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Reduction mammoplasty (RM) is one of the most common plastic surgeries in the United States. We aimed to demonstrate the rate of incidental atypical and malignant breast lesions (AMBL) found in RM specimens and the impact of the number of submitted tissue sections on the rate of AMBL.We analysed our database for patients who had undergone reduction mammoplasty between 2000 and 2018. Patients with a history of breast cancer were excluded from the study. All pathology reports were analysed for AMBL (ALH, LCIS, FEA, ADH, DCIS, invasive carcinoma). The grossing protocol was to submit 10 sections from each breast between 2000 and 2013 and six sections between 2014 and 2018. One hundred and sixty-nine of 5208 patients (3.3%) and 216 of 10 340 RM specimens (2.1%) showed at least one AMBL. Nineteen (0.36%) patients had incidental cancer. The median age of patients with AMBL was significantly higher than patients without ABL (aged 59 years versus 45 years). There was no cancer in patients aged30 years. The age-controlled rate of overall AMBL as well as atypia and cancer only did not decrease by submitting fewer sections during the 2014-18 period compared to the 2010-13 period.Decreasing the number of tissue sections from 10 to six did not lead to a significant decrease in the rate of overall AMBL or cancer. Our data suggest that submitting six tissue sections from each breast for patients aged30 years and two sections from each breast for patients aged30 years would be sufficient.

BACKGROUND Patients undergoing autologous breast reconstruction are at high risk of perioperative venous thromboembolic events. The efficacy of chemoprophylaxis in decreasing venous thromboembolic events is well established, but the timing of chemoprophylaxis remains controversial. The authors compare the incidence of bleeding following preoperative versus postoperative initiation of chemoprophylaxis in microvascular breast reconstruction. METHODS A retrospective chart review was performed from August of 2010 to July of 2016. Initiation of chemoprophylaxis changed from postoperative to preoperative in 2013, dividing subjects into two groups. Patient demographics, comorbidities, and complications were reviewed. RESULTS A total of 196 patients (311 flaps) were included in the study. A total of 105 patients (166 flaps) received preoperative enoxaparin (40 mg) and 91 patients (145 flaps) received postoperative chemoprophylaxis. A total of five patients required hematoma evacuation (2.6 percent). Of these, one hematoma (1 percent) occurred in the preoperative chemoprophylaxis group. Seven patients received blood transfusions: three in the preoperative group and four in the postoperative group (2.9 percent versus 4.4 percent; p = 0.419). There was a total of one flap failure, and there were no documented venous thromboembolic events in any of the groups. CONCLUSIONS This study demonstrates that preoperative chemoprophylaxis can be used safely in patients undergoing microvascular breast reconstruction. The higher rate of bleeding in the postoperative group may be related to the onset of action of enoxaparin of 4 to 6 hours, which allows for intraoperative hemostasis in the preoperative group and possibly potentiating postoperative oozing when administered postoperatively. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, III.

Lower extremity reconstruction after resection of long bone tumors in children is challenging because of the unique functional demands and growth potential of the lower extremity. The use of a free fibula flap inside a massive bone allograft provides a reliable reconstructive option. The authors evaluate the surgical and functional outcomes of using this technique.This is a retrospective review of 12 consecutive patients who underwent reconstruction of segmental femur or tibia defects using a free fibula flap inside a massive bone allograft between 2003 and 2011. Complications and functional outcomes are reported.Twelve patients with a mean age of 15.8 years (range, 3 to 49 years) were included in the study. Eight femur defects and four tibia defects were reconstructed. The mean follow-up time was 41.4 months. Two constructs were removed because of infection, three patients required bone grafting for nonunion, one patient required an additional operation to excise a skin paddle, and one patient experienced a lower extremity deep vein thrombosis. The mean time to achieve full weight bearing was 14.3 months.The use of a free fibula flap inside a massive bone allograft after bone tumor resection provides an option for lower extremity reconstruction. The allograft component increases the initial strength of the reconstruction, whereas the vascularized fibula component is thought to increase the biologic potential for osteosynthesis and ultimately provide a potentially lifelong durable reconstruction. Patients who achieve oncologic control are likely to enjoy a highly functional long-term outcome.Therapeutic, IV.

Preoperative nasoalveolar molding (NAM) in combination with primary gingivoperiosteoplasty (GPP) reduces the need for secondary alveolar bone grafting by 60% in patients with unilateral cleft lip and palate (CL/P). Herein, we investigate the efficacy of NAM and primary GPP in patients with bilateral CL/P. All patients (n = 38) with bilateral CL/P who underwent NAM and primary GPP from 1988 to 1998 with at least 14 years of follow-up were included in this study. Panoramic and periapical radiographs were used to assess dentoalveolar bone formation. A total of 38 patients were identified with median follow-up of 18 years (range 14-26 years). Of the 27 patients who underwent bilateral GPP, 14 (51%) patients had successful dentoalveolar bone formation bilaterally and 13 (49%) had unilateral bone formation. No patient had a bilateral failure. Of the 11 patients who underwent unilateral GPP, 7 (63%) patients had successful dentoalveolar bone formation. Bilateral successful dentoalveolar bone formation following primary bilateral GPP has a dependent probability of 52% and a conditional probability of 82%.

Despite significant advances in cleft lip and palate treatment, anatomical controversies remain. Some have proposed that the width of the cleft is due to alveolar segmental displacement. Others suggest that the width is due to palatoalveolar hypoplasia. Improving our understanding of cleft anatomy may have implications for presurgical orthopedics and tissue engineering therapies. Palatoalveolar impressions of 17 noncleft children and 11 children with complete (alveolar, primary, and secondary) unilateral cleft palates were taken. Maxillary tuberosity positions and maxillary volumes were compared. Tuberosity position was determined by facebow transfer of palatoalveolar casts into geodetic datum boxes, and identification of the Cartesian coordinates (x, y, z) of the tuberosities relative to the box surfaces and Frankfurt horizontal. Maxillary volume was determined by immersing the palatoalveolar casts and measuring sand displacement. A significant difference was noted in the average tuberosity to contralateral tuberosity distance between cleft and noncleft cohorts. On average, cleft palate tuberosities were laterally displaced 8.7 mm compared with noncleft palates (P < 0.05). There was neither statistically significant alveolar segment elevation nor retroversion. A significant difference was noted in the average palatoalveolar volumes. The cleft palatoalveolar volume was 5.7 cm, and the noncleft palatoalveolar volume was 7.2 cm (P < 0.05). A palatal cleft is due to both alveolar tissue displacement and deficiency. Therefore, ideal cleft palate care should involve the correction of a displaced and deficient alveolus.

The application of distraction osteogenesis is an effective treatment for mandibular deficiencies. A priori, a horizontal vector of distraction was hypothesized to produce horizontal movement of the mandible and a vertical vector of distraction to produce primarily downward vertical elongation of the ramus. This study was designed to test this hypothesis.A retrospective clinical and radiographic review was conducted of all patients who underwent bilateral, uniplanar distraction with an external device at the New York University Medical Center between October of 1990 and February of 2004 (n = 185). A subset of 15 patients was identified who satisfied inclusion criteria and had adequate predistraction and postdistraction lateral cephalograms. Cephalometric tracings were made and multiple landmarks were assessed before and after distraction.A strong correlation was noted between the vector of distraction and rotation of the symphyseal plane, movement of the mandibular symphysis, and change in interocclusal angle. A horizontal vector of distraction resulted in minimal counterclockwise rotation of the symphyseal plane, greater downward vertical translation of the mandibular symphysis, and minimal closure of an anterior open bite. In contrast, a vertical vector resulted in greater counterclockwise rotation of the symphyseal plane, greater horizontal projection of the mandibular symphysis, and greater closure of an anterior open bite. Mathematical formulas were derived to correlate the distraction vector and mandibular movements.Successful distraction is dependent on accurate prediction of outcomes. This study demonstrates that the vector of distraction predictably affects the mandibular response during bilateral distraction osteogenesis but contradicts the a priori hypothesis.

Although recent studies indicate that regional dura mater influences the fate of the overlying cranial suture, little is known about the assembly of extracellular matrix (ECM) molecules within the patent and fusing murine cranial suture complexes. Confocal laser scanning microscopy was used to study ECM assembly within patent and fusing cranial suture complexes. Coronal sections (20 microm thick) of patent sagittal (SAG) and fusing posterior frontal (PF) sutures from postnatal 8-, 14-, and 18-day-old Sprague-Dawley rats were scanned in 0.5-microm increments, and images were collected consecutively to create a z-series for three-dimensional reconstruction. Spatial and temporal collagen arrangements were compared between SAG and PF sutures by measuring interfiber distance, fiber thickness, and total collagen surface area at each time point. We demonstrate that on day 8 (before the onset of suture fusion), collagen bundles are randomly arranged in both the SAG and PF sutures. By day 14 (midfusion period), there was a statistically significant reduction in total collagen surface area (80.5% versus 67.4%; P < 0.05) as the collagen bundles were organized into orthogonal lattices along the anterior and endocranial margins of the PF suture. Furthermore, new bone matrix deposition was observed along the edges of these organized collagen bundles. In contrast, collagen within the SAG suture remained randomly arranged and unossified. By day 18 (late fusion period), the PF suture was completely fused except for the posterior-ectocranial portion. This patent section of the PF suture contained a highly organized mineralizing orthogonal collagen lattice. The total collagen surface area in the day-18 PF suture continued to decline compared with the day-8 PF suture (80.5% versus 55.6%; P < 0.05). In the day-18 SAG suture, the collagen bundles remained randomly arranged, and the total surface area did not change. The same analysis was performed in a human pathologic fusing and patent suture. Similar results were observed. The total collagen surface area significantly decreased in the pathologic fusing human suture compared with the patent suture (92.8% versus 60.6%; P < 0.05). Moreover, the pathologically fusing suture contained a highly organized mineralizing orthogonal collagen lattice. This is the first analysis of collagen patterns in patent and fusing cranial sutures.

The incidence of postoperative complications in cleft care is low. In this 19-year retrospective analysis of cleft lip and palate patients treated with preoperative nasoalveolar molding, we examine the incidence of postoperative oronasal fistulae. The charts of 178 patients who underwent preoperative nasoalveolar molding by the same orthodontist/prosthodontist team and primary cleft lip/palate repair by the same surgeon over a 19-year period were reviewed. Millard, Mohler, Cutting, or Mulliken-type techniques were used for cleft lip repairs. Oxford-, Bardach-, or von Langenbeck-type techniques were used for cleft palate repairs. One nasolabial fistula occurred after primary cleft lip repair (0.56% incidence) and was repaired surgically. Four palatal fistulae (3 at the junction between soft and hard palate and 1 at the right anterior palate near the incisive foramen) occurred, but 3 healed spontaneously. Only 1 palatal fistula (0.71%) required surgical repair. All 5 fistulae occurred within the first 8 years of the study period, with 4 (80%) of 5 occurring within the first 3 years. Although fistula rate may be related to surgeon experience and the evolution of presurgical techniques, nasoalveolar molding in conjunction with nasal floor closure contributes to a low incidence of oronasal fistulae.

Craniofacial vascularized composite allotransplantation is especially challenging when bony components are required. Matching the complex three-dimensional anatomy of the donor and recipient craniofacial skeletons to optimize bony contact and dental occlusion is a time-consuming step in the operating room. Currently, few tools exist to facilitate this process. The authors describe the development of a virtual planning protocol and patient-specific device design to efficiently match the donor and recipient skeletal elements in craniofacial vascularized composite allotransplantation. The protocol was validated in a cadaveric transplant. This innovative planning method allows a "snap-fit" reconstruction using custom surgical guides while maintaining facial height and width and functional occlusion. Postoperative overlay technology in the virtual environment provides an objective outcome analysis.

Nasoalveolar molding was developed to improve dentoalveolar, septal, and lower lateral cartilage position before cleft lip repair. Previous studies have documented the long-term maintenance of columella length and nasal dome form and projection. The purpose of the present study was to determine the effect of presurgical nasoalveolar molding on long-term unilateral complete cleft nasal symmetry.A retrospective review of 25 consecutively presenting nonsyndromic complete unilateral cleft lip-cleft palate patients was conducted. Fifteen patients were treated with presurgical nasoalveolar molding for 3 months before surgical correction, and 10 patients were treated by surgical correction alone. The average age at the time of follow-up was 9 years. Four nasal anthropometric distances and two angular relationships were measured to assess nasal symmetry.All six measurements demonstrated a greater degree of nasal symmetry in nasoalveolar molding patients compared with the patients treated with surgery alone. Five symmetry measurements were significantly more symmetric in the nasoalveolar molding patients and one measurement demonstrated a nonsignificant but greater degree of symmetry compared with the patients treated with surgery alone.The data demonstrate that the lower lateral and septal cartilages are more symmetric in the nasoalveolar molding patients compared with the surgery-alone patients. Furthermore, the improved symmetry observed in nasoalveolar molding-treated noses during the time of the primary surgery is maintained at 9 years of age.

BACKGROUND: Unilateral craniofacial microsomia is characterized by soft-tissue and bony deficiencies. Mandibular distraction osteogenesis can be used to augment the hypoplastic skeleton and improve facial symmetry. The aim of this study was to determine how the vector of unilateral mandibular distraction affects treatment outcomes. METHODS: A retrospective chart and radiographic review was conducted of all patients treated with external mandibular distraction osteogenesis between October of 1990 and February of 2004 (n = 185). A subset of 42 patients underwent primary unilateral, uniplanar, external distraction, and 13 patients were found to have satisfied inclusion criteria and had adequate predistraction and postdistraction lateral and posteroanterior cephalograms. Cephalometric tracings were made and multiple points and planes were assessed before and after distraction. RESULTS: A strong correlation was noted between the vector of distraction and the movement of the mandible. A horizontal vector of distraction resulted in minimal increase in ramal length but a marked shift in the mandibular midline (r = 0.68, p < 0.05). In contrast, a vertical vector of distraction resulted in marked mandibular ramus lengthening but minimal mandibular midline shift (r = 0.73, p < 0.05). Mathematical formulas were derived to correlate the distraction vector and mandibular movements to improve preoperative planning. CONCLUSIONS: Successful distraction is dependent on accurate preoperative planning and prediction of outcomes. This study demonstrates a predictable relationship between the vector of unilateral distraction and the mandibular response.

The decision to replant a severed part is based on the numerous factors that influence survival of the part and the functional and aesthetic benefits gained from replanting. Not all amputees will benefit from or are candidates for replantation. The decision to proceed is therefore made by the surgeon who must consider the mechanism and extent of injury, the age of the patient, the presence of other medical or surgical conditions, the likely functional outcomes, and the patient's motivation to undergo a difficult procedure, which is followed by a lengthy recovery. This is a meta-analysis of the available studies that tracks the outcomes, based on 9 criteria, after the amputation of a total of 1803 digits in 1299 patients. By combining the data from numerous sources, a statistically significant picture emerges which may be used to educate patients and help guide the surgeon in the decision to replant.