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The indications for using biologic wound agents have expanded greatly since first being employed for acute burn management. The majority of the literature details the use of said agents in the adult population; however, there is little representation regarding their uses for reconstructing defects typically observed in the pediatric population. Ironically, children, and to a lesser extent adolescents, greatly benefit from their use given the reduced skin laxity and amount of surrounding tissue available for locoregional tissue transfer when compared with adults. Herein, we detail the use of acellular and cellular biologic wound agents in the pediatric population.

At a tertiary-care, level 1 pediatric trauma center, we have observed fractures of the distal phalanx involving the physis, with associated nail bed injuries, that are distinct from the classic description of the Seymour fracture. We investigated the time to definitive management and the associated morbidity of these Seymour fracture variants compared with classically described Seymour fractures. We hypothesize that these Seymour variants are similarly problematic in terms of complications and delays to the definitive treatment and thus warrant increased awareness.A retrospective chart review was performed of all patients with distal phalanx fractures involving the physis and associated nail bed injuries that were treated with operative intervention at a single pediatric specialty institution over a 9-year period. Radiographs and clinical photographs were reviewed to determine if the patient presented with a classic Seymour fracture or variant. Primary outcomes included time from injury to definitive treatment and complication rate.Of the 66 Seymour fractures identified in the chart review, 36 (55%) were identified as classic Seymour fractures and 30 (45%) were identified as variants. The mean time to operative intervention in the classic and variant groups was 7.3 versus 12.7 days (P=0.216). The complication rates in the classic and variant groups were 11.1% versus 23.3% (P=0.185), with infections accounting for nearly all complications identified. Overall infection rates for the classic and variant cohorts were 8.3% and 20.0% (P=0.169), respectively, with the majority presenting preoperatively (5.6% vs. 13.3%, P=0.274).We found that patients with classic Seymour fractures or radiographic variants had statistically similar incidence rates, complication rates, and delays in treatment, with a trend towards higher complication rates and delayed time to treatment in patients with variant-type injuries. We propose a minor expansion of the definition of Seymour fractures to include common variants to increase awareness of these problematic injuries, minimize delays in treatment, and decrease complications.Level III; Retrospective Comparative Study.

Purpura fulminans can result in significant full-thickness wounds, posing a challenge in the pediatric population, given the paucity of donor sites for reconstruction. The authors present the case of an 11-month-old patient for whom a split-thickness skin allograft (TheraSkin) was successfully implemented as a temporizing measure for a large leg wound.

Peripheral nerve injuries of the upper extremity can result from a wide array of etiologies, with the two most common being compression neuropathy and traumatic injuries. These types of injuries are common and can be psychologically, functionally, and financially devastating to the patient. A detailed preoperative evaluation is imperative for appropriate management. Traumatic injuries can typically be treated with local burial techniques, targeted muscle reinnervation, and regenerative peripheral nerve interfaces. Median nerve compression is frequently managed with complete release of the antebrachial fascia/transverse carpal ligament and/or use of flap coverage such as the hypothenar fat pad flap and local muscle flaps. Ulnar nerve compression is commonly managed via submuscular transposition, subcutaneous transposition, neurolysis, and nerve wrapping. In this review, we discuss the preoperative evaluation, surgical techniques, and advantages and disadvantages of each treatment modality for patients with compressive and traumatic upper extremity nerve injuries.

Extrarenal malignant rhabdoid tumors (MRT) are highly aggressive tumors of childhood with a poor overall prognosis. While most commonly found within the kidney and central nervous system, MRT can also occur in other locations and present highly specific challenges for pediatric surgical providers in an effort to achieve a meaningful resection. Cervical rhabdoid tumors are extremely rare. We report the multidisciplinary management of a patient with a complex cervicothoracic malignant rhabdoid tumor who underwent successful surgical resection with a greater than one year survival.

Background: Hand injuries are common in the pediatric population with a wide spectrum of morbidity that can occur. Simple injuries are distinguished from complex injuries by the number of fingers/systems that are involved. The epidemiology of simple and complex operative hand trauma in the pediatric population has not yet been defined. Methods: A retrospective review was performed of all pediatric patients requiring operative intervention for hand trauma at a major children’s hospital over a 3-year period (2015-2017). Data pertaining to demographics, mechanism, severity, type of surgery, and other factors related to hand trauma were then analyzed and interpreted. Results: Three hundred seventy-one pediatric hand injuries over a 3-year period required surgical intervention, with 19.2% being classified as complex. The average patient age was 11.0 years. A total of 68.7% of patients were men. Bony injuries made up 86.3% of simple injuries, with the proximal phalanx being the most commonly fractured bone. Complex injuries occurred more frequently in men and required a greater number of surgeries (1.6 vs 1.0). Of the complex injuries, only major injuries (severity score >100) required a significantly greater number of surgeries. Major hand injuries were mostly caused by motorized vehicles and required a significantly greater number of surgeries (3.8), compared with other causes of injuries. Conclusions: Operative hand injuries occur along a spectrum of morbidity in the pediatric population. While most of the injuries are simple and require only 1 procedure, more complex injuries can also occur and deserve a higher level of care and attention.

Background Despite increasing literature support for the use of acellular dermal matrix (ADM) in expander-based breast reconstruction, the effect of ADM on clinical outcomes in the presence of post-mastectomy radiation therapy (PMRT) has not been well described. Objectives To analyze the impact ADM plays on clinical outcomes on immediate tissue expander (ITE) reconstruction undergoing PMRT. Methods We retrospectively reviewed patients who underwent ITE breast reconstruction from 2004 to 2014 at MD Anderson Cancer Center. Patients were categorized into four cohorts: ADM, ADM with PMRT, non-ADM, and non-ADM with PMRT. Outcomes and complications were compared among cohorts. Results Over 10 years, 957 patients underwent ITE reconstruction (683 non-ADM, 113 non-ADM with PMRT, 486 ADM, and 88 ADM with PMRT) with 1370 reconstructions. Overall complication rates for the ADM and non-ADM cohorts were 39.0% and 16.7%, respectively (P < 0.001). Within both cohorts, mastectomy skin flap necrosis (MSFN) was the most common complication, followed by infection. ADM use was associated with a significantly higher rate of infections and seromas in both radiated and non-radiated groups; however, when comparing radiated cohorts, the incidence of explantation was significantly lower with the use of ADM. Conclusions The decision to use ADM for expander-based breast reconstruction should be performed with caution, given higher overall rates of complications, including infections and seromas. There may, however, be a role for ADM in cases requiring PMRT, as the overall incidence of implant failure is lower than non-ADM cases. Level of Evidence: 3

Background The purpose of this study was to compare functional outcomes between nerve grafting and nerve transfer procedures in the setting of isolated, posttraumatic axillary nerve injuries. Methods A systematic review was performed using the PubMed, Scopus, and Cochrane databases to identify all cases of isolated, posttraumatic axillary nerve injuries in patients aged 18 years or older. Patients who underwent axillary nerve reconstruction were included and categorized by technique: graft or transfer. Demographics were recorded, including age, time to operation, and presence of concomitant injuries. Functional outcomes were evaluated, including British Medical Research Council strength and range of motion for shoulder abduction. Results Ten retrospective studies met criteria, for a total of 66 patients (20 nerve grafts and 46 nerve transfers). Median time from injury to operation was equivalent across the nerve graft and nerve transfer groups (8.0 months versus 7.0 months; p = 0.41). Postoperative follow-up was 24.0 months for nerve grafting versus 18.5 months for nerve transfer (p = 0.13). Clinically useful shoulder abduction, defined as British Medical Research Council grade M3 or greater, was obtained in 100 percent of nerve graft patients versus 87 percent of nerve transfer patients (p = 0.09). Grade M4 or better strength was obtained in 85 percent of nerve graft patients and 73.9 percent of nerve transfer patients (p = 0.32). Conclusions Significant differences in functional outcomes between nerve graft and transfer procedures for posttraumatic axillary nerve injuries are not apparent at this time. Prospective outcomes studies are needed to better elucidate whether functional differences do exist. Clinical question/level of evidence Therapeutic, IV.

Preaxial polydactyly is a common, often sporadic, congenital anomaly that must be addressed surgically early in life. Ideally, the surgeon seeks to accomplish three goals: construction of a thumb that is adequate in size, preservation of pinch function, and reconstruction of all components in one procedure. Although each case is unique, several classification systems attempt to describe the various types. In this article, the authors discuss the various classification systems, procedures, and outcomes after surgery for pediatric thumb duplication.

Reconstruction of oncologic defects in the pediatric population is a unique challenge. Differences in patient comorbidities, size of the reconstructive components, response of the skeletally immature body to surgery and radiation, compliance, and overall recovery potential make the pediatric patient cohort distinct from the adult population. Considering that patients are enjoying longer life spans, it behooves the surgeon to reconstruct oncologic defects with durable and long-lasting tissue. Determining when to implement each of the reconstructive tools is based upon principles embodied by the reconstructive ladder and taking into account the defect-specific characteristics, including location and type of tissues involved. Within the setting of multi-disciplinary care, reconstruction can be associated with good long-term functional and aesthetic outcomes. J. Surg. Oncol. 2016;113:940-945. © 2016 Wiley Periodicals, Inc.

Background Infections in the pediatric population are a less well studied topic in hand surgery. Crucial aspects of the management of pediatric hand infections differ from adults, though much of current treatment is generalized from adult care. This study evaluates our clinical experience with regards to the epidemiology, management, and outcomes of pediatric hand infections requiring operative intervention. Methods A 7-year retrospective chart review was performed of all pediatric patients who required operative intervention for hand infections at Texas Children's Hospital. Clinical information was collected and analyzed, including demographics, infection characteristics, management, and outcomes. Results Fifty-seven patients met the inclusion criteria for our study over the 7-year period. Of these, 7% (n=4) had a pre-existing diagnosis of diabetes mellitus, and 5% (n=3) had a recent history of upper extremity infections. The most common infection was a discrete abscess, whereas urgent/emergent conditions represented 25% (n=14) of infections. Radiographic changes consistent with osteomyelitis were present in over one-quarter of patients (n=13, 23%). The median length of hospital stay was 3 days (95% confidence interval: 3.05-5.05) and the most common pathogen was Staphylococcus aureus (n=33, 58%), with slightly more being methicillin sensitive (MSSA) than resistant (MRSA) (n=19, 33% vs. n=14, 25%). The incidence of reoperation was 12.5% (n=7). Conclusions Hand infections are a common problem in the pediatric population. Cases tend to be associated with accidental trauma and discrete abscesses colonized by MSSA/MRSA. The vast majority of cases require only one operation and a short course of wound care before discharge. Level of evidence Level IV-therapeutic study.

The CASPER system offers a lightweight, multi-disciplinary approach to detect the execution of anomalous code by monitoring the unintended electronic device emissions. Using commodity hardware and a combination of novel signal processing, machine learning, and program analysis techniques, we have demonstrated the ability to detect unknown code running on a device placed 12” from the CASPER system by analyzing the devices RF emissions. Our innovations for the sensors subsystem include multi-antenna processing algorithms which allow us to extend range and extract signal features in the presence of background noise and interference encountered in realistic training and monitoring environments. In addition, robust feature estimation methods have been developed that allow detection of device operating conditions in the presence of varying clock frequency and other aspects that may change from device to device or from training to monitoring. Furthermore, a band-scan technique has been implemented to automatically identify suitable frequency bands for monitoring based on a set of metrics including received power, expected spectral feature content (based on loop length and clock frequency), kurtosis, and mode clustering. CASPER also includes an auto-labeling feature that is used to discover the signal processing features that provide the greatest information for detection without human intervention. The system additionally includes a framework for anomaly detection engines, currently populated with three engines based on n-grams, statistical frequency, and control flow. As we will describe, the combination of these engines reduces the ways in which an attacker can adapt in an attempt to hide from CASPER. We will describe the CASPER concept, components and technologies used, a summary of results to-date, and plans for further development. CASPER is an ongoing research project funded under the DARPA LADS program.

Infections are common in hand surgery and proper management is important to achieve optimal outcomes. Although most cases are not urgent, less common, severe infections such as flexor tenosynovitis and necrotizing fasciitis require urgent identification with both medical and surgical management. It is common for diagnoses to be missed or delayed because clinical and laboratory indicators are often variably present. Delayed identification and management can result in poor outcomes with permanent deficits. This article will provide a review of hand infections with a focus on identifying serious hand infections requiring urgent or emergent treatment, and distinguishing these from less urgent scenarios.

Biodegradable plates have been used extensively in fracture fixation since the 1960s. They rarely cause stress-protection atrophy or problems requiring secondary plate removal, common complications seen with metallic plates. However, aseptic foreign-body reactions have been reported, sometimes years after the original implantation. Both inadequate polymer degradation and debris accumulation have been implicated as causes. The current generation of commercial biodegradable plates is formulated to minimize this complication by altering the ratio of polylactic and polyglycolic acids. This in vivo study compares the degree of local foreign-body reaction of two commercially available resorbable plates in rabbits. Two types of biodegradable plates were examined: poly(D/L)lactide acid (PDLLA) and polylactide-co-glycolide acid (PLGA). Each plate was placed into a periosteal pericalvarial pocket created beneath the anterior or posterior scalp of a rabbit. Humane killing occurred at 3, 6, and 12 months postoperatively. Foreign-body reaction was evaluated histologically. The PDLLA plates demonstrated marked local foreign-body reactions within the implant capsule as early as 3 months after implantation, with presence of inflammatory cells and granulomatous giant cells in close association with the implant material. All local foreign-body reactions were subclinical with no corresponding tissue swelling requiring drainage. PLGA plates did not demonstrate any signs of inflammatory reactions. In addition, the PLGA plates did not appear to resorb or integrate at 12 months. Neither PDLLA nor PLGA plates demonstrated inflammation of the soft tissue or adjacent bone outside the implant capsule. In our study, the PDLLA plates demonstrated histological evidence of foreign-body reaction that is confined within the implant capsule, which was not seen with the PLGA plates. This finding may be attributable to the lack of significant resorption seen in the PLGA plates. Both PDLLA and PLGA plates were biocompatible with the rabbit tissue environment and should be considered for continued use in craniofacial, maxillofacial, and orthopedic reconstruction.

Reconstruction of oncologic defects in the pediatric population is a unique challenge. Differences in patient comorbidities, size of the reconstructive components, response of the skeletally immature body to surgery and radiation, compliance, and overall recovery potential make the pediatric patient cohort distinct from the adult population. Considering that patients are enjoying longer life spans, it behooves the surgeon to reconstruct oncologic defects with durable and long-lasting tissue. Determining when to implement each of the reconstructive tools is based upon principles embodied by the reconstructive ladder and taking into account the defect-specific characteristics, including location and type of tissues involved. Within the setting of multi-disciplinary care, reconstruction can be associated with good long-term functional and aesthetic outcomes. J. Surg. Oncol. 2016;113:940-945. © 2016 Wiley Periodicals, Inc.

The treatment of pediatric facial fractures, although similar to that of adults, requires a separate and thorough understanding of the unique developmental issues inherent to this age group. The contribution of several of these factors allows for a large portion of these injuries to be managed more conservatively; however, operative indications still exist. The optimal form of management in these situations must balance the risks of impacting dentition or future skeletal growth versus obtaining acceptable stability and reduction for healing. Although these principles have remained largely unchanged over the years, a more current discussion on the state of resorbable and titanium fixation is offered to highlight evolving management considerations. Although uniquely challenging, the proper management of pediatric facial trauma is possible if the treating physician remains aware of key anatomic, epidemiological, evaluation, and management issues.

Background: Postoperative management following rhinoplasty varies greatly among aesthetic surgeons. Few studies have addressed practice trends in postoperative rhinoplasty care or questioned the frequency of packing and splinting. Many conventional postoperative techniques remain controversial (eg, packing). Objective: To investigate current postoperative practices in the United States, correlating the results with surgical education, practice type, and complication rates. Methods: An online survey was distributed to members of the American Society for Aesthetic Plastic Surgery. Respondents were polled about their background, route of education, type of practice, frequency and preference of postoperative nasal care, and most frequent rhinoplasty complications. Statistical analysis was performed with the χ2 test. Results: Of the 1550 total surveys sent, 126 responses were received (8.1%). The majority of respondents were in private practice (86%) and trained in plastic surgery (83%). Approximately 33% continue to regularly employ packing following rhinoplasty, but data show that surgeons performing 21 or more rhinoplasties per year were less likely to utilize packing ( P = .06). Those surgeons with higher rhinoplasty case volumes were significantly more likely to utilize a secondary therapy (eg, steroids, arnica) in combination with ice packs ( P = .03) to prevent postoperative ecchymosis. Finally, surgeons with lower rhinoplasty case volumes reported more frequent postoperative nasal tip deformities ( P = .01). Conclusions: Postoperative rhinoplasty care varies greatly among practicing aesthetic surgeons. Importantly, a high percentage of private practice aesthetic surgeons continue to utilize nasal packing following rhinoplasty. However, these numbers trend downward in surgeons who perform rhinoplasties more frequently.

Isolated unilateral lambdoid craniosynostosis is often confused with posterior positional plagiocephaly because of a general overlap in their clinical presentations; however, distinction between these 2 entities is important because of the differences in appropriate management. Historical literature teaches that ear position is posterior in lambdoid synostosis, whereas it is anterior in positional plagiocephaly. Recently, several cases of anterior ear position in isolated unilateral lambdoid synostosis presented to the Texas Children's Hospital. A review of the cases and literature revealed that there are now 37 cases of unilateral lambdoid synostosis in the literature in which ipsilateral ear position is reported. Twelve cases (32%) had anteriorly displaced ears, 6 cases (16%) were nondisplaced, 7 cases (19%) were displaced posteriorly, 4 cases (11%) anteroinferiorly, 1 case (3%) inferiorly, and 7 cases (19%) posteroinferiorly. Based on this review, it seems that the diagnostic significance of the external ear position is unclear at this point.

Background: Although primary thinning of the anterolateral thigh (ALT) flap has been successful in Asia, clinical and anatomic studies have demonstrated that this may be inadvisable in Western patients. Recent reports have demonstrated successful thinning of the ALT using smaller flaps. A systematic review was attempted, to assess whether ALT size affects the incidence of vascular compromise after primary thinning. Methods: A systematic review was undertaken to examine the relevant literature. Student t-test was used to compare flaps that did and did not have complications. Fisher exact test was used to compare outcomes of flaps measuring less than and greater than 150 cm 2 . Results: Eleven articles met the inclusion criteria. Eighty-eight ALT flaps were reported, and vascular compromise was seen in 11 (12.5%). The average size of flaps that demonstrated necrosis was 180.73 cm 2 ; those without necrosis averaged 123.19 cm 2 (P = 0.06). Flaps >150 cm 2 had a significantly increased rate of compromise (25.93% vs. 6.56%; P < 0.05). Conclusions: A systematic literature review confirms that it is inadvisable to primarily thin large ALT flaps in the Western population. When large ALT flaps are required, primary thinning must be avoided to keep linking vessels intact.

Nasoorbitoethmoid fractures account for ∼5% of adult and 15% of pediatric facial fractures. The appropriate management of these injuries requires an understanding of the anatomic features of the region, the classification of injury severity, assessment, and treatment methods. The purpose of this article is to provide a general overview of the topic, with a more specific focus on the pearls of managing these fractures. Prompt and proper management of these injuries can achieve both adequate functional and aesthetic outcomes.

Mandibular trauma is a common problem seen by plastic surgeons. When fractures occur, they have the ability to affect the patient's occlusion significantly, cause infection, and lead to considerable pain. Interventions to prevent these sequelae require either closed or open forms of reduction and fixation. Physicians determining how to manage these injuries should take into consideration the nature of the injury, background information regarding the patient's health, and the patient's comorbidities. Whereas general principles guide the management of the majority of injuries, special consideration must be paid to the edentulous patient, complex and comminuted fractures, and pediatric patients. These topics are discussed in this article, with a special emphasis on pearls of mandibular trauma management.

Background: Nasal airway obstruction is a frequently-encountered problem, often secondary to inferior turbinate hypertrophy. Medical treatment can be beneficial but is inadequate for many individuals. For these refractory cases, surgical intervention plays a key role in management. Objective: The authors evaluate the current trends in surgical management of inferior turbinate hypertrophy and review the senior author’s (SS) preferred technique. Methods: A questionnaire was devised and sent to members of the American Society for Aesthetic Plastic Surgery (ASAPS) to determine their preferred methods for assessment and treatment of inferior turbinate hypertrophy. Results: One hundred and twenty-seven physicians responded to the survey, with 85% of surveys completed fully. Of the responses, 117 (92%) respondents were trained solely in plastic surgery and 108 (86.4%) were in private practice. Roughly 81.6% of respondents employ a clinical exam alone to evaluate for airway issues. The most commonly-preferred techniques to treat inferior turbinate hypertrophy were a limited turbinate excision (61.9%) and turbinate outfracture (35.2%). Conclusions: Based on the results of this study, it appears that limited turbinate excision and turbinate outfracture are the most commonly-used techniques in private practice by plastic surgeons. Newer techniques such as radiofrequency coblation have yet to become prevalent in terms of application, despite their current prevalence within the medical literature. The optimal method of management for inferior turbinate reduction should take into consideration the surgeon’s skill and preference, access to surgical instruments, mode of anesthesia, and the current literature.

International surgical missions, particularly those that address patients with clefts of the lip and palate, have become increasingly common. Numerous groups have been organized to provide these services. A plastic surgeon participating in these endeavors should have full knowledge of the details involved not just for himself but to maximize safety and optimize outcomes for these patients. An understanding of the issues surrounding trip preparation, the in-country logistics, proper preoperative patient selection, and intraoperative and postoperative issues are all essential to a successful experience. In this article, the authors review and discuss lessons learned from a combined total of more than 100 international trips. Relevant literature is reviewed, and additional pearls from this body of knowledge are presented.

Background: Secondary deformities of the bilateral cleft lip are unfortunately very common, and severe cases can involve scar contracture, vermilion deficiency, and a tight upper lip. In these cases, reconstruction often requires replacement of the central philtral unit with full-thickness tissue, including vermilion, orbicularis oris, and skin. The Abbe flap offers full-thickness reconstruction of the central aesthetic unit of the upper lip by replacing the deficient and scarred tissue and restoring functional competence to the oral sphincter. Methods: A review was performed of the authors' operating room video files to evaluate their technique for performing secondary bilateral cleft lip revision using the Abbe flap. Results: The Abbe flap has been used successfully for secondary revisions of the bilateral cleft lip at the Texas Children's Hospital. A technique video was made using video clips from two secondary bilateral cleft lip revisions. Conclusions: Results of bilateral cleft lip repair are often poor because of inappropriate use of the hypoplastic prolabial tissue, failure to anatomically reunite the orbicularis muscle, and scarring. The Abbe flap is an effective tool for reconstruction of the philtral landmarks, reconstitution of oral competence of the orbicularis, and recreation of Cupid's bow and the central pout. Although this procedure is relatively straightforward, special attention to designing the new philtrum, marking intact landmarks, and careful dissection of the labial artery are required for successful reconstruction.

Craniofacial bony remodeling has been recognized as an important contributor to the facial aging process. Multiple studies have demonstrated significant craniofacial skeletal changes with age. However, no review has assembled this information in a concise, cogent fashion. Furthermore, the etiology of these skeletal changes has not been elucidated. This information is important for understanding the mechanisms of facial aging and for further development of facial rejuvenation.A literature review of all articles discussing remodeling of the craniofacial skeleton with age was performed. Studies that used objective measurements of craniofacial skeletal parameters for different age groups were collected and analyzed.The studies demonstrated consistent morphologic changes in the craniofacial skeleton with age. These changes included trends toward increased facial bony width in women; contour changes of the orbit, anterior maxilla, and mandibular body; and decreased dimensions of the glabellar, pyriform, and maxillary angles.The craniofacial skeleton remodels with aging. Many of the observed changes in soft tissue contour and position reflect these skeletal changes. Changes in facial muscle function through the process of mechanotransduction may be responsible for these skeletal changes.

Diabetic patients are prone to developing myocardial fibrosis and suffer from decreased wound healing capabilities. The purpose of this study was to determine whether diabetes alters cardiac fibroblast activity in the myocardium in a 6-wk streptozotocin-induced type 1 diabetic model. In vivo echocardiography indicated significant dilation of the left ventricle (LV) in the diabetic animals, while cardiac function was comparable to that in the normal group. We isolated cardiac fibroblasts from diabetic and control hearts and observed increased proliferation of the diabetic fibroblasts. Microarray analysis using mRNA collected from whole LVs revealed downregulation of known inhibitors of proliferation, p53 and p21, in the diabetic group, consistent with our proliferation data. Western blot analysis confirmed a reduction in p53 protein expression in the diabetic hearts compared with control. We explored the potential signaling underlying the downregulation of these cell cycle mediators and determined that activated Akt, a signal that inhibits p53, was elevated in the diabetic group. Surprisingly, the hearts from the diabetic group contained lower levels of the myofibroblast marker α-smooth muscle actin (α-SMA) and higher levels of desmin and platelet endothelial cell adhesion molecule (PECAM). The isolated fibroblasts from the diabetic group also contained significantly less α-SMA. These data suggest that early-stage diabetic hearts contain highly proliferative fibroblasts, which predisposes the diabetic myocardium to fibrosis, but have fewer myofibroblasts, which may compromise wound healing.

Advances in anatomic understanding are frequently the basis upon which surgical techniques are advanced and refined. Recent anatomic studies of the superficial tissues of the face have led to an increased understanding of the compartmentalized nature of the subcutaneous fat. This report provides a review of the locations and characteristics of the facial fat compartments and provides examples of how this knowledge can be used clinically, specifically with regard to soft tissue fillers.

Cardiac fibroblasts and myofibroblasts are responsible for post-MI remodeling which occurs via regulation of extracellular matrix (ECM). Accelerated post-MI remodeling leads to excessive ECM deposition and fibrosis, contributing to impaired contractile function, arrhythmias, and heart failure. We have previously reported that type VI collagen induces myofibroblast differentiation in cultured cardiac fibroblasts, and that type VI collagen and myofibroblast content were both elevated in the myocardium 20 weeks post-MI. The purpose of this study was to determine the expression patterns of type VI collagen and myofibroblast content in early post-myocardial infarction (MI) remodeling to gain insight into whether type VI collagen induces in vivo myofibroblast differentiation via specific matrix-receptor interactions. Adult male Sprague-Dawley rats were anesthetized and left coronary arteries were permanently ligated. Histological tissue sections and whole tissue protein lysates were obtained from infarcted and non-infarcted areas of MI hearts and sham operated controls. At 3 days post-MI, we observed a significant increase in alpha(3) integrin expression (2.02+/-0.18 fold); at 7 days post-infarction both type VI collagen (2.27+/-0.18 fold) and myofibroblast (4.65+/-0.6 fold) content increased. By 14 days myofibroblast content returned to sham control levels, although type VI collagen (2.42+/-0.11 fold) was still elevated. In vitro cross-linking confirmed that the alpha(3) integrin interacts with type VI collagen, and alpha(3) integrin function blocking antibodies inhibited the differentiation of isolated cardiac fibroblasts. Collectively, our in vitro results indicate that the alpha(3) integrin receptor interacts with type VI collagen to promote myofibroblast differentiation, and that this interaction may impact in vivo post-MI remodeling.

Background Microcystic lymphatic malformations (LM) are congenital birth defects that can cause severe functional or esthetic deformity. At this time, several treatment interventions are possible, but there is no ideal therapy. A recently published article noted a coincidental improvement in microcystic LMs with the use of sildenafil for pulmonary hypertension, but conclusive and reproducible data is lacking regarding its efficacy. Methods and results A prospective study was conducted to examine the subjective and objective results associated with sildenafil use in the treatment of microcystic LMs. Patients under the age of 18 were enrolled, and after evaluation with pre-intervention magnetic resonance imaging (MRI) studies, each was given a 6-week course of sildenafil. Subjective outcomes were obtained, and postoperative MRIs were used to objectively quantify changes. Five patients between the ages of 4 and 11 were enrolled in the study. All patients had microcystic LMs of the head and neck. All patients had undergone previous treatment interventions utilizing various modalities, and each was now seeking treatment for functional and cosmetic purposes. All patients had minimal to no response from a subjective standpoint. Comparison of pre- and post-treatment MRIs also demonstrated minimal to no response. Conclusions The use of sildenafil for the treatment of microcystic lymphatic malformations did not have any appreciable effect on our selected population of pediatric patients who had been resistant to previous therapies. Further studies would be necessary to determine if other cohorts may benefit.

The objective of trainee recruitment is to identify candidates likely to perform well as trainees and subsequent faculty. The effectiveness of this process has not been established. The goal of this study was to identify trainee selection criteria predictive of excellent performance.Twenty-nine microsurgery fellows were enrolled from 2008 to 2012. Each candidate was interviewed and rated based on presentation, plastic surgery (PS) training experience, academic potential, personality, social skills, communication skills, and ability to be a team player. An unadjusted rank list was generated based on weighted averages, and an adjusted rank list was then generated at a faculty meeting. At the conclusion of fellowship, each fellow was rated based on the ACGME core competencies. Spearman correlation coefficients (r) were used to measure the correlations between fellow selection criteria and fellow performance.Plastic surgery training and academic potential had, by far, the strongest correlation to overall performance (r: 0.678, p0.001 and r: 0.56, p0.002), and to all ACGME competencies. When reformulated to weight PS training and academic potential more heavily than subjective criteria, the scoring system was significantly more predictive of excellent performance (r: 0.49 vs 0.70). The unadjusted rank list was more predictive of excellent performance than the adjusted rank list (r: 0.45 vs 0.65).Plastic surgery training experience and academic potential were better predictors of performance than any subjective information ascertained during the interview. Adjustments to the rank list based on faculty discussion resulted in lower performance candidates moving up in ranking. Ranking criteria and interview techniques must be refined to improve predictive power. It may be beneficial for semi-objective criteria to carry more weight than subjective criteria and raw scores to remain unadjusted by extraneous information.

The authors provide an overview of nasal soft tissue reconstruction and of the senior author's practice. Nasal soft tissue reconstruction is a challenging endeavor as the nose is one of the most prominent and complex facial features. A multitude of surgical repair options exist, which can make the decision-making process unnecessarily complicated. It is advisable that the reconstructive surgeon become facile with a handful of surgical techniques versus trying to master many techniques.

Distributed arrays provide a way to exploit MIMO and other array transmission and processing approaches using several single-antenna nodes connected via an Intra-Cluster Network (ICN). Recruitment of nodes within the transmit cluster for relaying a distributed space-time block code (STBC) transmission can be coordinated by a source node. Subject to synchronization and coherence recovery, when the receive ICN (R-ICN) capacity is high, samples of the signals received at the distributed nodes can be forwarded to a combining node to achieve the performance of a connected array. However, when ICN bandwidth is limited, the situation is more challenging. In this paper, methods for efficient combining of signals on the receive side as well as recruitment and relaying of the STBC on the transmit side in limited-bandwidth ICNs are discussed. Methods for trading detection performance and receive ICN data rate requirements are also addressed.

Allergic responses to insect bites are both a common and unwelcome occurrence for many individuals. In certain situations, however, they can have serious sequelae. In this case report, we describe the first case of compartment syndrome in a child who developed a large local reaction to a mosquito bite.

Orbital fractures account for a significant portion of traumatic facial injuries. Although plastic surgery literature is helpful, additional pearls and insights are provided in this article from the experience of an oculoplastic surgeon. The fundamentals remain the same, but the perceptions differ and provide a healthy perspective on a long-standing issue. The most important thing to remember is that the optimal management plan is often variable, and the proper choice regarding which plan to choose rests upon the clinical scenario and the surgeon having an honest perception of his or her level of expertise and comfort level.

To determine whether oral zinc supplementation might affect the efficacy and duration of botulinum toxin treatments.In a double-blind, placebo-controlled, crossover pilot study, we examined the efficacy of three botulinum toxin preparations (onabotulinumtoxinA, abobotulinumtoxinA, and rimabotulinumtoxinB) following oral supplementation with zinc citrate 50 mg and phytase 3,000 PU, zinc gluconate 10 mg, or lactulose placebo in individuals treated for cosmetic facial rhytids, benign essential blepharospasm, and hemifacial spasm.In seventy-seven patients, 92% of subjects supplemented with zinc 50 mg and phytase experienced an average increase in toxin effect duration of nearly 30%, and 84% of participants reported a subjective increase in toxin effect, whereas no significant increase in duration or effect was reported by patients following supplementation with lactulose placebo or 10 mg of zinc gluconate. The dramatic impact of the zinc/phytase supplementation on some patients' lives clinically unmasked the study and prompted an early termination.This study suggests a potentially meaningful role for zinc and/or phytase supplementation in increasing the degree and duration of botulinum toxin effect in the treatment of cosmetic facial rhytids, benign essential blepharospasm, and hemifacial spasm.

We report a unique case of bilateral proximal delta phalanges with secondary distal accessory ossification centers of the long fingers in a 16-month-old boy. The bony anomalies presented as severe ulnar deviation at the proximal interphalangeal joints bilaterally. This is a unique occurrence of congenital clinodactyly which has not been previously reported. Several family members show similar deformity, although to lesser degrees, suggesting an autosomal dominant mode of inheritance with incomplete penetrance and variable expressivity.

Fractures of the facial skeleton can result in the loss of an aesthetically pleasing appearance and basic function, and many cases subsequently require an operative intervention. The surgeon managing these facial fractures must, at the same time, be cognizant of concomitant injuries, including neurologic, ophthalmologic, and cervical spine issues. For most situations, early stabilization in anatomical position using rigid fixation will give the most accurate reduction for the optimal return of preoperative appearance and function, while reducing long-term soft-tissue contracture.

Most medical centers routinely perform or require the pathologic examination of breast tissue that is excised for adolescent gynecomastia; however, its utility is questionable, given the benign nature of the condition.A retrospective chart review was conducted to examine the incidence of pathologic abnormalities in patients 21 years or younger who had undergone subcutaneous mastectomy for gynecomastia. A literature review was also performed to determine the historical prevalence of cases of atypia or malignancy in cases of adolescent gynecomastia. Finally, an informal survey was performed of major children's hospitals regarding their practice of pathologic examination for adolescent gynecomastia.The chart review demonstrated that over the past 10 years, 81 patients with gynecomastia underwent subcutaneous mastectomy. All cases were negative for malignancy, with only one case of cellular atypia. The literature has historically reported six cases of carcinoma and five cases of atypia. Of 22 survey respondents, all either routinely performed or required pathologic examination of breast tissue excised for gynecomastia. The out-of-pocket cost for self-pay patients to perform pathologic examinations has been quoted at $1268 for bilateral cases.The incidence of malignancy or abnormal pathology associated with gynecomastia tissue in the adolescent male is extremely low, and given the associated costs, the pathologic examination of breast tissue excised for gynecomastia in individuals 21 years of age or younger should be neither routinely performed nor required but should be performed only when desired by either the patient, the patient's family, or the managing physician.

Facial fractures are common problems encountered by the plastic surgeon. Although ubiquitous in nature, their optimal treatment requires precise knowledge of the most recent evidence-based and technologically advanced recommendations. This article discusses a variety of contemporary issues regarding facial fractures, including physical and radiologic diagnosis, treatment pearls and caveats, and the role of various synthetic materials and plating technologies for optimal facial fracture fixation.

For MIMO systems, the ST-BICM approach using iterative processing has been recognized as a method for achieving near-capacity performance. However, the a posteriori probability calculator in the MIMO detector, relying on exhaustive or partial search of candidate bit vectors, is not amenable to practical implementation at high rates ( ≥ 16 raw bits per channel use) due its exponential complexity in rate. On the other hand, recently developed low complexity single stream demappers based on a parallel approach, while yielding comparable performance in ideal conditions, suffer significant performance loss in several practical scenarios. In this paper, we propose a novel demapper which closes the performance gap between the low complexity detectors based on single stream demapping and their exponentially complex counterparts.

In this paper we investigate practical adaptivity methods for tactical multiple-input multiple-output (MIMO) applications that need to operate on-the-move in variable multipath environments. The key features of these methods include the ability to estimate in real-time the MIMO channel between the transmitter and receiver in a dynamic multipath environment, select the highest performance spatial operating mode, and adapt the transmit waveform and receive/transmit processing. As channel dynamics vary, the proposed adaptive MIMO system determines whether to operate in Uninformed Transmitter (without feedback) or Informed Transmitter mode based on both spatial and temporal metrics that characterize the channel conditions. The adaptivity methods investigated in this study will be used in a real-time testbed designed to demonstrate the key features of an adaptive MIMO link and assess performance in a real-world environment. In this paper we also describe the adaptive MIMO testbed, the frame transmission structure, and channel sounding waveform used for the spatial adaptivity tests.

Purpose The subtarsal incision is a frequently used approach to orbital floor fractures. Compared with the subciliary incision, there is a lower rate of lower lid retraction. Unlike the transconjunctival incision, there is no need to perform a lateral canthoplasty to restore canthal integrity. Despite its widespread use, the exact location of the subtarsal incision is not uniform among surgeons. Materials and Methods Twenty patients underwent open reduction and internal fixation of orbital floor fractures by a single surgeon over a 4-month period, using the subtarsal incision. Postoperative photographs of the first 7 consecutive patients were analyzed by 4 nonmedical personnel and 4 plastic surgeons regarding scar visibility. Pearson correlation coefficients were calculated to determine if a correlation existed between more inferior placement of the scar and scar visibility. Results No patients in the series developed any complications such as lower lid retraction or enophthalmos. One patient developed transient facial palsy. The results of the survey showed a positive correlation between distance from lash line to scar and scar visibility at the level of the lateral limbus (Pearson r coefficient, 0.73) and at the level of the lateral canthal angle (Pearson r coefficient, 0.65). Conclusions The results of this study indicate that the optimal placement of the subtarsal incision is as close as possible to the inferior border of the tarsal plate. The incision should be placed within an existing skin crease, if possible, and should be made with the knowledge that the more inferior the incision is placed, the greater the visualization of the fracture, but the more visible the scar.