 ± 4.1 mm and 24.71 ± 6.83 mm, respectively. The zone of maximum change was distributed equally in the transverse and vertical dimensions of the posterior vault. CONCLUSIONS The CI normalizes rapidly after sagittal strip craniectomy (57.2 days), with equal distribution of the change in CI occurring before and during helmet therapy. Three-dimensional analysis revealed significant vertical and transverse expansion of the posterior cranial vault. Further studies are needed to assess the 3D changes that occur after other sagittal strip craniectomy techniques.

Robotic Approaches to Palatoplasty and the Treatment of Velopharyngeal Dysfunction.

The operative techniques used to address palatoplasty and velopharyngeal dysfunction rely on traditional methods of surgical exposure and tissue handling. As the role of robotic surgical systems has expanded, emphasis has shifted from extirpative to reconstructive applications. We discuss the possible role of surgical telemanipulation systems in the treatment of these diagnoses. Furthermore, we present a feasibility study that addresses a commonly performed treatment of velopharyngeal dysfunction-posterior pharyngeal flap (PPF). In brief, PPFs were successfully performed on a small series of cadaveric human specimens. The technical aspects of the procedure, including telemanipulator set-up, positioning, surgical instrumentation, and timing are described in detail. All cadavers underwent successful performance of PPFs. Operative times were within an acceptable range and use of the robotic system demonstrated a steep learning curve. Many of the potential advantages and costs associated with robotic surgical systems are discussed.

Adopted children with cleft lip and/or palate: a unique and growing population.

BACKGROUND: Standard clinical pathways are well established for children with cleft lip and/or palate. Treatment of internationally adopted children differs because of the late age at presentation, a newly evolving child-family relationship, and variable extent and quality of previous treatment. METHODS: The authors characterized the presentation and treatment patterns of all internationally adopted children with clefts at their institution between 1997 and 2011. RESULTS: Among 1841 children with clefts, 216 (12 percent) were internationally adopted: 78 percent had cleft lip and palate, 18 percent had cleft lip, and 4 percent had cleft palate. Patients originated predominantly from China (80 percent). Median age at presentation was 31 months, and the rate of new presentations increased five-fold during the study period. Eighty-two percent presented with prior cheiloplasty, and revision was recommended for 64 percent of them. Thirty-seven percent of patients had prior palatoplasty, of which 34 percent presented with a palatal fistula. Secondary palatoplasty/pharyngoplasty was performed more frequently for patients who underwent primary palatoplasty before adoption than after adoption (95 percent CI, 0.20 to 0.77). Overall, adoptees required secondary surgery more often than nonadoptees (49 percent versus 28 percent) regardless of where their primary surgery was performed. Changes in adoptee growth indices suggested improvements in systemic health following adoption. CONCLUSIONS: Internationally adopted children with clefts have unique treatment challenges. Children with unrepaired clefts undergo surgery late, and children with prior repairs frequently undergo revision. Compared with nonadoptees, adoptees require more revisions and have a higher fistula rate. Further detailed study is important to optimize care.

Application of a robotic telemanipulator to perform posterior pharyngeal flap surgery: a feasibility study.

BACKGROUND: The instrumentation used during surgery to address velopharyngeal dysfunction has changed little over the past century. Recent advances in the use of robotic surgical systems in transoral surgery have expanded the use of these instruments beyond their traditional laparoscopic applications. The purpose of this study was to evaluate the feasibility of performing superiorly based, "Hogan"-style posterior pharyngeal flaps using a robotic surgical telemanipulator system. The authors hypothesize that use of this surgical platform provides equivalent safety, improved exposure, and more comfortable surgeon ergonomics compared with traditional methods of flap harvest and inset. METHODS: A pilot study was performed using three fresh cadaveric human heads. Superiorly based posterior pharyngeal flaps were successfully performed in all specimens. The technical aspects of the procedure, including telemanipulator setup, positioning, surgical instrumentation, and timing, are described in detail. RESULTS: All three subjects underwent successful transfer of posterior pharyngeal flaps. Mean surgical time was 113 minutes. Using a 30-degree angled endoscope, the area of the operative field was nearly doubled, and this allowed for easy visualization of the flap ports, an advantage when tailoring the flap. Technically, the learning curve for using the robot telemanipulator was steep, and both operating surgeons (J.M.S. and J.A.T.) felt that the instrumentation and setup were ergonomic. There was no damage to adjacent structures. CONCLUSIONS: Transoral robotic surgery for velopharyngeal dysfunction is feasible and may offer improved exposure and ergonomics compared with traditional methods. As the use of robotic surgical systems becomes more widespread, their use in intraoral cleft surgery warrants further investigation.

Squamosal suture synostosis: a cause of atypical skull asymmetry.

BACKGROUND: The squamosal suture is markedly different from the major calvarial sutures of the human skull. The unique properties of the suture are a result of the complex developmental biology of the temporal bone and biomechanical force exerted by surrounding structures. The dysmorphic effects of premature fusion of the suture, and possible treatment strategies in cases of synostosis, have received only brief description in the literature. METHODS: A retrospective case series was performed. The study included patients evaluated by one of the senior authors (S.P.B., R.R.R., and D.J.S.) between 1993 and 2009. All pertinent patient data including inpatient and outpatient charts, photographic records, and radiographic scans were reviewed. Any management performed under the direction of a craniofacial surgeon was documented--including orthotic helmet therapy and operative management. RESULTS: The study included 14 patients. Synostosis of the squamosal suture was noted to occur either in an isolated fashion or in the setting of other craniofacial malformations. Patients with isolated squamosal synostosis often suffered from a deformity that was mild in severity and tended to improve with time. However, when occurring in the setting of other forms of craniosynostosis, the deformity was often progressive, and transcranial surgery was frequently required. CONCLUSIONS: Synostosis of the squamosal suture can result in, or contribute to, significant craniofacial dysmorphism. The optimal form of therapy for this disorder is evolving.

Extended trimethoprim/sulfamethoxazole prophylaxis for implant reconstruction in the previously irradiated chest wall.

BACKGROUND: Patients who have undergone prior chest wall irradiation can present as challenging candidates for implant reconstruction because of troublesome rates of infectious complications. The issue of antibiotic prophylaxis remains controversial, and evidence-based postoperative strategies to reduce implant infections have not been well described in the literature. The purpose of this study was to determine the efficacy of extended trimethoprim/sulfamethoxazole therapy in preventing implant infections in the irradiated chest wall. METHODS: A retrospective chart review of hospital and office records was performed on all patients undergoing implant reconstruction performed by a single surgeon (J.M.S.) from August of 2005 to March of 2008. Before 2007, the senior author used 5 to 7 days of cephalosporin prophylaxis. Subsequent to this period, the prophylactic regimen was amended to provide patients with previous chest wall irradiation prophylactic trimethoprim/sulfamethoxazole for 30 days after implant insertion. RESULTS: Fifty-one implant reconstructions, in the setting of prior ipsilateral chest wall irradiation, were performed. The mean follow-up time was 39 months. The infection rate for the routine cephalosporin group was 35 percent as compared with 8 percent for the extended trimethoprim/sulfamethoxazole group (p = 0.038). After multivariate analysis, extended trimethoprim/sulfamethoxazole remained the only significant factor that influenced the rate of infection (p = 0.05). The mean time to infection was 13 weeks for the routine cephalosporin group and 1.5 weeks for the extended trimethoprim/sulfamethoxazole group (p = 0.044). CONCLUSION: Extended trimethoprim/sulfamethoxazole therapy demonstrates preliminary evidence as an effective adjunctive measure for reducing the rate of implant infections in breast reconstruction. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Analysis of differences in the cranial base and facial skeleton of patients with lambdoid synostosis and deformational plagiocephaly.

BACKGROUND: Earlier investigations suggest that the morphologic features of patients with lambdoid synostosis include ipsilateral occipital flattening, an ipsilateral mastoid prominence, downward cant of the posterior skull base to the affected side, and contralateral hemifacial deficiency. These features are absent in patients with deformational plagiocephaly. The authors hypothesize that significant differences in craniofacial morphology exist between patients with lambdoid synostosis and those with deformational plagiocephaly. METHODS: Craniometric measurements were performed on patients with unilateral lambdoid synostosis (n = 9) and deformational plagiocephaly (n = 12). Measurements were performed on affected and unaffected sides and included posterior fossa deflection angle, petrous ridge angle, middle cranial fossa and anterior cranial fossa area, temporomandibular joint displacement, and maxillary and mandibular dimensions. Appropriate statistical tests were performed. RESULTS: Statistically significant differences in posterior fossa deflection angle, petrous ridge angle, and middle cranial fossa were found between groups. Lambdoid synostosis patients demonstrated a larger petrous ridge angle (p = 0.0001) and middle cranial fossa (p = 3.37 × 10(-6)) on the unaffected side. Deformational plagiocephaly patients exhibited no discrepancies between sides. The mean posterior fossa deflection angle was 10.55 degrees for the lambdoid synostosis group and 3.59 degrees for the deformational plagiocephaly group (p < 0.0001). All lambdoid synostosis patients had deviation of the posterior cranial fossa toward the affected side. Deformational plagiocephaly patients had variable deflection. All lambdoid synostosis patients demonstrated marked posterior displacement of the contralateral temporomandibular joint. Deformational plagiocephaly patients had either symmetric temporomandibular joint position (75 percent) or slight contralateral posterior displacement (25 percent). Mandibular size was not significantly different between groups. CONCLUSION: Patients with lambdoid synostosis and deformational plagiocephaly manifest significant differences in cranial base morphology, contributing to the phenotypic differences seen in these two groups of patients.

Does previous chest wall irradiation increase vascular complications in free autologous breast reconstruction?

BACKGROUND: Prior radiation therapy to the chest, in theory, has a detrimental impact on the recipient vessels in breast reconstruction and may impact microvascular success. The purpose of this study was to determine whether prereconstruction radiation therapy affects the rate of vascular complications in free flap breast reconstruction. METHODS: This was a retrospective review of free flap breast reconstruction performed between 2005 and 2009 by the senior authors. In addition to medical and surgical history, vascular complications were recorded, including intraoperative and postoperative thromboses and technical difficulties resulting in a variation of the standard approach. RESULTS: In total, 226 flaps were placed into an irradiated field, whereas 799 were transposed into a radiation-naive defect. Vascular complications as a whole were more prevalent in the irradiated group (9.6 percent versus 17.3 percent; p = 0.001). In regression modeling, radiation therapy was identified as an independent risk factor (odds ratio, 1.68; 95 percent confidence interval, 1.04 to 2.70). In subanalysis, there is a significantly higher rate of intraoperative vascular complications (7.6 percent versus 14.2 percent; p = 0.003), although individual outcomes did not reach formal significance. Previous irradiation had no effect on delayed vascular complications, flap loss, fat necrosis, infection, skin flap necrosis, hematoma, seroma, or delayed wound healing. CONCLUSIONS: Prereconstruction radiation therapy increases the rate of vascular complications in free flap breast reconstruction, the majority of which appear intraoperatively. Although radiation does not hinder the overall success of reconstruction or contribute to postoperative complications, surgeons should be aware that working in a previously irradiated field carries additional technical risk.

The modified V-Y dorsal metacarpal flap for repair of syndactyly without skin graft.

BACKGROUND: Syndactyly repairs that use full-thickness skin grafts risk graft-related complications. The dorsal V-Y advancement flap offers a method of syndactyly release that can eliminate the need for full-thickness skin grafts in some cases of simple syndactyly. METHODS: A retrospective case series of all patients undergoing syndactyly release without skin grafting performed by the senior author (B.C.) between 1998 and 2007 was conducted. All outpatient and inpatient charts were reviewed for pertinent patient demographics and clinical outcomes, including the incidence of web creep, hypertrophic scarring, flexion contracture, infection, angulation deformity, limited range of motion, ischemia, and need for reoperation. RESULTS: A total of 28 syndactylies were included in the study: 25 simple incomplete and three simple complete. Mean follow-up time was 4.2 years. Mean operative time was 68 minutes. Two patients (7.1 percent) experienced postoperative complications; both were corrected by subsequent revision. CONCLUSION: The dorsal V-Y advancement flap without skin graft is an effective method of repair primarily in simple incomplete syndactyly.

Nitric oxide stimulates proliferation and differentiation of fetal calvarial osteoblasts and dural cells.

BACKGROUND: Infant dura mater plays a critical role in calvarial development. This investigation examines the expression of nitric oxide synthase isoforms in the craniofacial skeleton and the influence of nitric oxide signaling on the growth and differentiation of fetal dural and calvarial bone cells. METHODS: Sections of fetal and adult calvaria were evaluated for endothelial and inducible nitric oxide synthase expression by immunohistochemistry. Primary fetal (E18) murine dural cell and calvarial osteoblast cultures were treated with 1 microM or 10 microM DETA-NONOate, a nitric oxide donor compound, or 1 mM N-monomethyl-l-arginine (l-NMMA), a nitric oxide synthase inhibitor. Controls were left untreated. Cell proliferation was measured at 48 hours, and mRNA transcripts for Runx2, alkaline phosphatase, and osteopontin were measured by reverse transcription and quantitative real-time polymerase chain reaction at 2 to 18 days. Experiments were performed in triplicate. RESULTS: Fetal, but not adult, dural cells express endothelial nitric oxide synthase. DETA-NONOate stimulated osteoblast mitogenesis by 16 percent (p < 0.05) but did not affect proliferation of dural cells. l-NMMA inhibited proliferation of dural cells and calvarial osteoblasts by 35 percent (p < 0.01) and 17 percent (p = 0.05), respectively. Exogenous nitric oxide increased dural cell transcription of Runx2, alkaline phosphatase (p = 0.03), and osteopontin (p = 0.09) and calvarial osteoblast transcription of Runx2 (p = 0.02) and osteopontin (p < 0.01). Fetal calvarial osteoblasts and dural cells treated with l-NMMA demonstrated reduced transcription of Runx2 and alkaline phosphatase (p < 0.05). CONCLUSIONS: Fetal dural cells and calvarial osteoblasts express endothelial nitric oxide synthase. Nitric oxide enhances proliferation and differentiation of fetal dural cells and calvarial osteoblasts. These results suggest that endothelial nitric oxide synthase-derived nitric oxide may play an important role in development of the fetal craniofacial skeleton.