Risk factors of avascular necrosis in Takayasu arteritis: a cross sectional study.

Takayasu arteritis (TA) is a large-cell vasculitis, and is not usually associated with avascular necrosis (AVN). The objective of the study was to investigate any association between TA and AVN, including the possible pathogenic effect of glucocorticoid (GCs) use. The study design was retrospective and cross sectional. TA patients were enrolled in the study. Demographic variables, disease activity, treatments, physician global assessment, Indian Takayasu Clinical activity score 2010, and Kerr criteria were recorded. Logistic regression analysis was performed to identify predictors of AVN. A total of 29 patients were assessed. AVN was observed in four (13.8%) patients with TA. Male gender and elevated C-reactive protein (CRP) were found to be significantly associated with AVN (p = 0.001 and p = 0.006, respectively). While type IIb TA was more common in patients with AVN (n = 2, 50%), type V was more likely in the absence of AVN (n = 13, 52%). Descending aorta and thoracic aorta were usually involved in patients with AVN (both, n = 3, 75%). In multivariate logistic regression, increased CRP levels were the only predictor for AVN (OR = 1.183, 95% Cl = 1.025-1.364, p = 0.021). No association was identified between AVN in TA patients and either duration or cumulative dose of GCs. The present study found that higher CRP levels and male gender were associated with AVN in patients with TA.

Advanced Technical Pearls for Successful Supermicrosurgical Lymphaticovenular Anastomosis.

ABSTRACT: Lymphaticovenular anastomosis (LVA) is now accepted as one of the mainstays of surgical treatment of lymphedema. The unique advantages of LVA that set it apart from other procedures such as vascularized lymph node transfer are its safety and its minimally invasive nature. To date, there has been no report of worsening of disease as a result of LVA, even when performed unsuccessfully. Despite these notable advantages, the procedure is much less frequently performed compared with vascularized lymph node transfer because of inconsistent procedural outcome. In our experience, LVA is highly effective when performed with proper patient selection and meticulous technical execution. In this article, we share the senior author's LVA "tips and tricks" to help readers achieve greater success when performing this extraordinary supermicrosurgical procedure.

Management of Tessier Type 3 Cleft With a Novel Reverse Palatal Expander.

ABSTRACT: The purpose of this clinical report is to present the novel management of a type Tessier 3 cleft which was treated using a palatal expander in reverse fashion to reapproximate the craniofacial skeleton allowing for closure of the palate and soft tissue of the cleft. Reapproximation of the bony component of the cleft was achieved without osteotomies and allowed for easier and earlier realignment of the bony and soft tissue components of the cleft. To our knowledge, this is the first use of reverse palatal expansion in the treatment of type 3 Tessier cleft. Reverse palatal expansion made management of this cleft more straightforward and should be considered as a useful adjunct in the management of wide facial clefts.

Serial Posterior Cranial Vault Distraction for the Treatment of Complex Craniosynostosis.

ABSTRACT: Posterior cranial vault distraction is an important modality in the management of craniosynostosis. This surgical technique increases intracranial volume and improves cranial aesthetics. A single procedure is often inadequate in patients with complex multisuture craniosynostosis, as some will go on to develop intracranial hypertension despite the operation. Considering the negative effects of intracranial hypertension, some patients may warrant 2 planned distractions to prevent this scenario from ever occurring. Three patients with complex multiple-suture synostosis and severe intracranial volume restriction (occipital frontal head circumferences [OFCs] <1st percentile) were treated with 2 planned serial posterior cranial vault distractions at the institution between 2013 and 2018. Demographics, intraoperative data, and postoperative distraction data were collected. The OFC was recorded pre- and postdistraction, at 3- and 6-month follow-up appointments. Patients had a corrected average age of 18 weeks at the time of their initial procedure. There was an average of 38 weeks between the end of consolidation and the time for their 2nd distraction procedure. There was an average age of 79 weeks at the time of the 2nd procedure. All patients had a substantial increase in OFC and improvement of the posterior calvarium shape. The average increase in OFC was 5.2 cm after first distraction and 4.3 cm after 2nd distraction. No postoperative complications were encountered. Planned serial posterior cranial vault distraction is a safe and effective strategy for increasing intracranial volume, improving aesthetic appearance, and preventing the consequences of intracranial hypertension in patients with multisuture craniosynostosis and severe intracranial volume restriction.

Clinical Anatomy of Submental Intubation: A Review of the Indications, Technique, and a Modified Approach.

Since its original description in 1986 by Hernandez, submental intubation has been used in a wide variety of craniomaxillofacial cases as a way to satisfy both surgeon and anesthesiologist to provide access to necessary surgical sites and airway protection. Many modifications to the original technique have been described. There has been a paucity of plastic surgery literature over the last 10 years that have reviewed the anatomy, technique, and complications. In this article, the authors review the pertinent anatomy related to this method of intubation. A cadaver was used to enhance visualization of important structures and to show the modification used by our group. Submental intubation provides a useful alternative to tracheostomy in several craniomaxillofacial procedures. Our approach uses a reinforced endotracheal tube to prevent kinking and provide additional intraoperative protection of the airway. Submental intubation may be indicated in select patients undergoing craniomaxillofacial surgery. Therefore, it is pertinent to be aware of the important anatomy and the complications of this technique to appropriately counsel patients. Our modification provides safe airway control.

Anatomical Location of the Infraorbital Foramen in Infant Dry Skulls: Implications for Cleft Surgery.

BACKGROUND: Infraorbital foramen (IOF) is an important anatomical landmark in cleft lip surgery. The location of IOF within the maxilla of infants is different from adults. However, little information about anatomy of IOF in infants exists in the literature. This study aims to determine the location of IOF in infant dry skulls based on key surgical landmarks. METHODS: All dry skulls under age 2 years old were selected from the Hamann-Todd Human Osteological Collection at the Cleveland Museum of Natural History (Cleveland, OH). Specimens without cranial bones or complete maxilla were excluded. Seven anatomical measurements were taken on each side of the face for each individual skull (14 measurements for each skull). Anatomical landmarks used for the measurements included infraorbital rim, aperture piriformis, alveolar ridge, zygomaticomaxillary buttress, anterior nasal spine (ANS), and inferolateral corner of the aperture piriformis. RESULTS: Twenty-seven halves of 14 dry skulls were included in the final analysis. The mean age of specimens was 0.57 years. Mean distances from infraorbital foramen to infraorbital rim, aperture piriformis, alveolar ridge, zygomaticomaxillary, and ANS buttress were 4.11 ±â€Š0.82, 9.4 ±â€Š1.62, 12.7 ±â€Š2.71, 11.7 ±â€Š1.54, and 18.4 ±â€Š2.11 mm, respectively. CONCLUSION: This study also shows that the infraorbital foramen in infants is located at the level of the ANS or within 2 mm higher and that the distance between the infraorbital rim and foramen is only 3 to 4 mm. These findings should be applied to the cleft population with discretion.

Use of Bone Morphogenetic Protein in Pediatric Cranioplasty With Pre- and Postoperative Radiation Therapy.

INTRODUCTION: Bone morphogenetic protein (BMP) is a signaling protein that has proven efficacy in the setting of bone repair. It has been widely used in orthopedic surgery and is being implemented more in the field of craniofacial surgery, although there is limited report on its use in pediatric patients. CASE: A 6-year-old female with stage IV neuroblastoma with metastasis to the parietal parasagittal calvarium, which had failed to respond to multiple medical therapies, including radiation therapy. The tumor was excised and the defect was replaced with a combination of split calvarial bone graft and rhBMP-2. The patient received post-operative radiation therapy with no reports of complications of the defect site on immediate and long term follow up. CONCLUSION: The use of BMP has the potential to aid in bone generation for high-risk calvarial defects. It can be safe and efficacious to use in the pediatric population; however, future studies should be done to determine the safest and most effective dosing of BMP.

Maxillary Distraction Osteogenesis in a Patient With Osteogenesis Imperfecta.

Osteogenesis imperfecta (OI) is characterized by brittle bones, premature hearing loss, blue sclera, dental abnormalities, and short stature. Maxillofacial pathology is marked in many OI patients and includes a high incidence of class III malocclusion secondary to a retrusive maxilla relative to both the mandible and cranial base.Review of literature shows that most of the orthognathic surgeries performed in the setting of OI are double jaw surgeries, in the form of maxillary advancement and mandibular setback. However, severe maxillary hypoplasia is usually not correctable with single-stage maxillary advancement. Distraction osteogenesis (DO) is a technique that relies on the normal healing process that occurs between controlled, surgically osteotomized bone segments and it is a relatively widely used technique in modern management of craniofacial conditions.Distraction osteogenesis has been reported in only several patients with OI. There is only 1 previously documented case of maxillary distraction in the craniofacial literature. The authors present here the successful management of a patient with OI and severe class III malocclusion using LeFort I osteotomy and DO with an external rigid distractor.At 12 months follow-up, the patient had no complications and maintained stable maxillary position with normal occlusion, improvement of facial appearance, obstructive airway symptoms, speech, and chewing.This case serves to reinforce the safety and efficacy of DO in patients with OI. The authors did not significantly change our distraction protocol and did not have any complications, therefore the authors believe that DO should be the preferable treatment technique for severe malocclusion in OI patient population.

Acute Liver Failure and Hepatic Encephalopathy After Cleft Palate Repair.

Paracetamol is the most commonly used analgesic after cleft palate repair. It has rarely caused acute hepatic failure at therapeutic or supratherapeutic doses. Only one case of therapeutic paracetamol toxicity after cleft palate repair had been reported previously. Here, we present a similar patient who developed acute liver failure and hepatic encephalopathy after an uncomplicated cleft palate surgery. Lack of large prospective trials in young children due to ethical concerns increases the value of the case reports of acetaminophen toxicity at therapeutic doses. The dosing recommendations of paracetamol may need to be reconsidered after cleft palate surgery.

Bile duct ischemia developing after reconstruction of the hepatic artery during the Whipple operation.

A pancreaticoduodenectomy is a surgical procedure with a high morbidity and mortality rate. The injury of the hepatic artery may occasionally lead to intraoperative bleeding. Repair of the injured hepatic artery is of great importance in terms of maintaining the vascular supply of the liver. We report a case with an injury of the hepatic artery that was successfully reconstructed with the gastroduodenal artery and then developed a biliary leak due to bile duct ischemia at an early stage. A 33-year-old women complaining of right upper quadrant pain was found to have a solid pseudopapillary tumor of the pancreas. She underwent an immediate pancreaticoduodenectomy, and her hepatic artery was injured during the operation. The arterial ends were sutured with primary anastomosis, because they could be aligned without any tension. The biliary leak occurred on postoperative day 2. We detected bile duct ischemia and reanastomosed the artery. The patient was discharged on postoperative day 8. Surgeons should be prepared for anomalies of the peripancreatic vascular structures during pancreaticoduodenectomy. Computed tomography angiography should be considered to reveal these anomalies before the surgery. Insufficiency of the biliodigestive anastomosis due to bile duct ischemia in the postoperative period should be kept in mind, even in cases of successful repair.

Outcomes after tissue expander exchange to implant in two-stage prepectoral breast reconstruction with and without acellular dermal matrix: A retrospective cohort study.

As prepectoral implant placement becomes widely adopted, recent studies investigating the use of acellular dermal matrix (ADM) during tissue expander placement have demonstrated no major benefit with regard to postoperative outcomes. We sought to evaluate second-stage outcomes 1 year after tissue expander exchange to implant with and without ADM. Consecutive patients who underwent prepectoral tissue expander-based breast reconstruction with and without ADM were identified. Patients were followed up for 1 year after tissue expander exchange to implant. Second-stage outcomes of interest including implant rippling, capsular contracture, implant explantation, additional revision surgeries, and patient-reported outcomes were collected and compared. Sixty-eight breasts in the ADM cohort and sixty-one breasts in the no ADM cohort underwent tissue expander exchange to implant. Second-stage outcomes of interest were similar between the ADM and no ADM cohorts with no statistically significant differences identified regarding incidences of implant rippling (24.6% vs. 12.1%, p = 0.08), capsular contracture (4.5% vs. 3.3%, p = 1.00), and explantation (6.6% vs. 1.7%, p = 0.67) between the two cohorts. BREAST-Q scores were similar between the two cohorts with the exception of physical wellbeing and satisfaction in terms of implant rippling, as can be seen, which improved in the no ADM cohort (p = 0.04). Our study reports no major benefit for the inclusion of ADM with respect to implant rippling, capsular contracture, explantation, need for additional revision surgeries, and patient-reported satisfaction in prepectoral second-stage implant-based breast reconstruction.

An Evaluation of Early Complications after Prepectoral Tissue Expander Placement in First-Stage Breast Reconstruction with and without Acellular Dermal Matrix.

PURPOSE: Prepectoral breast reconstruction has become popularized with the concurrent use of acellular dermal matrix (ADM). We sought to compare three-month postoperative complication rates and explantation rates for first stage, tissue expander based prepectoral breast reconstruction with and without the use of ADM. METHODS: A single institution retrospective chart review was performed to identify consecutive patients undergoing prepectoral tissue-expander based breast reconstruction from August 2020 to January 2022. Chi-squared tests were used to compare demographic categorical variables and multiple variable regression models were used to identify variables associated with three-month postoperative outcomes. RESULTS: We enrolled 124 consecutive patients. Fifty-five patients (98 breasts) were included in the no-ADM cohort and 69 patients (98 breasts) were included in the ADM cohort. There were no statistically significant differences between ADM and no-ADM cohort in regard to 90-day postoperative outcomes. On multivariable analysis, there were no independent associations between seroma, hematoma, wound dehiscence, mastectomy skin flap necrosis, infection, unplanned return to the OR, or explanation in the ADM or no ADM groups after controlling for age, BMI, history of diabetes, tobacco use, neoadjuvant chemotherapy, and postoperative radiotherapy. CONCLUSION: Our results reveal no significant differences in odds of postoperative complications, unplanned return to the OR, or explantation between ADM and no-ADM cohorts. More studies are needed to evaluate the safety of prepectoral, tissue expander placement without ADM.

Mandibular Myofibroma and Severe Trismus: A Complex Case and Review of Complications.

A female child was investigated for insidious onset of temporomandibular joint dysfunction and trismus in the setting of a mandibular myofibroma. Myofibromas, benign mesenchymal neoplasms composed of spindle cells, are rarely found in the oral cavity, most commonly in the mandible. These lesions are historically described as indolent with a high cure rate and minimal recurrence rates following surgical resection. The patient initially presented with concerns regarding snoring, retrognathia, and jaw ankylosis, as well as a history of trouble latching as an infant but without obvious physical deformities. Imaging revealed a large expansile lytic mass of the mandible, but no temporomandibular joint involvement; surgical biopsy evidenced myofibroma, and the lesion was resected. Over the course of disease, the lesion continued to expand, and the patient's maximal incisal opening continued to decrease despite conservative management with jaw physiotherapy; eventually she could not open her mouth despite the absence of joint involvement. Re-exploration along with formal jaw physiotherapy was achieved and optimal jaw opening was maintained. Myofibromas are rare benign desmoid tumors that can present anywhere in the body in solitary and multicentric forms, and previously did not present significant challenges to surgical and medical management. Tumors of the mandible may present with trismus and soft tissue ankylosis, which can mimic temporomandibular joint dysfunction in the absence of joint involvement. Physical therapy, rehabilitation, and soft tissue contracture release are key to management and improving outcomes in oral cancer patients, regardless of tumor pathology.

First Report of Testicular Replantation Following Wrong-Site Surgery.

Testicular replantation represents a unique circumstance. There are very few reports documenting their experience with testicle replantation and to the best of the authors' knowledge, this is the first case that has been reported in the peer-reviewed literature following a wrong site surgery. Therefore, we detail our technique and outcome when faced with such a rare event. In addition we review the literature, in order to compare and report the experience of others. This case highlights the value of applied microsurgical knowledge and the importance of cross-disciplinary efforts to improve patient outcomes.

Comparison of miRNA expression in patients with seasonal and perennial allergic rhinitis and non-atopic asthma.

BACKGROUND: MicroRNAs (miRNA) are small non-coding molecules that play a significant regulatory role in several allergic diseases. However, their role in allergic rhinitis is still not clearly understood. The aim of this study was to identify the candidate miRNAs that can discriminate between different forms of allergic rhinitis and also differ in and out of the allergen season. METHODS: The study included 20 healthy children, 20 patients with seasonal allergic rhinitis (SAR), 20 non-atopic asthmatics (NA-A), and 12 patients with perennial allergic rhinitis (PAR). Patients with SAR were evaluated comparatively in and outside the allergen season. The changes in the expressions of selected miRNAs (miR- 125b, miR-126, miR-133b, miR-181a, and miR-206) that were found related to the allergic diseases according to the literature were determined using quantitative polymerase chain reaction. RESULTS: In the SAR group, expression levels of miR-125b (p=0.040) and miR181a (p=0.014) were lower than in the controls outside of the allergen season. Expression levels of miR-181a were different between patients with SAR and NA-A (p=0.003), also between the SAR and PAR (p=0.001) groups in multiple comparisons. In contrast, the expression of miR-206 was found to be decreased in patients with NA-A and PAR compared with the controls (p=0.005 and p=0.024, respectively). In correlation analysis, expression levels of miR-125b and peak expiratory flow (PEF) values were found to be negatively correlated in the SAR (p=0.013) and PAR (p=0.029) groups. The expression level of miR-206 was positively correlated with total IgE levels in PAR (p=0.007). Receiver operating characteristic analysis revealed that miR-125b and miR-181a predicted the risk of SAR (p=0.040 and p=0.014, respectively), and miR-206 for NA-A and PAR (p=0.005 and p=0.024, respectively). CONCLUSIONS: Our study showed that expression levels of miRNAs were different according to the type of allergic diseases and the presence of allergens. miR-181a and miR-125b can be candidate biomarkers for SAR, and miR-206 for NA-A and PAR.

Skeletal and Dental Outcomes after Facial Allotransplantation: The Cleveland Clinic Experience and Systematic Review of the Literature.

BACKGROUND: Most of the literature surrounding face transplantation focuses on technique, immunology, and psychology. Dental and skeletal outcomes remain persistently underreported. This study critically examined the worldwide face transplant experience to evaluate such outcomes. METHODS: A systematic review of all composite allografts containing midface and/or mandible was performed. Dental and skeletal complications were recorded. Formal imaging and photographs available in the literature were analyzed using skeletal measurements, soft-tissue cephalometrics, and the Angle classification. Outcomes of our face transplant patients, including condylar assessment and airway volume measurements, is also presented. RESULTS: Twenty-five patients received allografts containing midface (n = 7) or mandible (n = 2), whereas 16 contained a double-jaw. All midface-only transplants developed skeletal deformity; 57 percent developed a palatal fistula. Both partial and full arch transplantation patients developed skeletal deformity. Among double-jaw transplants, 69 percent developed palatal fistula or floor-of-mouth dehiscence, 66 percent developed malocclusion, 50 percent developed trismus, and 31 percent required corrective orthognathic surgery. In 40 percent of patients, malocclusion recurred after corrective orthognathic surgery. Forty percent of all patients developed dental cavities or periodontal disease. All of our patients received midface and/or mandible. One patient required corrective orthognathic surgery. Midfacial segments showed clockwise rotation. Airway volumes decreased over time. CONCLUSIONS: Skeletal and dental complications remain extremely common after facial allotransplantation involving either single- or double-jaw composites. Corrective orthognathic surgery and dental extraction is often necessitated. These data will aid face transplant teams during surgical planning and preoperative counseling. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, V.