Faculty Bibliography

Movement disorder emergencies of the aerodigestive tract are dramatic and often life threatening. With appropriate timely evaluation and intervention, most patients can be effectively managed and major morbidity avoided. This chapter provides a comprehensive review of both the causes and appropriate treatment of breathing disturbances secondary to primary disorders and iatrogenic causes, as well as swallowing emergencies. Additionally, basic physiology, anatomy, and various methods for assessment of the upper aerodigestive tract are reviewed. Specific disorders that are addressed include the following: spasmodic dysphonia, adductor laryngeal breathing dystonia, Shy-Drager abductor weakness, drug-induced tardive dystonia, oromandibulolingual dystonia, multiple system atrophy, multiple sclerosis, amyotrophic lateral sclerosis, Parkinson's disease, Huntington's disease, and palatal myoclonus.
Copyright

Background/Purpose: Traditional palatoplasty techniques rely on repositioning of soft palate muscle and mucosa to restore velopharyngeal closure. In the case of the wide cleft palate (10 mm or greater), we hypothesize that soft palate nasal mucosa closure can result in vertical shortening of the palate. Furthermore, horizontal release of the reconstructed soft palate nasal mucosa from the hard palate will result in significant lengthening of the soft palate, identifying a potential loss of domain of palatal length in patients with a wide cleft palate. This study characterizes this potential loss of vertical length of the nasal soft palate mucosa in patients with a wide cleft. Methods/Description: A retrospective review of all patients who underwent a primary cleft palate repair with a buccal flap prior to 18 months of age by a single plastic surgeon over a 2-year period. Inclusion criteria was defined as patients with cleft palate at least 10 mm in length at the area of the posterior nasal spine. All patients who met inclusion criteria underwent primary cleft palate repair with horizontal transection of the nasal mucosa during palatoplasty. This transection was performed after nasal mucosa repair, but prior to muscular reconstruction. The resulting mucosal defect was measured and reconstructed with a buccal flap. Patient demographics, intra-operative palatal measurements, and post-operative outcomes were analyzed.
Result(s): Twenty-two patients met inclusion criteria. Mean age at surgery was 10.68+/-1.04 months, mean gestational age at birth was 38.14+/-1.75 weeks, and mean weight at surgery was 8.75+/-1.22 kg. Three (13.6%) had a history of Pierre Robin sequence and 5 (22.7%) had an associated syndrome. Notably, 13 (59.1%) had a history of nasoalveolar molding, and 15 (68.2%) had previously had a cleft lip repair. No patients had a Veau I cleft, 7 (31.8%) had a Veau II, 12 (54.5%) had a Veau III, and 3 (13.6%) had a Veau IV cleft. Regarding palate repair techniques employed, 12 (54.5%) had a Bardach, 7 (31.8%) had a Von Langenbeck, 3 (13.6%) had an Oxford, and all had a concomitant radical intravelar veloplasty. All 22 (100%) patients had a right buccal flap during primary palatoplasty. The mean cleft width or horizontal separation of the palate at the posterior nasal spine was 10.6+/-2.82 mm, and the mean lengthening of the palate was measured as 10.5+/-2.23 mm. For complications, there were 2 (9.1%) fistulas, 1 (4.5%) wound dehiscence, 1 (4.5%) 30-day readmission (for RSV bronchiolitis), and no bleeding complications.
Conclusion(s): Patients with a wide cleft palate have a potential loss of vertical length of approximately 1 cm. Considering that patients with a wide palatal cleft are predisposed to developing VPI, these data provide supportive evidence that acute palatal lengthening during palatoplasty should be considered for this patient population. The buccal flap can mitigate the loss of domain in palatal length, and potentially improve palatal excursion

Background/Purpose: The relative value unit (RVU) is a metric established by Medicare to quantify physician time and intensity required to furnish a surgical service, and is broadly used for the purposes of billing and physician compensation. Despite widespread use since the 1990s, the accuracy of RVU assignments has not been scientifically evaluated for cleft and craniofacial surgery. We hypothesize that unbalanced RVU allocation creates inappropriate disparities in value amongst procedures performed by cleft and craniofacial surgeons. Methods/Description: The American College of Surgeons Pediatric National Surgical Quality Improvement Program (NSQIP) database was queried to identify all cleft and craniofacial surgery cases performed by plastic surgeons from 2012-2019 based on Current Procedural Terminology (CPT) code. Microsurgical cases and CPT codes with a case count of fewer than 10 were excluded. Total RVUs per case were calculated based on the sum of work RVUs for the principal procedure, and any other procedure that was performed during the case. Efficiency was defined as total RVUs divided by total operative time (i.e. RVUs/hour), based on previously published methodology. Mean efficiency per CPT code was ranked and compared by quartile using Student's t-tests.
Result(s): The sample consisted of 69 CPT codes with a total of 50,450 cases. The most common procedure was cleft palate repair of the soft and/or hard palate (CPT 42200). The mean efficiency for the top quartile of CPT codes was 15.65+/-4.22 (range 12.05-26.56) RVUs/hour, compared to 7.39+/-0.98 (range 5.57-8.69) RVUs/hour for the bottom quartile (p<0.001). The mean operative time for the top quartile of CPT codes was 167.14+/-90.29 minutes, compared to 107.79 +/-55.17 minutes for the lowest quartile (p=0.029). In the top quartile, the majority of CPT codes were craniofacial procedures including frontofacial procedures (23.53%) and craniectomies for craniosynostosis or bony lesions (35.29%). The lowest quartile was comprised mainly of CPT codes for cleft procedures including surgeries for velopharyngeal insufficiency (17.65%), cleft palate repair (23.53%), and cleft septoplasty (5.88%). It was 2.5 times more efficient for a cleft and craniofacial surgeon to perform a local skin flap (15.18 RVUs/ hour, CPT 14040) than a secondary palatal lengthening for cleft palate (6.09 RVUs/hour, CPT 42200).
Conclusion(s): The current RVU allocation to cleft and craniofacial procedures creates arbitrary disparities in physician efficiency, with cleft procedures disproportionately negatively affected despite being among the most common procedures. RVU assignments should be reevaluated to avoid disincentivizing cleft surgical care

Regional blocks are being increasingly utilized for anesthesia for various orthopedic procedures. Several studies have shown that regional anesthesia has fewer side effects and improved postoperative pain relief compared to general anesthesia, but regional blocks are not without risks. We present case reports of 2 patients who experienced posterior shoulder instability, one of whom had a posterior shoulder dislocation, immediately in the postanesthesia care unit after undergoing hand surgery with regional anesthesia. This paper highlights the importance of being aware that patients might be at increased risk of shoulder instability after upper extremity regional anesthesia, and appropriate perioperative precautions should be taken.

PURPOSE/OBJECTIVE:This study evaluated the effect of different tightening protocols on the probability of survival of screw-retained implant-supported anterior crowns. MATERIALS AND METHODS/METHODS:Seventy-two implants with internal conical connections (4.0 × 10mm, Ti-6Al-4V, Colosso, Emfils) were divided into four groups (n = 18 each): 1) Manufacturer's recommendations torque (25 N.cm for abutment's screw and 30 N.cm for crown's screw) (MaT); 2) Retightening after 10 min (ReT); 3) Torque 16% below recommended to simulate an uncalibrated wrench (AgT), and; 4) Temporary crown simulation (TeT), where crowns were torqued to 13 N.cm to simulate manual tightening, subjected to 11,200 cycles to simulate temporary crown treatment time (190 N), and then retightened to manufacturer torque (TeT). All specimens were subjected to cyclic fatigue in distilled water with a load of 190 N until 250,000 cycles or failure. The probability of survival (reliability) to complete a mission of 50,000 cycles was calculated and plotted using the Weibull 2-Parameter analysis. Weibull modulus and number of cycles at which 62.3% of the specimens would fail were also calculated and plotted. The failure mode was characterized in stereo and scanning electron microscopes (SEM). RESULTS:The probability of survival was 69.3% for MaT, 70% for ReT, 54.8% for AgT, and 40.3% for TeT, all with no statistically significant difference. Weibull modulus was approximately 1.0 for all groups. The characteristic number of cycles for failure was 105,000 cycles for MaT, 123,000 for ReT, 82,000 cycles for AgT, and 54,900 cycles for TeT, with no significant difference between groups. The chief failure mode for MaT, ReT, AgT groups was crown screw fracture, whereas abutment screw fracture was the chief failure mode for the TeT group. CONCLUSION/CONCLUSIONS:Tightening protocol did not influence the probability of survival of the screw-retained anterior crowns supported by internal conical implants (Ti-6Al-4V, Colosso, Emfils).

BACKGROUND:Incision planning is a critical factor in nipple-sparing mastectomy outcomes. Evidence on optimal incision patterns in patients undergoing nipple-sparing mastectomy and immediate microvascular breast reconstruction is lacking in the literature. METHODS:A single-institution retrospective review was performed of consecutive patients undergoing nipple-sparing mastectomy and immediate microvascular autologous reconstruction from 2007 to 2019. Outcomes-including major mastectomy flap necrosis, full nipple-areola complex necrosis, and any major ischemic complication of the skin envelope-were compared among incision types. Multivariable logistic regression identified factors associated with major ischemic complication. RESULTS:Two hundred seventy-nine reconstructions (163 patients) were identified, primarily using internal mammary recipient vessels (98.9 percent). Vertical incisions were used in 139 cases; inframammary, in 53; lateral radial, in 51; and inverted-T, in 35. Thirty-two cases (11.5 percent) had major mastectomy flap necrosis, 11 (3.9 percent) had full nipple-areola complex necrosis, and 38 (13.6 percent) had any major ischemic complication. Inframammary incisions had higher rates of major ischemic complication (25 percent) than vertical (5.8 percent; p < 0.001) and lateral radial (7.8 percent; p = 0.032) incisions. Inverted-T incisions also had higher rates of major ischemic complication (36.1 percent) than both vertical (p < 0.001) and lateral radial (p = 0.002) incisions. Inframammary incisions (OR, 4.382; p = 0.002), inverted-T incisions (OR, 3.952; p = 0.011), and mastectomy weight (OR, 1.003; p < 0.001) were independently associated with an increased risk of major ischemic complication. Inframammary incisions with major ischemic complication demonstrated significantly higher body mass index, mastectomy weight, and flap weight compared to those without. CONCLUSIONS:Inframammary and inverted-T incisions are associated with a higher risk of major ischemic skin envelope complications after nipple-sparing mastectomy and immediate microvascular breast reconstruction. Radial incisions can be considered to optimize recipient vessel exposure without compromising perfusion. CLINICAL QUESTION/LEVEL OF EVIDENCE/METHODS:Therapeutic, III.

GENERAL PURPOSE/UNASSIGNED:To provide information about arginine, its metabolism, and its role in acute and chronic wound healing, to assist providers in understanding the recommendations for arginine supplementation. TARGET AUDIENCE/BACKGROUND:This continuing education activity is intended for physicians, physician assistants, nurse practitioners, and nurses with an interest in skin and wound care. LEARNING OBJECTIVES/OUTCOMES/UNASSIGNED:After participating in this educational activity, the participant will:1. Describe the characteristics of arginine.2. Choose the metabolic processes that define arginine's role in wound healing.3. Identify the average daily intake of arginine in an American diet.4. Select the evidence that demonstrates the effectiveness of arginine supplementation for wound healing. ABSTRACT/UNASSIGNED:Nutrition has an important and integral role in wound healing. Arginine, a type of indispensable amino acid, has long been thought to have wound healing properties. The 2019 international guideline by the European Pressure Ulcer Advisory Panel, National Pressure Injury Advisory Panel, and Pan Pacific Pressure Injury Alliance recommends use of a high-protein, high-calorie oral nutrition supplement fortified with arginine and other antioxidants to treat adults with stage 2 or greater pressure injury and who are malnourished or at risk of malnutrition to foster healing. This article provides necessary background on this conditionally indispensable amino acid, its metabolism, and its role in acute and chronic wound healing to assist providers in understanding the recommendation for arginine supplementation.