Faculty Bibliography

Immediate breast reconstruction relies on healthy mastectomy flaps for success. Tissue perfusion of these mastectomy flaps is dependent on multiple patient-, operative-, and surgeon-specific factors, which must be optimized. Unfortunately, tissue perfusion is also notoriously difficult to accurately assess and investigate. In this review, we discuss the importance of tissue perfusion in successful reconstructive breast surgery with an emphasis on perfusion assessment and techniques to ensure that anatomic mastectomy flap perfusion is maintained for immediate breast reconstruction after mastectomy. Preoperative and patient-specific factors should be considered with operative plans modified to minimize ischemic risk. Intraoperatively, incision planning and mastectomy dissection will dictate skin flap perfusion. Most importantly, mastectomy dissection in a plane at the breast capsule will maximize preservation of the subdermal plexus and subcutaneous perforators that supply the breast skin envelope while also maximizing oncologic parenchymal resection. Such anatomic dissection has been demonstrated to decrease risk of ischemic complications in immediate breast reconstruction. Postoperatively, any potential or actual areas of impaired perfusion and ischemia must be diagnosed appropriately and managed proactively to ensure a successful reconstruction. It is also important for surgeons to be aware of imaging modalities and adjunctive technologies that can help promote and assess optimal mastectomy flap tissue perfusion. Plastic surgeons and breast surgeons must actively and collaboratively work together to ensure their mutual goals are met, and optimal outcomes are attained for patients undergoing immediate breast reconstruction after mastectomy.

BACKGROUND:Single-stage primary cleft lip and palate (PCLP) repair is controversial in the United States, and most patients are treated with a staged approach. In this study, early postoperative complications of the single-stage approach as compared to primary cleft lip (PCL) or primary cleft palate (PCP) alone were evaluated. This study represents the largest cohort of patients undergoing combined cleft lip and palate repair. METHODS:The American College of Surgeons National Surgical Quality Improvement Program-Pediatric database was used to identify patients undergoing single-stage PCLP, PCL, or PCP repairs. Preoperative factors and postoperative outcomes were compared between the 3 groups, as well as within the PCLP group between patients with and without complications. Univariate and multivariate analyses were performed. RESULTS:A TOTAL OF:: 181 patients were included in the single-stage PCLP group, 1007 in the PCP group and 783 in the PCL group. There was no difference in the rates of early complications between the 3 groups. Within the PCLP group, cardiac risk factors (β = 35.19; 95% confidence interval [CI] 7.88-75.21; P = 0.04) and complications (β = 77.31; 95% CI 35.82-118.79; P < 0.001) were significant risk factors for longer operative time. CONCLUSION/CONCLUSIONS:Analysis of a national database showed that single-stage PCLP repair is not associated with increased risk of early postoperative complications as compared to primary lip or palate repair alone. In-depth long-term analyses of craniofacial morphology, fistulae rate, speech, and dental outcomes are essential for a comprehensive assessment of the effects of combined cleft lip and palate repair.

INTRODUCTION/BACKGROUND:Orthognathic surgery plays an important role in restoring aesthetic facial contour, correcting dental malocclusion, and the surgical treatment of obstructive sleep apnea. However, the rate of complications following bimaxillary as compared with single-jaw orthognathic surgery remains unclear. The authors therefore sought to evaluate complication rates following bimaxillary as compared with single-jaw orthognathic surgery MATERIALS AND METHODS:: The American College of Surgeons National Surgical Quality Improvement Program database was used to identify comparison groups. Preoperative characteristics and postoperative outcomes were compared between groups. The listed procedures have different operating times and characteristics with longer time expected in the bimaxillary osteotomies group. Regression analyses were performed to control for potential confounders. RESULTS:The 3 groups of interest included patients who underwent mandibular osteotomies (n = 126), LeFort I osteotomy (n = 194), and bimaxillary osteotomies (n = 190). These procedures have different operating times, with a longer time expected with bimaxillary osteotomies. Patients undergoing bimaxillary osteotomies had significantly higher rates of early wound complications, overall complications, longer mean operative time, and mean hospital length of stay. Performing bimaxillary osteotomies in the outpatient setting was an independent risk factor for wound complications (OR = 12.58; 95% CI: 1.66-95.20; P = 0.01), while an ASA class of 3 or more was an independent risk factor for overall complications (OR = 3.61; 95% CI: 1.02-12.75; P = 0.04) and longer hospital length of stay (β = 4.96; 95% CI: 2.64 - 7.29; P < 0.001). CONCLUSIONS:Surgery in the outpatient setting as well as patient American Society of Anesthesiology physical status class 3 or higher were independent factors for postoperative adverse events in patients undergoing bimaxillary surgery. Our findings highlight the importance of addressing modifiable risk factors preoperatively and the need for closer postoperative monitoring in this patient population for optimal outcomes.

Nasal trauma is a common complication of nasal continuous positive airway pressure (NCPAP) and may range from erythema, edema, and skin breakdown to columellar necrosis. Although rare, columellar necrosis can be a devastating complication following NCPAP, and surgical repair remains challenging due to contour and color-match difficulties, tenuous vascularity, and limited available adjacent skin. In addition, because operative site protection is critical to a successful repair, many surgeons opt to delay surgical intervention from infancy until a later age so that the patient does not inadvertently injure and compromise the graft during the early postoperative period. Here, we present a case of composite nasal reconstruction in an infant following columellar necrosis secondary to NCPAP, along with the design and implementation of a simple, inexpensive, and protective nasal splint that allows for early repair at the time of infancy.

CASE/METHODS:A 32-year-old right-handed surgeon presented with a history of intermittent pain at the right medial epicondyle, a mild Tinel's sign, and dysesthesia in the ulnar nerve distribution. Dynamic ultrasound demonstrated a hypertrophic anconeus epitrochlearis bilaterally, and chronic irritation of the ulnar nerve. Anterior release with myectomy of the accessory muscle was performed. No compressive symptoms were present at 1-year follow-up. CONCLUSIONS:The anconeus epitrochlearis is an often-underappreciated cause of ulnar nerve compression that can lead to significant functional impairment. Dynamic ultrasound is an excellent diagnostic modality, and anterior release with myectomy provides durable relief with minimal downtime.

OBJECTIVE/UNASSIGNED:Informed decision-making relies on available information, including online resources. We evaluated the content and readability of websites published by American Cleft Palate-Craniofacial Association (ACPA)-approved cleft lip and/or palate (CLP) teams in the United States. DESIGN/UNASSIGNED:Team websites were reviewed, and teams with no accessible website or <30 sentences of content were excluded. Website content was scored by presence/absence of 20 variables derived from ACPA approval standards. Readability was evaluated with 8 scales. Readability was then compared to American Medical Association (AMA) recommendations. The relationship between website content and readability was assessed. MAIN OUTCOME MEASURE(S)/UNASSIGNED:Content and readability of team websites. RESULTS/UNASSIGNED:From 167 reviewed teams, 47 (28.1%) had nonfunctional links, 17 (10.2%) had no accessible website, and 39 (23.4%) had <30 sentences. The average content score for all 111 team websites included was 14.5 (2.6) of 20. The combined average reading level across all scales (10.7 [1.9]) exceeded the AMA-recommended sixth-grade reading level; this finding held true for each individual website. Children's Hospital-affiliated teams (n = 86) had a significantly higher content score (14.8 vs 13.5; P = .03) and better readability as evidenced by lower reading grade level (10.5 vs 11.4; P = .04). On linear regression, a higher content score significantly predicted better readability (β = -0.226; P < .001). CONCLUSIONS/UNASSIGNED:Websites published by ACPA-approved CLP teams vary in accessibility and content and exceed the recommended reading level. These findings could inform future efforts to improve patient-oriented resources.

PURPOSE/OBJECTIVE:To highlight the challenges and lessons learned in tooth-bearing maxillomandibular facial allotransplantation. PATIENTS AND METHODS/METHODS:Two patients with ballistic composite facial injury underwent tooth-bearing maxillomandibular facial transplantation (FT) after informed consent and institutional review board approval. Patient 1 had undergone total face, double jaw, teeth, and tongue transplantation in March 2012. Patient 2 had undergone partial face, double jaw, and teeth transplantation in January 2018. Le Fort III and bilateral sagittal split skeletal osteotomies were performed in both transplants. Computerized surgical planning was used in both cases, and the allografts were transferred in intermaxillary fixation (IMF) with prefabricated dental splints before rigid skeletal fixation. RESULTS:Normal class I occlusion was achieved at the conclusion of each surgery. Patient 1 had developed a 2 × 2-mm palatal fistula in the early postoperative period and had also gradually developed class III malocclusion. Orthodontic treatment was started at 5 months after transplantation but failed. A Le Fort III advancement was performed 1 month later with successful restoration of class I occlusion. The palatal fistula was successfully repaired at 9 postoperative months. Patient 2 developed a postoperative palate and floor of mouth dehiscence, requiring palatal repair and hyoid and genioglossus advancement on postoperative day (POD) 11. Orthodontic treatment was initiated for Class II malocclusion. On POD 108, left mandibular nonunion was diagnosed. Left coronoidectomy, open reduction, and internal fixation were performed. IMF was maintained for 2 weeks. Orthodontic treatment was then resumed, with normalization of the occlusion by 10 months after FT. CONCLUSIONS:Maxillomandibular transplantation is a viable reconstructive solution for composite midface defects not amenable to autologous reconstruction. Improvement of functional outcomes and prevention of major complications rely on close attention to occlusal relationships, temporomandibular joint dynamics, dental health, and the intraoral donor-recipient soft tissue interface.