The Melbourne Classification of the Complete Unilateral Cleft Lip Based on Hypoplasia.

BACKGROUND: The hypoplastic lateral lip element within the cleft lip presentation is a recognized entity that has been recently shown to be more common on the right side. The spectrum of such change is yet to be defined. The authors propose the Melbourne classification system of cleft lip hypoplasia and see it as an important step towards discerning the relevance of these anatomical observations to the management of cleft lip/palate patients. METHODS: This is a retrospective observational study of patients with complete unilateral cleft lips treated by the senior author (DKC) at the Royal Children's Hospital, Melbourne. Patient charts were retrospectively reviewed and patients were classified into different degrees of hypoplasia based on preoperative, intraoperative, and postoperative photography. Data was reported using descriptive statistics. RESULTS: Fifty-nine patients with complete unilateral cleft lip deformity were grouped according to lateral lip element hypoplasticity. Twenty patients had right-sided clefts and 39 patients had cleft lips on the left side. Of those with right-sided clefts, 18 patients had evidence of hypoplasia (90%). Three patients had Type 1 deformities, 3 patients were Type 2, and 12 patients were Type 3. Patients with left-sided clefts were found to have hypoplasia less frequently with 15 patients showing evidence (38.5%). CONCLUSIONS: The authors report a classification system of hypoplasia involving the lateral lip element in complete unilateral cleft lip. The authors propose this classification system as a new measure of cleft severity that will have implications for patient expectations, surgical planning, and future outcome studies.

A Guide to Bilateral Cleft Lip Markings: An Anthropometric Study of the Normal Cupid's Bow.

OBJECTIVE: The aim of this study was to define the ratio of the heights of the vermilion between the peaks and trough of the Cupid's bow and hence assist in defining the point of closure on the lateral lip element to achieve a balanced Cupid's bow in bilateral lip repair based on our findings. DESIGN: This study is a retrospective observational study of the anthropometrics of the upper lip's Cupid's bow. Three-dimensional (3D) images of toddlers between 2009 and 2016 were extracted from a normative 3D image database of toddlers at the Royal Children's Hospital, Melbourne. PATIENTS: Participants from the normative 3D image database at the age of 1 year were studied. This excluded any patients with prior trauma or surgical intervention of the nasolabial region. INTERVENTION: Landmarks measured were right and left crista philtri (cphR and cphL), labial superius (ls), stomion (sto), right and left chelion, and labial fissure (lf). OUTCOME: Vermilion height of the right peak, trough, and left peak of the Cupid's bow was calculated by analyzing the vertical linear distance between cphR-lf, ls-sto, and cphL-lf. The ratio between the median and paramedian heights were recorded. RESULTS: The paramedian height of the upper lip vermilion is consistently greater than the midline height. There was no significant sexual dysmorphism between ratio of paramedian to midline height on the right (P = .538) and left (P = .410). CONCLUSION: We describe an anthropometric observation of the vermilion relationship at the Cupid's bow and define a specific lateral lip marking for bilateral cleft lip repair based on our anthropometric findings.

Defining Double Capsules: A Clinical and Histological Study.

BACKGROUND: Macrotextured breast implants are associated with double capsules. There is little agreement as to what defines double capsules, how they present, and whether different degrees of double capsule exist. OBJECTIVES: This study aimed to define double capsules and report an association between double-capsule type and degree of tissue adherence. METHODS: Consecutive aesthetic patients undergoing explantation of Biocell (Allergan, Inc., Irvine, CA) implants between May 2018 and November 2018 were included if they were found to have double capsules intraoperatively. Patient demographics, implant characteristics, explantation reason, implant adherence, and intraoperative findings were recorded. Both adherent and double capsules were histologically examined. Data were analyzed by descriptive statistics. RESULTS: Eleven patients had 22 Biocell implants explanted during the study period. The average explantation time was 8.0 years. Sixteen implants were found to have some degree of nonadherence, and all areas of nonadherence were associated with double-capsule formation. Double capsules were either partial or complete. The architecture of the inner layer of double capsules varied between an organized capsular layer and a thin area of nascent capsule. Histologically, all capsular specimens demonstrated an overall hypocellular fibrous capsule with scattered chronic inflammatory infiltrates. Synovial metaplasia was present in all capsule types and spaces/cracks in the capsule were disproportionately represented in partially adherent capsules. CONCLUSIONS: This is the first study to identify a clinical and pathological correlation between double capsules and failed tissue adherence. Double capsules represent a spectrum of inner capsule formation ranging between nascent capsular tissue to a mature inner capsular layer.

Recurrent Breast Cerebrospinal Fluid Pseudocyst: A Complication of Ventriculoperitoneal Shunt Placement.

Ventriculoperitoneal (VP) shunt complications involving the breast are rare, with the majority involving the formation of a cerebrospinal fluid pseudocyst. We present the case of a 22-year-old woman with recurrent cerebrospinal fluid pseudocyst secondary to fracture of a VP shunt at the time of breast surgery for breast asymmetry. We review the literature on this topic and present our case that highlights the need of the breast surgeon to take into account the position of VP shunts placed at birth. Shunts placed on the chest wall may result in breast asymmetry requiring surgery in the adolescent. Shunts in place since birth may be at greater risk of fracture during breast implant placement due to manipulation of a calcified and fragile shunt leading to formation of a cerebrospinal fluid pseudocyst.

Regional flexibility in the S4-S5 linker regulates hERG channel closed-state stabilization.

hERG K(+) channel function is vital for normal cardiac rhythm, yet the mechanisms underlying the unique biophysical characteristics of the channel, such as slow activation and deactivation gating, are incompletely understood. The S4-S5 linker is thought to transduce voltage sensor movement to opening of the pore gate, but may also integrate signals from cytoplasmic domains. Previously, we showed that substitutions of G546 within the S4-S5 linker destabilize the closed state of the channel. Here, we present results of a glycine-scan in the background of 546L. We demonstrate site-specific restoration of WT-like activation which suggests that flexibility in the N-terminal portion of the S4-S5 linker is critical for the voltage dependence of hERG channel activation. In addition, we show that the voltage dependence of deactivation, which was recently shown to be left-shifted from that of activation due to voltage sensor mode-shift, is also modulated by the S4-S5 linker. The G546L mutation greatly attenuated the coupling of voltage sensor mode-shift to the pore gate without altering the mode-shift itself. Indeed, all of the S4-S5 linker mutations tested similarly reduced coupling of the mode-shift to the pore gate. These data demonstrate a key role for S4-S5 linker in the unique activation and deactivation gating of hERG channels. Furthermore, uncoupling of the mode-shift to the pore by S4-S5 linker mutations parallels the effects of mutations in the N-terminus suggestive of functional interactions between the two regions.

External protons destabilize the activated voltage sensor in hERG channels.

Extracellular acidosis shifts hERG channel activation to more depolarized potentials and accelerates channel deactivation; however, the mechanisms underlying these effects are unclear. External divalent cations, e.g., Ca(2+) and Cd(2+), mimic these effects and coordinate within a metal ion binding pocket composed of three acidic residues in hERG: D456 and D460 in S2 and D509 in S3. A common mechanism may underlie divalent cation and proton effects on hERG gating. Using two-electrode voltage clamp, we show proton sensitivity of hERG channel activation (pKa = 5.6), but not deactivation, was greatly reduced in the presence of Cd(2+) (0.1 mM), suggesting a common binding site for the Cd(2+) and proton effect on activation and separable effects of protons on activation and deactivation. Mutational analysis confirmed that D509 plays a critical role in the pH dependence of activation, as shown previously, and that cooperative actions involving D456 and D460 are also required. Importantly, neutralization of all three acidic residues abolished the proton-induced shift of activation, suggesting that the metal ion binding pocket alone accounts for the effects of protons on hERG channel activation. Voltage-clamp fluorimetry measurements demonstrated that protons shifted the voltage dependence of S4 movement to more depolarized potentials. The data indicate a site and mechanism of action for protons on hERG activation gating; protonation of D456, D460 and D509 disrupts interactions between these residues and S4 gating charges to destabilize the activated configuration of S4.

Proton block of the pore underlies the inhibition of hERG cardiac K+ channels during acidosis.

Human ether-a-go-go-related gene (hERG) potassium channels are critical determinants of cardiac repolarization. Loss of function of hERG channels is associated with Long QT Syndrome, arrhythmia, and sudden death. Acidosis occurring as a result of myocardial ischemia inhibits hERG channel function and may cause a predisposition to arrhythmias. Acidic pH inhibits hERG channel maximal conductance and accelerates deactivation, likely by different mechanisms. The mechanism underlying the loss of conductance has not been demonstrated and is the focus of the present study. The data presented demonstrate that, unlike in other voltage-gated potassium (Kv) channels, substitution of individual histidine residues did not abolish the pH dependence of hERG channel conductance. Abolition of inactivation, by the mutation S620T, also did not affect the proton sensitivity of channel conductance. Instead, voltage-dependent channel inhibition (δ = 0.18) indicative of pore block was observed. Consistent with a fast block of the pore, hERG S620T single channel data showed an apparent reduction of the single channel current amplitude at low pH. Furthermore, the effect of protons was relieved by elevating external K(+) or Na(+) and could be modified by charge introduction within the outer pore. Taken together, these data strongly suggest that extracellular protons inhibit hERG maximal conductance by blocking the external channel pore.

The Anatomical Subunit Approach to Managing Tessier Numbers 3 and 4 Craniofacial Clefts.

Patients with atypical facial clefts are rare, and there is a paucity of literature outlining the surgical approach to managing these patients. The anatomical subunit approach to the surgical correction of the cleft lip has revolutionized cleft care. Here, we outline our approach and operative technique to treating Tessier clefts 3 and 4 using a novel technique based on the anatomical subunit approach. Methods: All cases of Tessier facial clefts 3 and 4 between 2019 and 2021 from the senior author's practice were reviewed retrospectively. Patient demographics, clinical presentation, procedure details, and complications are reported. The senior author's technique is described in detail. Results: Five patients underwent treatment by the senior author during the study period. One patient had bilateral Tessier 4 clefts, one patient had bilateral Tessier 3 clefts, two patients had a unilateral Tessier 4 cleft, and one patient had a unilateral Tessier 3 cleft. Two of the patients had their clefts treated as secondary procedures. The surgical complication profile was a lost nasal stent in one patient. Treatment principles of the senior author's technique are presented. Conclusions: The anatomical subunit approach to managing atypical facial clefts provides a structured approach to a complex problem for the cleft and craniofacial surgeon. The technique of repair presented here can assist surgeons attempting to treat patients with Tessier 3 and 4 clefts.

What Do We Know About Treating Recalcitrant Auricular Keloids? A Systematic Review and Meta-Analysis.

BACKGROUND: Recalcitrant auricular keloids are keloids that have recurred after any previous treatment. They have been shown to have an increased likelihood of recurrence. There is no consensus on how best to treat recalcitrant auricular keloids. Here, we perform the first systematic review and meta-analysis investigating the evidence for treating recalcitrant auricular keloids. METHODS: We searched MEDLINE, EMBASE, CINAHL, and EBM Reviews using specific keywords. Prespecified inclusion and exclusion criteria were used to assess article eligibility. Data were extracted for number of recalcitrant keloids, treatment modality, recurrence, and minimum follow-up time. Included articles were stratified by treatment and assigned a level of evidence (LOE) based on the Oxford Centre for Evidence-Based Medicine guidelines. A meta-analysis was performed to estimate recurrence rates with 95% confidence intervals for each treatment modality. RESULTS: A total of 887 unique articles were identified and 13 included. Eleven were LOE III and 2 were LOE IV. Recurrence rates were found to be 9% (95% CI: 3%-25%) for excision with adjuvant brachytherapy, 14% (95% CI: 12%-17%) for excision with adjuvant compression therapy, 17% (95% CI: 3%-56%) for excision with adjuvant external beam radiation, and 18% (95% CI: 4%-53%) for excision with adjuvant steroid injections. No statistical significant difference was found. CONCLUSIONS: Data for treatment of auricular keloids are heterogeneous with few high-quality studies. Excision with adjuvant brachytherapy has the lowest recurrence rate in our analysis. Narrow confidence intervals reported here for brachytherapy and compression therapy may help surgeons more confidently recommend either of these treatment modalities to patients.

HISTORIQUE: Les chéloïdes auriculaires récalcitrantes sont celles qui se manifestent de nouveau après un traitement. Il est démontré que leur risque de récurrence est plus élevé. Il n'y a pas de consensus au sujet de leur traitement. Les chercheurs procèdent à la première analyse systématique et méta-analyse sur les données probantes relatives au traitement des chéloïdes auriculaires récalcitrantes. MÉTHODOLOGIE: Les chercheurs ont fouillé les bases de données MEDLINE, EMBASE, CINAHL et EBM Reviews au moyen de mots-clés précis. Ils ont utilisé des critères d'inclusion et d'exclusion préétablis pour évaluer l'admissibilité des articles. Ils ont extrait les données relatives au nombre de chéloïdes récalcitrantes, à la modalité thérapeutique, à la récurrence et à la durée minimale du suivi. Ils ont stratifié les articles retenus d'après le traitement utilisé et leur ont attribué une qualité de preuve (QdP) en fonction des directives de l'Oxford Centre for Evidence-Based Medicine. Ils ont procédé à une méta-analyse pour évaluer le taux de récurrence, d'après des intervalles de confiance à 95 % par modalité thérapeutique. RÉSULTATS: Les chercheurs ont relevé 887 articles uniques et en ont retenu 13. De ce nombre, 11 avaient une QdP III et deux, une QdP IV. Ils ont constaté un taux de récurrence de 9 % (IC à 95 %, 3 % à 25 %) après une excision et une curiethérapie adjuvante, de 14 % (IC à 95 %, 12 % à 17 %) après une excision et une thérapie de compression adjuvante, de 17% (IC à 95 %, 3 % à 56 %) après une excision et une radiothérapie externe adjuvante, et de 18 % (IC à 95 %, 4 % à 53 %) après une excision et des injections adjuvantes de stéroïdes. Ils n'ont constaté aucune différence statistiquement significative. CONCLUSIONS: Les données relatives au traitement des chéloïdes auriculaires sont hétérogènes, et peu d'études sont de qualité. À l'analyse, l'excision avec curiethérapie adjuvante présente le taux de récurrence le plus faible. Les faibles intervalles de confiance liés à la curiethérapie et à la thérapie de compression pourraient inciter les chirurgiens à recommander avec conviction l'une de ces deux modalités thérapeutiques aux patients.

Something Stinks! Finding Ways to Manage Noxious Odours in the Operating Room and Other Clinical Settings A Randomized Controlled Trial.

Objectives: The hospital can be saturated with noxious smells. Anecdotally, medical staff apply products to surgical masks to lessen the impact of these smells. This study aimed to determine the odour-masking ability of 4 inexpensive and convenient products. Methods: A randomized, single-blinded crossover study was conducted in Vancouver, Canada. Participants, 19 to 30 years old, were invited to participate. Participants with active allergies, upper respiratory tract infection, alteration to sense of smell, or failure of olfactory screen were excluded from the study. An experimental odour was used in lieu of a noxious surgical odour. After smelling the experimental odour without barriers, participants were re-exposed to the odour using 5 surgical masks in randomized order. Each mask was lined with a test product (cherry lip balm, tincture of benzoin, Mastisol, mint toothpaste, and control [plain mask]). Participants rated the effectiveness of products at masking the experimental odour from 0 to 100 (0 = completely ineffective, 100 = completely effective). Participants also rated the pleasantness of the products, recorded if the products made them feel unwell, and identified their preferred product overall. Results: Eighty participants were included in the study (33 male, 47 female), averaging 24.2 years of age. Mean odour-masking effectiveness for cherry lip balm was 66.5 (±24.6), tincture of benzoin: 62.6 (±25.0), Mastisol: 61.3 (±23.9), mint toothpaste: 57.5 (±27.4), and control: 21.9 (±21.8). All products performed better than the control (P < .001), but there was no significant difference in performance between products. Cherry lip balm was the most preferred odour-masking product (29 participants), followed by mint toothpaste (22), Mastisol (14), tincture of benzoin (10), and control (5). Conclusions: All tested products demonstrated equivalent odour-masking abilities. If health care professionals choose to use an odour-masking product, they should consider their own olfactory preferences.

Objectifs: L'hôpital peut être saturé d'odeurs nauséabondes. On rapporte que le personnel médical applique des produits sur leurs masques chirurgicaux pour atténuer l'impact de ces odeurs. Cette étude visait à déterminer l'efficacité de quatre produits masqueurs d'odeurs, et ce de façon pratique et peu couteuse. Méthodes: Une étude croisée a simple insu et a répartition aléatoire a été menée à Vancouver, Canada. Des participants âgés de 19 à 30 ans, ont été invités à participer. Les participants souffrant d'allergies actives, d'une infection des voies respiratoires supérieures, d'une altération olfactive, ou aillant échoué la procédure de sélection ont été exclus de l'étude. Une odeur expérimentale a été utilisée au lieu d'une odeur nauséabonde chirurgicale. Après avoir senti l'odeur expérimentale, les participants ont été réexposés à la même odeur à cinq reprises. A chaque reprise, le participant était muni d'un de 5 masques tapissé d'un agent masquant d'odeur (baume à lèvres aux cerises, teinture de benzoïne, mastisol, dentifrice à la menthe, et contrôle [masque standard]). L'ordre des masques a été déterminé de façon aléatoire. Les participants ont noté sur une échelle de 0 à 100 l'efficacité des produits à masquer l'odeur (0: complètement inefficace, 100: complètement efficace). Les participants ont également évalué la qualité plaisante des agents, si ceux-ci les rendaient nauséeux, et ont ensuite identifié leur produit préféré parmi l'ensemble. Résultats: Quatre-vingts participants ont été inclus dans l'étude (33 hommes, 47 femmes), âgés en moyenne de 24,2 ans. L'efficacité des produits à masquer l'odeur expérimentale étaient d'une moyenne de 66,5 (+24,6) pour le baume à lèvres aux cerises ; 62,6 (+25,0) pour la teinture de benzoine ; 61,3 (+23,9) le mastisol ; 57,5 (+27,4) pour le dentifrice à la menthe, et 21,9 (+21,8) le contrôle. Tous les agents testés ont reçu une note supérieure au contrôle (P < .001). Par-contre, il n'y avait pas de différence significative entre les agents. Le baume à lèvres aux cerises était le produit préféré (29 participants), suivi du dentifrice à la menthe (22), du mastisol (14), de la teinture de benzoine (10), et finalement du contrôle (5). Conclusions: Tous les produits testés ont démontré une efficacité similaire, celle-ci supérieure comparée au contrôle. Si les professionnels de la santé souhaitent d'utiliser un produit qui masque les odeurs, ils devraient tenir compte de leurs propres préférences.

Microbial community compositions in breast implant biofilms associated with contracted capsules.

Subclinical bacterial infections (biofilms) are strongly implicated in breast augmentation failure due to capsular contracture, and while these infections are generally ascribed to common skin commensals, this remains largely unsubstantiated through robust cultivation independent analyses. To determine capsule biofilm microbial community compositions, we employed amplicon sequencing of the 16S rRNA gene using DNA extracted from breast implant capsule samples. These cultivation independent analyses revealed that capsule associated biofilms are more diverse than canonical single-species infections, but have relatively low diversity (~ <100 species) compared to many host-associated microbial communities. In addition to taxa commonly associated with capsular contracture, the biofilms analyzed comprised a number of taxa that escaped detection in cultivation-dependent work. We have also isolated several key taxa identified through the culture-independent analyses. Together our analyses reveal that capsule biofilms are more diverse than cultivation studies suggest and can be heterogeneous within an individual capsule, between breasts of the same patient, across similar implant types, and over a range in severity of contracture. The complex nature of these communities requires further study across a broader suite of patients in addition to higher resolution analyses including metagenomics to better assess the fundamental role of microorganisms in capsular contracture.

Mutations within the S4-S5 linker alter voltage sensor constraints in hERG K+ channels.

Human ether-a-go-go related gene (hERG) channel gating is associated with slow activation, yet the mechanistic basis for this is unclear. Here, we examine the effects of mutation of a unique glycine residue (G546) in the S4-S5 linker on voltage sensor movement and its coupling to pore gating. Substitution of G546 with residues possessing different physicochemical properties shifted activation gating by ∼-50 mV (with the exception of G546C). With the activation shift taken into account, the time constant of activation was also accelerated, suggesting a stabilization of the closed state by ∼1.6-4.3 kcal/mol (the energy equivalent of one to two hydrogen bonds). Predictions of the α-helical content of the S4-S5 linker suggest that the presence of G546 in wild-type hERG provides flexibility to the helix. Deactivation gating was affected differentially by the G546 substitutions. G546V induced a pronounced slow component of closing that was voltage-independent. Fluorescence measurements of voltage sensor movement in G546V revealed a slow component of voltage sensor return that was uncoupled from charge movement, suggesting a direct effect of the mutation on voltage sensor movement. These data suggest that G546 plays a critical role in channel gating and that hERG channel closing involves at least two independently modifiable reconfigurations of the voltage sensor.

Outcomes and Complications of the Mustardé Otoplasty: A "Good-Fast-Cheap" Technique for the Prominent Ear Deformity.

BACKGROUND: The Mustardé otoplasty is a commonly used procedure for the correction of the prominent ear deformity. Complication rates related to suture extrusion and long-term outcomes are variable in the literature. The study's purpose was to examine the efficacy and safety of the Mustardé otoplasty and its resource utilization, using an "iron triangle" methodology incorporating quality, time, and cost. METHODS: Retrospective data were collected on patients under 18 years who underwent primary Mustardé otoplasty between 2009 and 2018. Patient demographics, intraoperative details, complications, follow-up, and satisfaction were collected and analyzed. RESULTS: There were 119 Mustardé otoplasties performed on 68 patients, with a median follow-up of 72 weeks (24-476 weeks). In total, 51 of the 68 patients underwent bilateral procedures. The median operative time was 95 minutes (31-133 minutes), translating to a facility case cost of $2046. A total of 24 complications were reported in 17 patients. Minor complications included the following: suture extrusion (n = 20), hematoma (n = 1), and suture abscess (n = 1). Major complications included reoperation (n = 2). The series had a revision rate of 1.7% (n = 2). No additional procedures were documented at other hospitals in the province. The majority (97%) of ear outcomes demonstrated both patient and surgeon satisfaction. CONCLUSIONS: The Mustardé otoplasty demonstrated a high efficacy in the correction of the prominent ear, with low reoperation rates and high patient and surgeon satisfaction. The procedure demonstrated intriguing results in resource utilization, with brief operative times, a "knife and fork" supply chain, and minimal overall case costs. This technique qualifies as a good, fast, and cheap outpatient otoplasty option.

The KS-Pexy: A Novel Method to Manage Horizontal Lower Eyelid Laxity.

BACKGROUND: Patients with horizontal lower lid laxity undergoing lower lid blepharoplasty are at a high risk for lid malposition. Prophylactic correction of horizontal lower lid laxity during blepharoplasty may alleviate this risk. In this article, the authors describe a novel lower lid blepharoplasty technique, the KS-pexy (named after its originators, Kuhnt and Szymanowski), for correcting horizontal lower lid laxity. METHODS: All cases of KS-pexy between September of 2009 and June of 2018 from an aesthetic practice were reviewed retrospectively. All patients were diagnosed with horizontal lower lid laxity and requested lower lid blepharoplasty for aesthetic concerns. Patient demographics, clinical presentation, procedure details, and intraoperative findings were analyzed. RESULTS: Sixty-two patients underwent KS-pexy performed by the senior author. The average follow-up was 41.1 months, ranging from 2 to 107 months. Thirteen patients had a negative vector, 54 patients received a KS-pexy in combination with another facial procedure, and 14 patients had their KS-pexy as a secondary procedure. The overall success rate was 96.8 percent. The complication profile was as follows: chemosis (27.4 percent), new-onset dry eyes persisting longer than 8 weeks (6.5 percent), temporary lower eyelid malposition (4.8 percent), lower eyelid malposition requiring surgical intervention (3.2 percent), poor scar quality (1.6 percent), lower lid abscess (1.6 percent), transient conjunctivitis (1.6 percent), lateral fat compartment swelling (1.6 percent), canthopexy dehiscence (1.6 percent), hordeolum (1.6 percent), and temporary V2 paresthesia (1.6 percent). CONCLUSION: The KS-pexy is an effective means to treat horizontal eyelid laxity prophylactically in patients requesting lower eyelid blepharoplasty for aesthetic reasons. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

A 3-Year Review of an Outpatient Burn Sedation Program in a Tertiary Burn Care Centre: Is It Safe and Does It Work?

INTRODUCTION: The burn treatment room at our tertiary-care centre is run by a multidisciplinary team, providing care to primarily burn patients who require moderate to deep sedation to undergo dressing changes in a monitored setting outside the operating room. There is little literature on the safety, efficacy, and logistics of treating outpatient pediatric burn patients in this manner. This study reviews the safety of deep sedation in the burn treatment room. METHODS: A retrospective chart review of patients with burns treated in the burn treatment room from 2013 to 2015 was conducted. Patient demographics, diagnosis, procedure details, sedation, and adverse events were recorded. Data were analyzed descriptively. RESULTS: Sevety-four patients with burns had a total of 308 visits in the burn treatment room for burn bath and/or dressing changes. Scald burns were the most common mechanism of injury (n = 56). Most burns were superficial and mid-dermal (54%), initially estimated at 5% to 10% TBSA (50%). Of the 308 visits, 304 required sedation. Adverse events were recorded in 11 (3.6%) of 304 sedated procedures. None of these events were critical: 7 patients required intravenous conversion due to inadequate oral sedation, 2 experienced brief apnea episodes but recovered spontaneously, and 2 had delayed discharge of more than 2 hours due to residual sedation. CONCLUSION: The burn treatment room is a safe and effective setting for treating pediatric burn patients, bypassing what might historically require operating suite inpatient management.

INTRODUCTION: La salle de traitement des brûlures du centre de soins tertiaires des chercheurs est dirigée par une équipe multidisciplinaire qui soigne surtout des patients brûlés ayant besoin d'une sédation modérée à profonde pour faire changer leurs pansements dans un milieu surveillé hors du bloc opératoire. Peu de publications portent sur l'innocuité, l'efficacité et la logistique de ce type de traitement ambulatoire pour les patients brûlés d'âge pédiatrique. La présente étude analyse l'innocuité de la sédation profonde à la salle de traitement des brûlures. MÉTHODOLOGIE: Les chercheurs ont procédé à une analyse rétrospective des dossiers de patients brûlés traités à la salle de traitement des brûlures entre 2013 et 2015. Ils ont noté les caractéristiques démographiques, le diagnostic, le détail des interventions, la sédation et les événements indésirables des patients et fait une analyse descriptive des données. RÉSULTATS: Soixante-quatorze patients brûlés sont allés un total de 308 fois à la salle de traitement des brûlures pour faire laver leurs brûlures ou changer leurs pansements. Les brûlures par liquide chaud étaient les plus courantes (n = 56). La plupart étaient superficielles et touchaient le derme moyen (54 %), pour une estimation initiale de 5 % à 10 % de la surface corporelle (50 %). Des 308 visites, 304 ont fait l'objet d'une sédation. Onze événements indésirables (3,6 %), dont aucun n'était critique, ont découlé des 304 interventions sous sédation. En effet, neuf patients ont dû passer à une sédation intraveineuse parce que la sédation orale était inadéquate, deux ont présenté de brefs épisodes d'apnée, mais se sont rétablis spontanément, et le congé de deux cas a dû être retardé de plus de deux heures à ause d'une sédation résiduelle. CONCLUSION: La salle de traitement des brûlures est un lieu sécuritaire et efficace pour traiter les patients brûlés d'âge pédiatrique et permet d'éviter ce qui nécessitait auparavant un passage au bloc opératoire et une hospitalisation.

Not All Breast Implants Are Equal: A 13-Year Review of Implant Longevity and Reasons for Explantation.

BACKGROUND: Augmentation mammaplasty is the most common aesthetic procedure. Textured implants control implant position and have improved capsular contracture rates; however, the impact of texturing on longevity and clinical findings at explantation is unclear. METHODS: All cases of explantation between January of 2005 and April of 2017 from an aesthetic practice were reviewed retrospectively. Patient demographics, implant characteristics, time to explantation, and clinical presentation and intraoperative findings at explantation were analyzed. RESULTS: Five hundred thirty-nine breast implants were explanted during the study period: 249 saline, 147 smooth gel, 123 Biocell, and 20 other nonaggressively textured breast implants. Average time from placement to explantation was 7.5, 5.6, 4.9, and 4.0 years for saline, other textured, smooth gel, and Biocell implants, respectively (p = 3.25e-08). The percentage of implants removed associated with implant performance failure was 50.3, 57.4, 75.0, and 85.4 percent for smooth gel, saline, other textured, and Biocell implants, respectively (p = 7.25e-09). In addition, 21.1 percent of Biocell implants versus 1.4 percent of all other implants presented with pain (p = 2.71e-15). Forty-five Biocell implants had double capsules; this phenomenon was not observed with any other implant type (p = 5.85e-37). Seven Biocell implants had late seromas, compared to three late seromas with any other implant type (p = 0.0013). CONCLUSIONS: Here, the authors provide evidence that Biocell implants have the shortest time to explantation and the highest proportion of implants associated with implant performance failure. This information should complement the informed consent process when selecting an appropriate implant.

Tissue Expansion for Severe Foot and Ankle Deformities: A 16-Year Review.

BACKGROUND: Tissue expansion in the lower extremity is controversial, with studies reporting complication rates as high as 83%. Few studies have looked at tissue expansion prior to orthopaedic correction of severe foot and ankle deformities, and those available are restricted to clubfoot in the pediatric population. Here, we report the largest case series on the use of tissue expanders for the reconstruction of severe foot and ankle deformity and the only report in adults. METHODS: This is a retrospective chart review of the senior author's practice over a 16-year study period. All patients over 18 years of age who underwent tissue expansion prior to definitive orthopaedic correction of a severe foot and ankle deformity were included. Patient demographics, etiology of deformity, rate of expansion, and complications were recorded. Major complications were defined as those which required surgical intervention. Data were analyzed using descriptive statistics. RESULTS: Nineteen cases were performed on 16 patients. Our overall complication rate was 31.6% (6/19), with major complications occurring in 21.1% (4/19) of cases, and minor complications occurring in 10.5% (2/19) of cases. Despite this, 94.7% (18/19) of cases went on to receive definitive orthopaedic correction after tissue expansion. No demographic parameters were associated with occurrence of complications. CONCLUSIONS: This represents the largest report on lower extremity tissue expansion for severe foot and ankle deformity correction. While we observed complications in 31.6% of patients, 94.7% of cases went on to receive definitive orthopaedic correction with successful primary closure.

HISTORIQUE: L'expansion tissulaire des membres inférieurs est controversée, car des études font état d'un taux de complications atteignant les 83 %. Peu d'études ont porté sur l'expansion tissulaire avant la correction orthopédique de graves déformations du pied et de la cheville, et celles qui existent se limitent au pied bot dans la population pédiatrique. Les auteurs rendent compte de la plus grande série de cas sur l'utilisation d'expandeurs tissulaires en vue de la reconstruction de graves déformations du pied et de la cheville, la seule à être menée chez des adultes. MÉTHODOLOGIE: La présente étude rétrospective traite des dossiers de l'auteur principal sur une période de 16 ans. Tous les patients de plus de 18 ans qui ont subi une expansion tissulaire avant la correction orthopédique définitive d'une grave déformation du pied et de la cheville en ont fait partie. Les chercheurs ont consigné la démographie des patients, l'étiologie des déformations, le taux d'expansion et les complications. Ils ont défini les complications majeures comme celles qui exigent une intervention chirurgicale. Ils ont analysé les données à l'aide de statistiques descriptives. RÉSULTATS: Les chercheurs ont relevé 19 cas chez 16 patients. Le taux de complications global s'élevait à 31,6 % (six cas sur 19). Des complications majeures se sont produites dans 21,1 % des cas (quatre sur 19) et des complications, mineures, dans 10,5 % des cas (deux sur 19). Malgré tout, 94,7 % des cas (18 sur 19) ont subi une correction orthopédique définitive après l'expansion tissulaire. Aucun paramètre démographique ne laissait présager les complications. CONCLUSIONS: La présente étude est le rapport le plus vaste des expansions tissulaires pour corriger de graves déformations du pied et de la cheville. Les auteurs ont observé des complications chez 31,6 % des patients, mais 94,7 % des cas ont profité d'une correction orthopédique définitive et d'une fermeture primaire réussie.

Perioperative and Long-Term Smoking Behaviors in Cosmetic Surgery Patients.

BACKGROUND: Many plastic surgeons advocate smoking cessation before patients undergo cosmetic surgery with extensive soft-tissue dissection. Smoking cessation rates after cosmetic surgery are unknown. The preoperative consultation may be an opportunity to promote long-term smoking cessation. METHODS: This is a retrospective, cross-sectional cohort study. All patients over an 8-year study period who smoked before their preoperative consultation; who quit 2 weeks before surgery; and who subsequently underwent rhytidectomy, abdominoplasty, or mastopexy were included. Patients were asked to complete a Web-based survey at long-term follow-up. RESULTS: Eighty-five smokers were included, and 47 patients completed the survey, for a response rate of 55.3 percent. Average follow-up was 63.3 months. Five respondents were social smokers and thus excluded. Of the 42 daily smokers, 17 patients (40.5 percent) were no longer smoking cigarettes on a daily basis at long-term follow-up. Of these 17 patients, 10 (23.8 percent) had not smoked since their operation. A total of 24 patients (57.1 percent) had reduced their cigarette consumption by any amount, and 70.8 percent (17 of 24) of these patients agreed that discussing adverse surgical outcomes related to smoking influenced their ability to quit/reduce. Twenty-one of 42 patients (50.0 percent) admitted that they were not compliant with the preoperative smoking cessation instructions. CONCLUSIONS: This is the first report to investigate long-term smoking cessation from a cosmetic surgery practice. The authors have shown a positive association between smoking cessation and cosmetic surgery. Requesting a period of cessation before cosmetic surgery may promote long-lasting smoking cessation.

Meaningful power grip recovery after salvage reconstruction of a median nerve avulsion injury with a pedicled vascularized ulnar nerve.

In cases of median nerve injury alongside an unsalvageable ulnar nerve, a vascularized ulnar nerve graft to reconstruct the median nerve is a viable option. While restoration of median nerve sensation is consistently reported, recovery of significant motor function is less frequently observed. The authors report a case involving a previously healthy man who sustained upper arm segmental median and ulnar nerve injuries and, after failure of sural nerve grafts, was treated with a pedicled vascularized ulnar nerve graft to restore median nerve function. Long-term follow-up showed near full fist, with 12 kg of grip strength, key pinch with 1.5 kg of strength and protective sensation in the median nerve distribution. The present case demonstrates that pedicled ulnar vascularized nerve grafts can provide significant improvements to median nerve sensory and motor function in a heavily scarred environment.

Une greffe du nerf cubital vascularisé pour reconduire le nerf médian est une solution viable lorsque le nerf cubital ne peut pas être récupéré. La sensation du nerf médian est presque toujours rétablie, mais la fonction motrice significative l'est moins. Les auteurs présentent le cas d'un homme auparavant en santé qui a subi des traumatismes des nerfs médian et cubital du bras et, après le rejet des greffes du nerf saphène externe, a subi une greffe du nerf cubital pédiculé vascularisé pour rétablir la fonction du nerf médian. Au suivi à long terme, le poing était presque complet, la prise de force atteignait 12 kg, la pince sub-termino-latérale s'associait à une force de 1,5 kg et la distribution du nerf médian était liée à une sensation protectrice. Le présent cas démontre que des greffes du nerf cubital pédiculé vascularisé peuvent améliorer considérablement la fonction sensorielle et motrice du nerf médian très cicatrisé.