Search

Panniculectomy and abdominoplasty are uptrending procedures to address excess skin after weight loss which affects patient-reported quality of life. The authors aimed to identify factors associated with low preoperative quality of life, quantify the benefit of these procedures, and evaluate benefits across grades of obesity.Patients seeking panniculectomy and abdominoplasty between 2018 and 2019 with a completed preoperative BODY-Q questionnaire were identified. Stratification by quality of life in tertiles for each BODY-Q domain allowed identification of characteristics associated with low quality of life using chi-square tests. Wilcoxon signed-rank tests were used to compare preoperative to postoperative change in quality of life. Differences in quality of life by obesity class (1-2 vs. 3) were ascertained using chi-square tests.A total of 183 patients completed preoperative quality-of-life questionnaires. Preoperative factors associated with low quality of life included age older than 40 years, Black race, public insurance, hypertension, and American Society of Anesthesiologists class (all p0.05). Of patients who completed a preoperative BODY-Q and underwent surgery, 46 (63 percent) completed both surveys. Quality of life improved postoperatively across all domains ( p0.01). The presence of a surgical site occurrence (e.g., infection, delayed healing, hematoma, seroma) did not impact postoperative quality of life in any domain ( p0.05). Obesity classification did not affect change in quality of life preoperatively to postoperatively ( p0.05).Quality of life is significantly lower at baseline in older, Black, publicly insured patients, and multimorbid patients, but improves dramatically after panniculectomy and abdominoplasty regardless of incidence of complications or degree of obesity. .Therapeutic, IV.

The paper aims to study and analyze a framework that is theoretical and cognitive of the green target cost. Also, studying and analyzing the level of applications of Al-Zawraa State Company for Electrical and Electronic Industries for the techniques and methods of strategic management accounting, especially the green target cost. In addition to apply it in the company to build a sustainable competitive advantage by applying one of the products produced by the company, which is the solar panel's product model (450) watts. Problem statement was represented by the weakness of keeping pace with Al-Zawraa State Company for Electrical and Electronic Industries with technological developments, the high costs of its products and the low level of sustainability due to its poor awareness of contemporary strategic management accounting techniques with its various methods. The research reached a set of conclusions, the most important of which was the possibility of reducing production costs by applying the green target cost, as well as the absence of solutions to reduce the costs of the solar panel product (450 watts) model by applying green target costs to its sustainability or green properties. This makes it maintain the sustainable competitive advantages that distinguish it from other traditional products.

Local tissue rearrangement, free flap reconstruction, and Bilayer Wound Matrix represent reconstructive modalities for coverage of scalp defects; however, preferred indications are less clear. The authors aimed to evaluate the efficacy of these interventions.A retrospective review (2008 to 2019) was performed of subjects requiring soft-tissue reconstruction of oncologic scalp wounds. Subjects were dual matched into two comparative cohorts: (1) local tissue rearrangement versus Bilayer Wound Matrix, and (2) free flap reconstruction versus Bilayer Wound Matrix. Ninety-day wound coverage, hospital length of stay, operative time, and wound complications were compared.In total, 361 subjects were included. Following matching, 126 subjects constituted the local tissue rearrangement versus Bilayer Wound Matrix cohort, and 56 constituted the free flap reconstruction versus Bilayer Wound Matrix cohort. Local tissue rearrangement/Bilayer Wound Matrix median defect size was 35 ± 42.5 cm2. Local tissue rearrangement provided significantly better wound coverage at 90 days (95.2 percent) compared to Bilayer Wound Matrix (84.1 percent) (p0.040). Median defect size in the free flap reconstruction/Bilayer Wound Matrix cohort was 100 ± 101.1 cm2. Ninety-day success (free flap reconstruction, 92.9 percent; Bilayer Wound Matrix, 96.4 percent; p1.00) and reoperation rates (14.3 percent versus 3.6 percent; p0.352) were similar. However, free flap reconstruction had significantly greater operative times (418 minutes versus 100 minutes; p0.001).Local tissue rearrangement may be more reliable for smaller wounds (100 cm2) compared to Bilayer Wound Matrix. Bilayer Wound Matrix may have comparable efficacy to free flap reconstruction for larger defects (150 to 250 cm2), and may be more cost-effective, given greater operative time and length of stay associated with free flap reconstruction.Therapeutic, III.

Purpose Carbonated calcium phosphate (CCP) cement is an alloplastic material which has been increasingly utilized for cranioplasty reconstruction, however there is a paucity of data investigating its use in patients with syndromic craniosynostosis. The purpose of this study was to characterize our institutional experience with CCP cement for secondary contouring cranioplasty in these patients to establish safety and aesthetic efficacy. Methods Patients with syndromic craniosynostosis undergoing cranioplasty with CCP cement from 2009-2022 were retrospectively reviewed for prior medical and surgical history, cranioplasty size, cement usage, and postoperative complications. Aesthetic ratings of the forehead region were quantified using the Whitaker scoring system at three time-points: preoperative (T1), < 6 months postoperative (T2), and > 1 year postoperative (T3). Results Twenty-one patients were included. Age at surgery was 16.2 ± 2.8 years, forehead cranioplasty area was 135 ± 112 cm2, and mass of cement was 17.2 ± 7.8 grams. Patients were followed for 3.0 ± 3.1 years. Whitaker scores decreased from 1.9 ± 0.4 at T1 to 1.4 ± 0.5 at T2 (p = 0.005). Whitaker scores at T2 and T3 were not significantly different (p = 0.720). Two infectious complications (9.5%) were noted, one at 4.5 months postoperatively and the other at 23 months, both requiring operative removal of CCP cement. Conclusion Our results suggest that aesthetic forehead ratings improve after CCP contouring cranioplasty and that the improvement is sustained in medium-term follow-up. Complications were uncommon, suggesting that CCP is relatively safe though longer-term follow-up is needed before reaching definitive conclusions.

Summary Background Scalp wounds pose reconstructive challenges due to the lack of skin elasticity, potential for compromised adjacent tissue, and desire for the restoration of esthetic contour. Bilayer Wound Matrix (BWM) has been successfully employed as a treatment modality for complex, full-thickness wounds of the scalp. We aimed to highlight risk factors for BWM success and failure in complex wounds of the scalp. Methods A retrospective case-control study was performed from 2012 to 2019 of adult subjects who presented to plastic or dermatological surgery with complex scalp defects with or without exposed calvarium, who underwent staged reconstruction with BWM and split-thickness skin grafting or secondary intention. Success was defined as complete wound re-epithelialization within 90-day follow-up without additional operative procedures for wound coverage. Demographics, comorbidities, treatment history, wound characteristics, and clinical course were analyzed and correlated with reconstructive outcomes. Results In total, 127 subjects were identified for inclusion, with mean age 74.6 ± 12.2 years, defect area 80.2 ± 89.4 cm2, and wound age 10.0 ± 65.4 days. Successful wound reconstruction occurred in 107 (84%) subjects. Postoperative wound infections were an independent predictor of BWM failure at 90 days (Odds Ratio: 6.4, 95% Confidence Interval: 1.5 – 26.7, and p Conclusion BWM represents a reliable and efficacious modality in the treatment of complex scalp wounds. Patient comorbidities may not heavily influence the success of BWM to establish adequate wound coverage; however, preoperative radiation and postoperative wound infection may often lead to reconstructive failure.

We present a comparative series to utilize minimally invasive endoscopic, total extraperitoneal laparoscopic (TEP-lap), and transabdominal preperitoneal robotic perforator (TAP-RAP) harvest of the deep inferior epigastric (DIE) vessels for autologous breast reconstruction (ABR) to mitigate donor site morbidity. We hypothesized that TEP-lap and TAP-RAP harvests of abdominal-based free flaps are safe techniques associated with decreased fascial incision when compared with the endoscopic harvest.We designed a retrospective cohort series of subjects with newly diagnosed breast cancer who presented for ABR using endoscopic (control), laparoscopic, or robotic assistance between September 2017 and April 2019. The primary outcome variables were flap success (i.e., absence of perioperative flap loss), fascial incision length, and intraoperative complications. Secondary variables included operating time, costs, and postoperative complications within 90 days (arterial thrombosis, venous congestion, bulge/hernia, and operative revision). Exclusion criteria included90 days follow-up.In total 94, 38, and 3 subjects underwent endoscopic, TEP-lap, and TAP-RAP flap harvests. Mean lengths of fascial incisions for the endoscopic and laparoscopic cohorts were 4.5 ± 0.5 cm and 2.0 ± 0.6 cm (p 0.0001), while incision length depended on the concurrent procedure in the robotic cohort. No subjects required conversion to an open harvest. There were no bleeding complications, intra-abdominal injuries, flap losses, or abdominal bulges/hernias noted in the TEP-lap and TAP-RAP cohorts.Minimally invasive DIEP flap harvest may decrease fascial injury when compared with conventional open harvest. There are significant trade-offs among harvest methods. TEP-lap harvest may better balance the trade-off related to abdominal wall morbidity.

Syndromic craniosynostosis (CS) represents a relatively uncommon disease process that poses significant reconstructive challenges for the craniofacial surgeon. Although there is considerable overlap in clinical features associated with various forms of syndromic CS, key extracranial features and close examination of the extremities help to distinguish the subtypes. While Virchow's law can easily guide the diagnosis of single suture, nonsyndromic CS, syndromic CS traditionally results in atypical presentations inherent to multiple suture fusion. Coronal ring involvement in isolation or associated with additional suture fusion is the most common pattern in syndromic CS often resulting in turribrachycephaly.

Sagittal craniosynostosis may present with complete or partial fusion of the sagittal suture, but relationships between degree of sagittal suture fusion and head shape are currently poorly described. The aim of this study was to characterize sagittal suture fusion patterns and determine associations with head shape in a cohort of patients with nonsyndromic sagittal craniosynostosis.Patients with nonsyndromic sagittal craniosynostosis at a tertiary care center with available computed tomography imaging were included in this study. The anterior and posterior distances of sagittal suture patency were measured along 3-dimensional parietal bones. Degree of sagittal suture fusion was compared to head shape characteristics, including cephalic index (CI), frontal bossing, and occipital bulleting.Ninety patients (69 male) were included in this retrospective study. The sagittal suture was on average 85.6±20.1% fused, and 45 (50.0%) patients demonstrated complete fusion of the sagittal suture. CI was associated with increased degree of fusion for the anterior one-half (ρ=0.26, P =0.033) and anterior one-third (ρ=0.30, P =0.012) of the sagittal suture. Complete fusion of the anterior one-third of the sagittal suture predicted higher CI (β=13.86, SE=6.99, z =-0.25, P =0.047). Total degree of sagittal suture fusion was not predictive of CI or head shape in any analysis.Decreased fusion of the anterior one-third of the sagittal suture, but not total suture, may paradoxically predict increased severity of scaphocephaly as quantified by CI in nonsyndromic sagittal craniosynostosis.

Orbital hypertelorism (OHT) represents a congenital condition defined by lateralization of the bony orbit, unlike soft tissue telecanthus in which there is an increase in intercanthal distance without true bony lateralization. Existing literature remains very limited in its postoperative assessment of bony versus soft tissue relapse, which may both clinically present as telecanthus. We performed a critical appraisal of the literature to determine the postoperative incidence of bony versus soft tissue relapse following OHT repair. The PubMed, MEDLINE, EMBASE, Scopus, Cochrane Central Register of Controlled Trials, and clinicaltrials.org were searched systematically for all English studies published in any time frame reporting relapse rates following primary OHT repair. The primary outcome was incidence of bony and soft tissue relapse defined as orbital lateralization and medial canthal drift, respectively. The secondary outcome measures include postoperative complications, predictors of postoperative complications, timing and type of surgery, and revision rates. Eleven articles were included. A total of 84 (35.3%) patients experienced bony relapse while 43 (27.2%) patients experienced soft tissue relapse. Age at time of intervention (p < 0.92), severity at presentation (p < 0.90), and surgical technique (p < 0.09) were not found be significantly associated with relapse rate. Methods for long-term follow-up were not standardized, and there was no consistent measure to objectively assess telecanthus. There is no general consensus on predictive factors of long-term relapse following OHT repair in the form of box osteotomy or facial bipartition. These findings call for cross-sectional outcome standardization to better understand long-term outcomes across institutional, provider, and patient differences.

Background Total extraperitoneal laparoscopically assisted harvest of the deep inferior epigastric vessels permits a decrease in myofascial dissection in deep inferior epigastric artery perforator flap breast reconstruction. The authors present a reliable technique that further decreases donor-site morbidity in autologous breast reconstruction. Methods The authors conducted a retrospective cohort study of female subjects presenting to the senior surgeon (S.K.K.) from March of 2018 to March of 2019 for autologous breast reconstruction after a newly diagnosed breast cancer. The operative technique is summarized as follows: a supraumbilical camera port is placed at the medial edge of the rectus muscle to enter the retrorectus space; the extraperitoneal plane is developed using a balloon dissector and insufflation; two ports are placed through the linea alba below the umbilicus to introduce dissection instruments; the deep inferior epigastric vessels are dissected from the underside of the rectus muscle; muscle branches and the superior epigastric are ligated using a Ligasure; and the deep inferior epigastric pedicle is ligated and the vessels are delivered through a minimal fascial incision. The flap(s) is transferred to the chest for completion of the reconstruction. Results Thirty-three subjects totaling 57 flaps were included. All flaps were single-perforator deep inferior epigastric artery perforator flaps. Mean fascial incision length was 2.0 cm. Sixty percent of subjects recovered without narcotics. Mean length of stay was 2.5 days. Flap salvage occurred in one subject after venous congestion. Two pedicle transections occurred during harvest that required perforator-to-pedicle anastomosis. Conclusion Total extraperitoneal laparoscopically assisted harvest of the deep inferior epigastric pedicle is a reliable method that decreases the donor-site morbidity of autologous breast reconstruction. Clinical question/level of evidence Therapeutic, IV.

Background: Various surgical techniques exist for lower extremity reconstruction, but limited high-quality data exist to inform treatment strategies. Using multi-institutional data and rigorous matching, the authors evaluated the effectiveness and cost of three common surgical reconstructive modalities. Methods: All adult subjects with lower extremity wounds who received bilayer wound matrix, local tissue rearrangement, or free flap reconstruction were retrospectively reviewed (from 2010 to 2017). Cohorts’ comorbidities and wound characteristics were balanced. Graft success at 180 days was the primary outcome; readmissions, reoperations, and costs were secondary outcomes. Results: Five hundred one subjects (166 matrix, 190 rearrangement, and 145 free flap patients) were evaluated. Matched subjects (n = 312; 104/group) were analyzed. Reconstruction success at 180 days for matrix, local tissue rearrangement, and free flaps was 69.2 percent, 91.3 percent, and 93.3 percent (p < 0.001), and total costs per subject were $34,877, $35,220, and $53,492 (p < 0.001), respectively. Median length of stay was at least 2 days longer for free flaps (p < 0.0001). Readmissions and reoperations were greater for free flaps. Local tissue rearrangement, if achievable, provided success at low cost. Free flaps were effective with large, traumatic wounds but at higher costs and longer length of stay. Matrices successfully treated older, obese patients without exposed bone. Conclusions: Lower extremity reconstruction can be performed effectively using multiple modalities with varying degrees of success and costs. Local tissue rearrangement and free flaps demonstrate success rates greater than 90 percent. Bilayer wound matrix-based reconstruction effectively treats a distinct patient population. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Background: Little is known about the efficacy of newer skin substitute scaffolds to reconstruct complex lower extremity wounds. The investigators present a multihospital experience of reconstructive surgeons utilizing collagen-GAG bilayer wound matrix in lower extremity soft-tissue reconstruction with the goals to (1) characterize a suitable patient population, (2) categorize failures to optimize patient selection, and (3) determine wound factors affecting success. Methods: Subjects underwent collagen-GAG–based lower extremity wound reconstruction from May of 2010 to June of 2017. The primary outcome variable was 180-day graft success, defined as eventual split-thickness skin grafting after bilayer wound matrix application; failure was defined as inadequate wound bed for split-thickness skin grafting, requirement for vascularized tissue transfer, or eventual amputation. Eligible subjects had at least one lower extremity wound and were at least 18 years old. Exclusion criteria included third-degree burn wounds or failure to follow up for at least 60 days postoperatively. Predictor variables included demographics, medical comorbidities, perioperative characteristics, postoperative complications, and cost-related data for each hospitalization. Results: There were 147 subjects with 191 wounds. Mean patient age was 60.1 years (range, 21.0 to 95.6 years), and mean body mass index was 30.5 kg/m2 (range, 14.4 to 64.7 kg/m2). Average wound size was 73.1 ± 137.7 cm2, with 49.0 percent of subjects receiving adjunct postoperative negative-pressure wound therapy. Seventy percent of wounds were successfully healed at 180 days. Most were localized between the knee and ankle (50.8 percent) or foot (46.1 percent). Tendon exposure (p < 0.05), bone exposure (p < 0.01), and bone excision (p < 0.04) were associated with reconstructive failure. Conclusions: The authors present the largest reported multihospital, multidisciplinary experience with collagen-GAG wound matrix for lower extremity reconstruction. Tendon and/or bone exposure and socioeconomic factors were associated with failure. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

OBJECTIVES Spring-mediated cranial vault expansion (SMC) may enable less invasive treatment of sagittal craniosynostosis than conventional methods. The influence of spring characteristics such as force, length, and quantity on cranial vault outcomes are not well understood. Using in vivo and ex vivo models, we evaluate the interaction between spring force, length, and quantity on correction of scaphocephalic deformity in patients undergoing SMC. METHODS The authors retrospectively studied subjects with isolated sagittal craniosynostosis who underwent SMC between 2011 and 2019. The primary outcome measure of in vivo analysis was head shape determined by cephalic index (CI). Ex vivo experimentation analyzed the impact of spring length, bend, and thickness on resultant force. RESULTS Eighty-nine subjects underwent SMC at median 3.4 months with median preoperative CI 69% (interquartile range: 66, 71%). Twenty-six and 63 subjects underwent SMC with 2 and 3 springs, with mean total force 20.1 and 27.6 N, respectively (P < 0.001).Postoperative CI increased from 71% to 74% and 68% to 77% in subjects undergoing 2- and 3-spring cranioplasty at the 6-month timepoint, respectively (P < 0.001). Total spring force correlated to increased change in CI (P < 0.002). Spring length was inversely related to transverse cranial expansion at Postoperative day 1, however, directly related at 1 and 3 months (P < 0.001). Ex vivo modeling of spring length was inversely related to spring force regardless of spring number (P < 0.0001). Ex vivo analysis demonstrated greater resultant force when utilizing wider, thicker springs independent of spring arm length and degree of compression. CONCLUSIONS A dynamic relationship among spring characteristics including length, bend, thickness, and quantity appear to influence SMC outcomes.

LEARNING OBJECTIVES After studying this article, the participant should be able to: 1. Understand age-related changes to the face and neck and pertinent anatomy and discuss important aspects of fat graft harvesting, processing, and infiltration. 2. Recognize key differences between common techniques for fat processing and infiltration and develop a plan for patients based on site-specific facial anatomical zones. 3. Appreciate the utility of fat grafting as an adjunct to other facial rejuvenating procedures such as face lift and blepharoplasty procedures and list the potential complications from fat grafting to the face and neck. SUMMARY Fat grafting to the face and neck aids in volume restoration, thereby addressing soft-tissue atrophy associated with the aging face, acquired conditions, or congenital malformations. Often, fat grafting may sufficiently restore facial volume alone or in conjunction with other facial rejuvenation procedures. Facial/neck fat grafting requires a systematic and thoughtful approach, with special care to atraumatic technique. This CME article covers the principles and techniques for modern facial fat grafting to the face and neck. Increasing data support the ability of autologous fat to produce significant and sustainable appearance-related changes. The authors follow the general principles of the Coleman technique for facial fat grafting and have observed tremendous success over the years. Other techniques for facial fat grafting are also discussed including microfat and nanofat processing. As the understanding of facial fat compartments continues to evolve, the authors may better predict fat grafting outcomes following augmentation. Finally, the technique described as "lipotumescence" has been successfully used in the breast and other regions of the body that have radiation damage and is discussed in this article specifically for the face and neck.

Background Our institution supports a chief resident aesthetic clinic with the goal of fostering autonomy and preparedness for independent practice in a safe environment. Objectives The aim of this study was to compare safety profiles and costs for common aesthetic procedures performed in our resident versus attending clinics. Methods A retrospective review was conducted of all subjects presenting for aesthetic face, breast, and/or abdominal contouring surgery at our institution from 2008 to 2017. Two cohorts were identified: subjects undergoing surgery through the chief resident versus attending clinics. Aesthetic procedures queried included: (1) blepharoplasty, rhinoplasty, or rhytidectomy; (2) augmentation mammaplasty, reduction mammaplasty, or mastopexy; (3) abdominoplasty; and (4) combination. Demographics, perioperative characteristics, costs, and postoperative complications were analyzed. Results In total, 262 and 238 subjects underwent aesthetic procedures in the resident and attending clinics, respectively. Subjects presenting to the residents were younger (P < 0.001), lower income (P < 0.001), and had fewer comorbidities (P < 0.001). Length of procedure differed between resident and attending cohorts at 181 and 152 minutes, respectively (P < 0.001), although hospital costs were not significantly increased. Total costs were higher in the attending cohort independent of aesthetic procedure (P < 0.001). Hospital readmissions (P < 0.05) and cosmetic revisions (P < 0.002) were more likely to occur in the attending physician cohort. Postoperative complications (P < 0.50) and reoperative rates (P < 0.39) were not significantly different. Conclusions The resident aesthetic clinic provides a mechanism for increased autonomy and decision-making, while maintaining patient safety in commonly performed cosmetic procedures.

Salivary gland tumors are rare, constituting approximately 0.5% of pediatric malignancies, yet account for over 50% of malignant salivary gland neoplasms, of which a majority are mucoepidermoid carcinomas (MECs). We present a case of MEC involving the palatal minor salivary gland of an adolescent patient successfully reconstructed using buccal myomucosal flap. The subject presented as a 17-year-old male with a painless left hard palatal mass found to have imaging suspicious for minor salivary gland tumor and punch biopsy consistent with a low-grade MEC. The subject underwent wide local excision of a 1.0 × 1.2 cm mass with 1.0 cm margins down to hard palate nasal mucosa excluding the abutting first and second molars of the ipsilateral maxilla. Pathology confirmed low-grade MEC confined to hard palate. Two weeks, thereafter, the subject underwent buccal myomucosal flap reconstruction inset into the palatal defect and divided 2 weeks thereafter. Postoperative course was complicated by a pinpoint oronasal fistula at the posterior aspect of the flap-palate junction requiring reelevation and advancement. The subject subsequently recovered without complication. Mucoepidermoid carcinomas represent rare, malignant minor salivary gland tumors with nonspecific presentations that require multidisciplinary workup and management. The authors recommend reconstruction of resultant palatal defects to prevent progression to oronasal fistulae or speech and swallow impairment.

Orbital hypertelorism represents lateralization of the orbits, meaning increased interorbital and outer orbital distances. Interorbital hypertelorism represents a failure of medial orbital wall medialization in the setting of normally positioned lateral orbital walls. The etiology and type of hypertelorism influence selection of an operative procedure, whereas the severity of deformity dictates surgical need. Choice of surgical procedure is dictated by anatomic considerations, such as degree of orbital hypertelorism, midfacial proportions, and occlusal status.

World War II has brought suffering for all people; it has led people to have a nostalgic feeling. The war has many faces all of them are ugly, like death, separation, loneliness, violence, crime, betrayal, and disconnection and many other meanings. Michael Ondaatje in his novel The English Patient (1992) portrays a picture of the effect of World War II on four different characters; Hana a Canadian nurse, The English patient who is Hungarian, Caravaggio a Canadian-Italitan thief, and Kip an Indian sapper. They live together in one house, share their secrets and memories about World War II. Ondaatje brings them together to reveal their secrets and to heal their wounds of the war experience.

Phenotypic severity dictates the timing and type of surgical intervention required. Mandibular distraction in children without respiratory and feeding difficulties remains controversial with regard to long-term mandibular growth outcomes and reducing surgical burden. Early mandibular distraction does not obviate secondary orthognathic surgery at skeletal maturity; it provides improved functional, aesthetic, and psychosocial outcomes, at least in the short term. Costochondral rib grafting for Pruzansky type IIB and III mandibles can produce reliable results, especially when combined with subsequent mandibular distraction. Secondary 2-jaw orthognathic surgery plus genioplasty at skeletal maturity benefits from improved bone volume from prior mandibular distraction.

BACKGROUND Patients undergoing cranial expansion including spring-mediated cranioplasty (SMC) and cranial vault remodeling (CVR) receive costly and high acuity post-operative intensive care (ICU) given concerns over neurologic and hemodynamic vulnerability. The authors analyzed perioperative and post-operative events for patients presenting with sagittal craniosynostosis (CS) undergoing SMC and CVR in order to compare complication profiles. METHODS The authors performed a single center retrospective cohort study of patients undergoing SMC and CVR for the treatment of nonsyndromic, isolated sagittal CS from 2011 to 2018. Perioperative and post-operative factors were collected, focusing on hemodynamic instability and events necessitating ICU care. Mann-Whitney U and Fisher exact tests were used to compare data with significance defined as P

Spring-mediated cranial vault expansion (SMC) has become a primary treatment modality at our institution to correct scaphocephalic head shape in the setting of isolated sagittal craniosynostosis (CS). Spring-mediated cranioplasty is associated with minimal procedural morbidity and reliable clinical efficacy, although long-term outcomes are not well elucidated. Herein we describe our institutional experience and lessons learned with SMC. We hypothesize that SMC performed in young infants offers durable scaphocephalic correction as measured by cephalic index (CI) at the 1, 3, and 5-year postoperative timepoints.Patients with isolated sagittal CS who underwent SMC at our institution during an 8-year period were retrospectively studied. The primary outcome measure was long-term head shape determined by CI at the 1, 3, and 5-year postoperative timepoints. Secondary outcomes included patient and spring factors associated with change in CI, including age and spring force. All statistical tests were 2-tailed with P < 0.05 denoting significance.In total, 88 patients underwent SMC at a median age of 3.3 months with a median preoperative CI 69 (interquartile range: [66, 71]). The postoperative CI increased to 73 [71, 76] at postoperative day 1. At 1 month, the CI increased by 8.6 to 77 (P < 0.0001) and appeared to reach a plateau at 3 months (76, [74, 78]) without further improvement (P < 0.10). At 5 years, CI remained stable without relapse (76, [75, 81], demonstrating an 8.9 increase from preoperative CI. Age at time of spring placement and change in CI were inversely related (P < 0.005). Total spring force directly correlated with increased change in postoperative CI at the 6-month postoperative timepoint (P < 0.02).In summary, SMC offers durable correction of scaphocephaly as measured by CI for patients with isolated sagittal CS at the 5-year postoperative timepoint. The cranial expansion observed 1-month post-spring implantation may serve as a proxy for long-term CI.

Orbital hypertelorism (OHT) represents a congenital condition defined by lateralization of the bony orbit, unlike soft tissue telecanthus in which there is an increase in intercanthal distance without true bony lateralization. Existing literature remains very limited in its postoperative assessment of bony versus soft tissue relapse, which may both clinically present as telecanthus. We performed a critical appraisal of the literature to determine the postoperative incidence of bony versus soft tissue relapse following OHT repair.The PubMed, MEDLINE, EMBASE, Scopus, Cochrane Central Register of Controlled Trials, and clinicaltrials.org were searched systematically for all English studies published in any time frame reporting relapse rates following primary OHT repair. The primary outcome was incidence of bony and soft tissue relapse defined as orbital lateralization and medial canthal drift, respectively. The secondary outcome measures include postoperative complications, predictors of postoperative complications, timing and type of surgery, and revision rates.Eleven articles were included. A total of 84 (35.3%) patients experienced bony relapse while 43 (27.2%) patients experienced soft tissue relapse. Age at time of intervention (p0.92), severity at presentation (p0.90), and surgical technique (p0.09) were not found be significantly associated with relapse rate. Methods for long-term follow-up were not standardized, and there was no consistent measure to objectively assess telecanthus.There is no general consensus on predictive factors of long-term relapse following OHT repair in the form of box osteotomy or facial bipartition. These findings call for cross-sectional outcome standardization to better understand long-term outcomes across institutional, provider, and patient differences.

INTRODUCTION Soft-tissue reconstruction of the scalp has traditionally been challenging in oncologic patients. Invasive tumors can compromise the calvarium, necessitating alloplastic cranioplasty. Titanium mesh is the most common alloplastic material, but concerns of compromise of soft-tissue coverage have introduced hesitancy in utilization. The authors aim to identify prognostic factors associated with free-flap failure in the context of underlying titanium mesh in scalp oncology patients. METHODS A retrospective review (2010-2018) was conducted at a single center examining all patients following oncologic scalp resection who underwent titanium mesh cranioplasty with free-flap reconstruction following surgical excision. Patient demographics, comorbidities, ancillary oncological treatment information were collected. Operative data including flap type, post-operative complications including partial and complete flap failure were collected. RESULTS A total of 16 patients with 18 concomitant mesh cranioplasty and free-flap reconstructions were identified. The majority of patients were male (68.8%), with an average age of 70.5 years. Free-flap reconstruction included 15 ALT flaps (83.3%), 2 latissimus flaps (11.1%), and one radial forearm flap (5.5%). There were three total flap losses in two patients. Patient demographics and comorbidities were not significant prognostic factors. Additionally, post-operative radiation therapy, ancillary chemotherapy, oncological histology, tumor recurrence, and flap type were not found to be significant. Pre-operative radiotherapy was significantly associated with flap failure (P < 0.05). CONCLUSION Pre-operative radiotherapy may pose a significant risk for free-flap failure in oncologic patients undergoing scalp reconstruction following mesh cranioplasty. Awareness of associated risk factors ensures better pre-operative counseling and success of these reconstructive modalities and timing of pre-adjuvant treatment.

Introduction Neck pain is common in the post-operative period after craniofacial procedures. If patients present with neck pain and torticollis, it could be a manifestation of atlantoaxial rotatory subluxlation (AARS), which describes a rare condition in which there is lateral displacement of C1 relative to C2. When this occurs in the post-operative patient, it is termed Grisel syndrome. In this case series, we report on 3 patients diagnosed with Grisel syndrome after a craniofacial procedure. Methods A retrospective chart review of a single craniofacial surgeon at a pediatric hospital was conducted over the last 3 decades. Demographics, procedures performed, and management strategies of AARS were included for review. Results Three patients were identified who were diagnosed with Grisel syndrome after a craniofacial procedure and required inpatient cervical traction. All patients presented with torticollis within 1 week of their operation. Conservative management was ineffective, and all 3 patients were admitted for inpatient cervical traction, for an average of 13 days followed by an average of 47 days of outpatient therapy. No patients showed any signs of recurrence after removal of outpatient traction device. Conclusion Grisel syndrome is a rare, but serious complication of craniofacial procedures. Physicians caring for these patients must have a high degree of suspicion if a patient with a recent craniofacial procedure presents with torticollis. Delaying the initiation of therapy has been shown to lead to higher rates of recurrence and increases the likelihood that patients will require surgical intervention.

PURPOSE Components separation of the abdominal musculature remains a mainstay for closure of complicated midline and paramedian abdominal wall defects. The authors critically analyzed their experience with this technique to identify prognosticators affecting long-term clinical outcomes. METHODS A retrospective review was performed of patients undergoing components separation by a single senior surgeon (J.M.R.) between 2000 and 2010. Numerous perioperative patient characteristics were collected and analyzed to determine their effects on long-term clinical outcomes. Multivariable logistic regression was used to predict hernia recurrence and other adverse clinical outcomes. RESULTS A total of 311 patients were identified (male, 51.1%). Mean age was 53.1 ± 14.0 years, preoperative body mass index was 33.1 ± 8.2 kg/m, and defect width was 11.4 ± 7.5 cm. Patients who had prior hernia repair were 97.4%, with 38.3% having prior mesh placement. Average follow-up was 2.9 ± 2.4 years. Overall hernia recurrence rate was 18.3%. Postoperative complications included seroma (9.3%), superficial wound infection (9.0%), skin dehiscence (4.82%), hematoma (3.2%), deep vein thrombos or pulmonary emolbus (3.2%), and skin flap ischemia (1.0%). Respiratory comorbidity (odds ratio, [OR], 2.02; P < 0.029), prior failed mesh repair (OR, 1.86; P < 0.045), and occurrence of any postoperative complication (OR, 2.02; P < 0.034) significantly increased the risk of eventual hernia recurrence. Preoperative body mass index was not associated with hernia recurrence (P < 0.351) or increased incidence of any aforementioned postoperative complications. CONCLUSIONS This study provides a comprehensive review of one of the largest single-surgeon experiences using components separation to date. Patients with respiratory comorbidities, prior failed mesh repair, and the occurrence of any postoperative complication are at significantly increased risk for hernia recurrence.

Objectives The objectives of this study were (1) to evaluate dog bite-related injuries and associated medical documentation and (2) to compare these results with a study of dog bites from the same institution 10 years prior. Methods Data were retrospectively collected from a pediatric emergency department from July 2007 to July 2011 for patients treated for dog bites. These data were then compared with data from the same institution from 10 years prior. Results A total of 1017 bite injuries were treated (average, 254.25 bites/year), which represents a 25% increase compared with 10 years prior. Comparing the 1997 and 2007 to 2011 cohorts, patient demographics, bite rate among children less than 5 years old, rate of dog breed documentation, and setting of injury were similar. Dog breed was reported in 47% (95% confidence interval [CI], 40.2-53.9) and 41% (95% CI, 38.0-44.0) of cases, respectively, in the 2 cohorts. Bites to the craniofacial region were most common (face only reported for 1997: 43.2%; 95% CI, 36.4-50 versus 2007-2011: 66.1%; 95% CI, 63.2-69.0). In both cohorts, the child's home was the most frequent setting, accounting for 43% of bites (1997: 95% CI, 30.2-55.9 and 2007-2011: 95% CI, 39.3-46.7). Conclusions Pediatric dog bites continue to occur frequently, and the associated factors did not change over the 10-year period: young age of child, bites to the craniofacial region, and dogs familiar to the child. Although accurate medical documentation of dog bites is a prerequisite to develop effective prevention strategies, current medical documentation of dog bites may be misguided.