Faculty Bibliography

Gustilo IIIC injuries of the lower extremity pose a significant challenge to the reconstructive surgeon. Key principles include early vascular repair and serial debridement followed by definitive coverage within 10 days. Primary reconstructive options following vascular repair include the anterolateral thigh flap or the latissimus dorsi muscle flap. Complications include elevated rates of microvascular thrombosis requiring return to the operating room, partial and complete flap loss, and infection. There is also an elevated rate of secondary amputation. However, in spite of higher complication rates, when approached thoughtfully and with an experienced multidisciplinary team, patients can achieve reasonable functional outcomes.

Background/UNASSIGNED:A rare, but consequential, risk of gender affirming surgery (GAS) is post-operative regret resulting in a request for surgical reversal. Studies on regret and surgical reversal are scarce, and there is no standard terminology regarding either etiology and/or classification of the various forms of regret. This study includes a survey of surgeons' experience with patient regret and requests for reversal surgery, a literature review on the topic of regret, and expert, consensus opinion designed to establish a classification system for the etiology and types of regret experienced by some patients. Methods/UNASSIGNED:This anonymous survey was sent to the 154 surgeons who registered for the 2016 World Professional Association for Transgender Health (WPATH) conference and the 2017 USPATH conference. Responses were analyzed using descriptive statistics. A MeSH search of the gender-affirming outcomes literature was performed on PubMed for relevant studies pertaining to regret. Original research and review studies that were thought to discuss regret were included for full text review. Results/UNASSIGNED:The literature is inconsistent regarding etiology and classification of regret following GAS. Of the 154 surgeons queried, 30% responded to our survey. Cumulatively, these respondents treated between 18,125 and 27,325 individuals. Fifty-seven percent of surgeons encountered at least one patient who expressed regret, with a total of 62 patients expressing regret (0.2-0.3%). Etiologies of regret were varied and classified as either: (I) true gender-related regret (42%), (II) social regret (37%), and (III) medical regret (8%). The surgeons' experience with patient regret and request for reversal was consistent with the existing literature. Conclusions/UNASSIGNED:In this study, regret following GAS was rare and was consistent with the existing literature. Regret can be classified as true gender-related regret, social regret and medical regret resulting from complications, function, pre-intervention decision making. Guidelines in transgender health should offer preventive strategies as well as treatment recommendations, should a patient experience regret. Future studies and scientific discourse are encouraged on this important topic.

OBJECTIVE/UNASSIGNED:This study evaluates skeletal and dental outcomes of LeFort I advancement surgery in patients with cleft lip and palate (CLP) with varying degrees of maxillary skeletal hypoplasia. DESIGN/UNASSIGNED:Retrospective study. METHOD/UNASSIGNED:: ≤-10 mm. PARTICIPANTS/UNASSIGNED:Fifty-one patients with nonsyndromic CLP with hypoplastic maxilla who met inclusion criteria. INTERVENTION/UNASSIGNED:LeFort I advancement. MAIN OUTCOME MEASURE/UNASSIGNED:Skeletal and dental stability post-LeFort I surgery at a 1-year follow-up. RESULTS/UNASSIGNED:At T2, LeFort I surgery produced an average correction of maxillary hypoplasia by 6.4 ± 0.6, 8.1 ± 0.4, and 10.7 ± 0.8 mm in the mild, moderate, and severe groups, respectively. There was a mean relapse of 1 to 1.5 mm observed in all groups. At T3, no statistically significant differences were observed between the surgical groups and controls at angle Sella, Nasion, A point (SNA), A point, Nasion, B point (ANB), and overjet outcome measures. CONCLUSIONS/UNASSIGNED:LeFort I advancement produces a stable correction in mild, moderate, and severe skeletal maxillary hypoplasia. Overcorrection is recommended in all patients with CLP to compensate for the expected postsurgical skeletal relapse.

Multisystem inflammatory syndrome in children (MIS-C) is thought to follow SARS-CoV-2 infection and presents with fever and multisystem dysfunction. We report three children with suspected MIS-C found to have retropharyngeal edema without evidence of a bacterial etiology. We raise the possibility that an association between MIS-C and retropharyngeal edema exists.

BACKGROUND:A long-term neurocognitive comparison of patients with sagittal synostosis who underwent spring-assisted surgery or cranial vault remodeling has not been performed. METHODS:Patients with sagittal synostosis who underwent spring-assisted surgery or cranial vault remodeling were recruited from Wake Forest School of Medicine and Yale School of Medicine, respectively. Cognitive tests administered included an abbreviated intelligence quotient, academic achievement, and visuomotor integration. An analysis of covariance model compared cohorts controlling for demographic variables. RESULTS:Thirty-nine spring-assisted surgery and 36 cranial vault remodeling patients were included in the study. No significant differences between cohorts were found with respect to age at surgery, sex, race, birth weight, family income, or parental education. The cranial vault cohort had significantly older parental age (p < 0.001), and mean age at testing for the spring cohort was significantly higher (p = 0.001). After adjusting for covariates, the cranial vault cohort had significantly higher verbal intelligence quotient (116.5 versus 104.3; p = 0.0024), performance intelligence quotient (109.2 versus 101.5; p = 0.041), and full-scale intelligence quotient (114.3 versus 103.2; p = 0.0032). When included patients were limited to intelligence quotients from 80 to 120, the cranial vault cohort maintained higher verbal (108.0 versus 100.4; p = 0.036), performance (104.5 versus 97.7; p = 0.016), and full-scale (107.6 versus 101.5; p = 0.038) intelligence quotients. The cranial vault cohort had higher visuomotor integration scores than the surgery group (111.1 versus 98.1; p < 0.001). There were no significant differences in academic achievement. CONCLUSIONS:Sagittal synostosis patients who underwent cranial vault remodeling had higher intelligence quotient and visuomotor integration scores. There were no differences in academic achievement. Both cohorts had intelligence quotient scores at or above the normal range. Further studies are warranted to identify factors that may contribute to cognitive outcome differences. CLINICAL QUESTION/LEVEL OF EVIDENCE/METHODS:Therapeutic, II.

Since its introduction by Smith and Robinson, the anterior approach to the subaxial cervical spine has become one of the standard procedures for numerous cervical spine pathologies, including, but not limited to degenerative disease, trauma, tumor, deformity, and instability. Along with its increasing popularity and improvements in anterior instrumentation techniques, a comprehensive knowledge of the surgical anatomy during the anterior exposure is critical for trainees and experienced spine surgeons alike to minimize the infrequent but potentially devastating risks associated with this approach. Understanding the anatomy and techniques to minimize damage to relevant structures can reduce the risks of developing notable postoperative complications and morbidity.

BACKGROUND:Occipital neuralgia (ON) is a primary headache disorder characterized by severe, paroxysmal, shooting or stabbing pain in the distribution of the greater occipital, lesser occipital, and/or third occipital nerves. Both medical and surgical options exist for treating headaches related to ON. The purposes of this study are to summarize the current state of surgical ON management through a systematic review of the literature and, in doing so, objectively identify future directions of investigation. METHODS:We performed a systematic review of primary literature on surgical management for ON of at least level IV evidence. Included studies were analyzed for level of evidence, therapeutic intervention, study design, sample size, follow-up duration, outcomes measured, results, and risk of bias. RESULTS:Twenty-two studies met the inclusion criteria. All 22 studies used patient-reported pain scores as an outcome metric. Other outcome metrics included complication rates (7 studies; 32%), patient satisfaction (7 studies; 32%), quality of life (7 studies; 18%), and analgesic usage (3 studies; 14%). Using the ROBINS-I tool for risk of bias in nonrandomized studies, 7 studies (32%) were found to be at critical risk of bias, whereas the remaining 15 studies (68%) were found to be at serious risk of bias. CONCLUSIONS:Greater occipital nerve decompression seems to be a useful treatment modality for medically refractory ON, but further prospective, randomized data are required.

General and local anesthetics are generally well tolerated in the healthy population. Complications may arise affecting the surgical and anesthetic course. We present a case of severe bradycardia and hypotension, along with ST depressions which developed following general anesthesia and local injection of lidocaine with epinephrine to the nose in a healthy male during routine otolaryngological surgery. Symptoms improved with atropine, epinephrine and chest compressions. Subsequent electrocardiogram and Troponin were abnormal, and normalized within days. Reviewing the literature, several possible etiologies arise. These include the Trigeminocardiac Reflex, Takotsubo cardiomyopathy and others. These are discussed and the condition's immediate management recommended.