Neonatal mandibular distraction osteogenesis

Mandibular distraction has revolutionized the treatment of Robin sequence associated with severe airway obstruction. The distraction technique remains the only intervention that directly corrects mandibular hypoplasia and the retropositioned tongue, providing efficient relief of airway stenosis. Multiple studies have demonstrated the efficacy of distraction in avoiding tracheostomy and decreasing the severity airway obstruction in this patient population. The benefit to avoiding tracheostomy and relieving airway obstruction is superior to that of tongue-lip adhesion. It is, therefore, not surprising that mandibular distraction has become the first-line intervention at many centers for the surgical treatment of Robin sequence. The complication profile associated with mandibular distraction appears low; the most common complication is infection, which can be treated by antibiotics alone. The severity of airway obstruction can be quantified by polysomnogram: This tool has become one of the most widely used objective metrics in the Robin sequence population. Therefore indications for surgery, timing of palatoplasty and long-term assessment of airway function should be performed in conjunction with sleep study analysis. The effects of mandibular lengthening on feeding difficulty in Robin sequence patient remains a topic of controversy. Studies have demonstrated conflicting results: This can be an area of future study. Agreed-upon indications for surgery and definitive protocols of care have yet to be formulized; future research should focus on achieving these goals. Such studies would require agreed-upon terminology for Robin sequence, an increase in comparative and prospective analysis, and the use of quantifiable metrics of clinical results.

Nasal airway and septal variation in unilateral and bilateral cleft lip and palate

Cleft lip and palate (CLP) affects the dentoalveolar and nasolabial facial regions. Internal and external nasal dysmorphology may persist in individuals born with CLP despite surgical interventions. 7-18 year old individuals born with unilateral and bilateral CLP (n = 50) were retrospectively assessed using cone beam computed tomography. Anterior, middle, and posterior nasal airway volumes were measured on each facial side. Septal deviation was measured at the anterior and posterior nasal spine, and the midpoint between these two locations. Data were evaluated using principal components analysis (PCA), multivariate analysis of variance (MANOVA), and post-hoc ANOVA tests. PCA results show partial separation in high dimensional space along PC1 (48.5% variance) based on age groups and partial separation along PC2 (29.8% variance) based on CLP type and septal deviation patterns. MANOVA results indicate that age (P = 0.007) and CLP type (P ≤ 0.001) significantly affect nasal airway volume and septal deviation. ANOVA results indicate that anterior nasal volume is significantly affected by age (P ≤ 0.001), whereas septal deviation patterns are significantly affected by CLP type (P ≤ 0.001). Age and CLP type affect nasal airway volume and septal deviation patterns. Nasal airway volumes tend to be reduced on the clefted sides of the face relative to non-clefted sides of the face. Nasal airway volumes tend to strongly increase with age, whereas septal deviation values tend to increase only slightly with age. These results suggest that functional nasal breathing may be impaired in individuals born with the unilateral and bilateral CLP deformity.

The cost of intraoperative plastic surgery education

PURPOSE

Within the surgical community, it is commonly accepted that the length and cost of a surgical case increase when a resident physician participates. Many accountable care organizations, however, believe the opposite, that is, resident assistance enhances efficiency and diminishes operative time. The purpose of this study is to determine the opportunity cost to the attending surgeon for intraoperative teaching during index plastic surgery cases.

METHODS

A single senior surgeon's experience over a 7-year period was evaluated retrospectively for Current Procedural Terminology codes 40700 (repair of primary, unilateral cleft lip) and 42200 (palatoplasty). Variables collected include operative time, the presence or absence of a physician learner, and postgraduate year level. Statistical analysis was performed with the Kruskal-Wallis test using the S+ programming language. A cost analysis was performed to quantify the effect of longer operative times in terms of relative value units (RVUs) lost.

RESULTS

During the study period, a total of 45 patients had primary, unilateral cleft lip repair; 70 patients had cleft palate repair. Of those cases, 39 (87%) cleft lip repairs and 60 (86%) cleft palate repairs were performed with a resident or fellow present. There was a statistically significant difference in the amount of time required to perform either surgery with a physician learner than without, with operative times being 60% (p = 0.020) longer for cleft lip repair and 65% (p = 0.0016) longer for cleft palate repair. The results were further stratified based on level of training, with craniofacial fellows and plastic surgery residents (independent and integrated) compared separately. Cases where a craniofacial fellow was present required the longest operative times: 103% (p = 0.0012) longer for cleft lip repairs and 104% (p < 0.0001) longer for cleft palate repairs when compared with the senior surgeon operating alone. Using the 2011 physician work RVUs for these surgeries and the 2011 Medicare conversion factor for RVUs to dollars, the opportunity cost is over $275 per case per trainee for any physician learner. When craniofacial fellows are analyzed separately, over $440 is invested in intraoperative teaching per case per fellow.

CONCLUSIONS

Resident involvement in the operating room is crucial to the education of independent surgeons. This involvement, however, comes at a significant opportunity cost to the attending surgeon. As an incentive to retain academic surgeons and uphold a quality academic environment in the OR, compensation should be offered for intraoperative teaching.

Congenital lower lip pits (van der Woude syndrome): what pathologists need to know

Congenital lower lip pits are cardinal findings of van der Woude syndrome [OMIM 119300]. The nosologic context of how lower lip pits are catalogued is easily lost because of insufficient clinical history, subtle findings misidentified as artifacts, lack of awareness by the pathologist, the perception that these are identify/confirm descriptive-diagnosis only, not necessarily an element of an actionable report, and/or the rarity with which these specimens are accessioned (in the authors' experience, less than 1 case per year). We present the salient findings on 19 lower lip pits specimens from the files of a single institution collected over the last 25 years.

Chin IX: Unusual Soft Tissue Problems of the Lower Face

When the editor asked me to write something related to the chin, I (B.M.Z.) told him I would like to concentrate on the soft tissue of the perioral and chin region, something previously not presented before in this Journal specifically or anywhere. Dr. Flores and I have chosen certain soft tissue cases of the lower face, each of which presents certain dilemmas. The reconstructive methods in each case are unique, previously not shown, and represent salvage from prior failures. Case 1 shows how an interior Abbe flap can be used for ipsilateral lip reconstruction. Case 2 shows how a large upper lateral lip elemental loss can be regained from cheek and not the lower lip. Cases 3 and 4 show how to regain proper white roll bulge and symmetry by overcorrection, then exact adjustment in a second stage. Case 5 shows how a failed chin/lip reconstruction can be salvaged to regain sulcus height and aesthetic unit reconstruction. Each case depicts unique reconstructive designs to produce an aesthetic final result.

Intraoperative Sensorcaine Significantly Improves Postoperative Pain Management in Outpatient Reduction Mammaplasty

BACKGROUND

Breast reduction is one of the most frequently performed plastic surgical procedures in the United States; more than 160,500 patients underwent the procedure in 2005. Many outpatient reduction mammaplasty patients report the greatest postoperative discomfort in the first 48 hours. The authors' investigated the effect of intraoperative topical application of the long-acting local anesthetic agent bupivacaine (Sensorcaine or Marcaine) on postoperative pain, time to postanesthesia care unit discharge, and postoperative use of narcotic medication.

METHODS

In a prospective, randomized, single-blind trial, intraoperative use of Sensorcaine versus placebo (normal saline) was compared. Postoperative pain was quantified using the visual analogue scale, and time to discharge from the postanesthesia care unit was recorded. Patients documented their outpatient pain medication usage.

RESULTS

Of the 37 patients enrolled in the study, 20 were treated with intraoperative topical Sensorcaine and 17 received placebo. Patients treated with Sensorcaine were discharged home significantly faster (2.9 hours versus 3.8 hours, p = 0.002). The control arm consistently had higher pain scores in the postanesthesia care unit (although not statistically significant) than the Sensorcaine group using the visual analogue scale system. Furthermore, patients receiving Sensorcaine required significantly less narcotic medication while recovering at home (mean, 3.5 tablets of Vicodin) than the control group (mean, 6.4 tablets; p = 0.001). There were no complications resulting from Sensorcaine usage.

CONCLUSIONS

This prospective, randomized, single-blind study demonstrates that a single dose of intraoperative Sensorcaine provides a safe, inexpensive, and efficacious way to significantly shorten the length of postanesthesia care unit stay and significantly decrease postoperative opioid analgesic use in patients undergoing ambulatory reduction mammaplasty.

Nonextremity replantation: the management of amputations of the facial parts and testicle

Successful nonextremity replantations, particularly of the facial anatomy and testicles, are rare procedures, and only a handful of cases have been reported. This article reviews the current literature in nonextremity replantations and representative cases performed at the authors' institution. Certain underlying themes and problems are consistently encountered in the surgical management of these cases. These are identified and reviewed. Although the replantation of these body parts remains technically challenging, all efforts should be made, when indicated, to repair these injuries microsurgically, because it currently offers the best reconstructive solution for these patients.

Effect of prior hyperglycemia on IL-6 responses to exercise in children with type 1 diabetes

The proinflammatory cytokine interleukin-6 (IL-6) may modulate the onset and progression of complications of diabetes. As this cytokine increases after exercise, and many other exercise responses are altered by prior glycemic fluctuations, we hypothesized that prior hyperglycemia might exacerbate the IL-6 response to exercise. Twenty children with type 1 diabetes (12 boys/8 girls, age 12-15 yr) performed 29 exercise studies (30-min intermittent cycling at approximately 80% peak O2 uptake). Children were divided into four groups based on highest morning glycemic reading [blood glucose (BG) < 150, BG 151-200, BG 201-300, or BG > 300 mg/dl]. All exercise studies were performed in the late morning, after hyperglycemia had been corrected and steady-state conditions (plasma glucose < 120 mg/dl, basal insulin infusion) had been maintained for > or = 90 min. Blood samples for IL-6, growth factors, and counterregulatory hormones were drawn at pre-, end-, and 30 min postexercise time points. At all time points, circulating IL-6 was lowest in BG < 150 and progressively higher in the other three groups. The exercise-induced increment also followed a similar dose-response pattern (BG < 150, 0.6 +/- 0.2 ng/ml; BG 151-200, 1.2 +/- 0.8 ng/ml; BG 201-300, 2.1 +/- 1.1 ng/ml; BG > 300, 3.2 +/- 1.4 ng/ml). Other measured variables (growth hormone, IGF-I, glucagon, epinephrine, cortisol) were not influenced by prior hyperglycemia. Recent prior hyperglycemia markedly influenced baseline and exercise-induced levels of IL-6 in a group of peripubertal children with type 1 diabetes. While exercise is widely encouraged and indeed often considered part of diabetic management, our data underscore the necessity to completely understand all adaptive mechanisms associated with physical activity, particularly in the context of the developing diabetic child.