Surgical Delay of Thoracodorsal Artery Perforator Flaps for Total Autologous Breast Reconstruction

BACKGROUND

When abdomen-based free flap reconstruction is contraindicated, the muscle-sparing thoracodorsal artery perforator (TDAP) flap may be considered for total autologous breast reconstruction. The TDAP flap is often limited by volume and is prone to distal flap necrosis. We aim to demonstrate our experience combining the delay phenomenon with TDAP flaps for total autologous breast reconstruction.

METHODS

Patients presenting for autologous breast reconstruction between April 2021 and August 2023 were recruited for surgically delayed TDAP flap reconstruction when abdominally based free flap reconstruction was contraindicated because of previous abdominal surgery or poor perforator anatomy. We dissected the TDAP flap except for a distal skin bridge and then reconstructed the breast 1 to 7 days later. Data included flap dimensions (in centimeters × centimeters), delay time (in days), predelay and postdelay perforator caliber (in millimeters) and flow (in centimeters per second), operative time (in minutes), hospital length of stay (in days), complications/revisions, and follow-up time (in days).

RESULTS

Fourteen patients and 16 flaps were included in this study. Mean age and body mass index of patients were 55.9 ± 9.6 years and 30.1 ± 4.3 kg/m2, respectively. Average flap skin island length and width were 32.1 ± 3.3 cm (n = 8 flaps) and 8.8 ± 0.7 cm (n = 5 flaps), respectively. Beveled flap width reached 16.0 ± 2.2 cm (n = 3 flaps). Average time between surgical delay and reconstruction was 2.9 days, ranging from 1 to 7 days (n = 18 flaps). Mean predelay and postdelay TDAP vessel caliber and flow measured by Doppler ultrasound increased from 1.4 ± 0.3 to 1.8 ± 0.3 mm (P = 0.03) and 13.3 ± 5.2 to 43.4 ± 18.8 cm/s (P = 0.03), respectively (n = 4 flaps). Complications included 1 donor site seroma and 1 mastectomy skin flap necrosis. Follow-up ranged from 4 to 476 days (n = 17 operations).

CONCLUSIONS

We demonstrate surgically delayed TDAP flaps as a viable option for total autologous breast reconstruction. Our series of flaps demonstrated increased perforator caliber and flow and enlarged volume capabilities and had no incidences of flap necrosis.

Modern Approaches to Abdominal-Based Breast Reconstruction

Modern approaches to abdominal-based breast reconstruction have evolved since the introduction of the transverse musculocutaneous flap by Dr Carl Hartrampf in the 1980s. The natural evolution of this flap is the deep inferior epigastric perforator (DIEP) flap, as well as the superficial inferior epigastric artery flap. As breast reconstruction has advanced, so too has the utility and nuances of abdominal-based flaps, including the deep circumflex iliac artery flap, extended flaps, stacked flaps; neurotization; and perforator exchange techniques. Even the delay phenomenon has been successfully applied to DIEP and SIEA flaps to augment flap perfusion.

Regenerative vs flap-based limb salvage: a multi-centered, prospective, randomized controlled trial

Aim: The goal of this study was to compare success rates of a regenerative limb salvage approach (rLS) using dehydrated human chorion amnion membrane (dHACM) to traditional flap-based limb salvage (fLS). Materials & methods: This prospective RTC enrolled patients presenting with complex extremity wounds over a 3-year period. Primary outcomes included success of primary reconstruction, persistence of exposed structures, time to definitive closure, and time to weight bearing. Results: Patients meeting inclusion criteria were randomized to fLS (n = 14) or rLS (n = 25). The primary reconstructive method was successful for 85.7% of fLS subjects and 80% of rLS subjects (p = 1.00). Conclusion: This trial provides strong evidence that rLS is an effective option in the setting of complex extremity wounds, with success rates comparable to traditional flaps. Clinical Trial Registration: NCT03521258 (ClinicalTrials.gov).

Surgical Delay-Induced Hemodynamic Alterations of the Superficial Inferior Epigastric Artery Flap for Autologous Breast Reconstruction

BACKGROUND

The superficial inferior epigastric artery (SIEA) flap allows transfer of tissue without violating the rectus fascia. Traditionally it is best used in single stage reconstruction when vessel caliber is 1.5 mm; 56% to 70% of SIEAs are less than 1.5 mm and, therefore, not reliable. We aim to demonstrate the increased reliability of SIEA through surgical delay by quantifying reconstructive outcomes and delay-induced hemodynamic alterations.

METHODS

Patients presenting for autologous breast reconstruction between May 2019 and October 2020 were evaluated with preoperative imaging and received either delayed SIEA or delayed deep inferior epigastric (DIEP) reconstruction based on clinical considerations, such as prior surgery and perforator size/location. Prospective data were collected on operative time, length of stay, and complications. Arterial diameter and peak flow were quantified with Doppler ultrasound predelay and postdelay.

RESULTS

Seventeen delayed SIEA flaps were included. The mean age (± SD) was 46.2 ± 10.55 years, and body mass index was 26.7 ± 4.26 kg/m2. Average hospital stay after delay was 0.85 ± 0.90 days, and duration before reconstruction was 6 days to 14.5 months. Delay complications included 1 abdominal seroma (n = 1, 7.7%). Superficial inferior epigastric artery diameter predelay (mean ± 95% confidence interval) was 1.37 ± 0.20 mm and increased to 2.26 ± 0.24 mm postdelay. A significant increase in diameter was noted 0.9 ± 0.22 mm (P < 0.0001). Mean peak flow predelay was 14.43 ± 13.38 cm/s and 44.61 ± 60.35 cm/s (n = 4, P = 0.1822) postdelay.

CONCLUSIONS

Surgical delay of the SIEA flap augments SIEA diameter, increasing the reliability of this flap for breast reconstruction. Superficial inferior epigastric artery delay results in low rates of complications and no failures in our series. Although more patients are needed to assess increase in arterial flow, use of surgical delay can expand the use of SIEA flap reconstruction and reduce abdominal morbidity associated with abdominal flap breast reconstruction.

The Impact of Indocyanine Green Angiography on Fat Necrosis in Deep Inferior Epigastric Perforator Flap Breast Reconstruction

BACKGROUND

The deep inferior epigastric perforator flap (DIEP) is a widely known reliable option for autologous breast reconstruction. One common complication of DIEP procedures is fat necrosis. Consequences of fat necrosis include wound healing complications, pain, infection, and the psychological distress of possible cancerous recurrence. Clinical judgment alone is an imperfect method to detect at-risk segments of adipose tissue. Objective methods to assess perfusion may improve fat necrosis complication rates, reducing additional surgeries to exclude cancer and improve cosmesis for patients.

METHODS

The authors performed a retrospective review of patients who underwent analysis of DIEP flap vascularity with or without intraoperative indocyanine green angiography (ICGA). Flap perfusion was assessed using intravenous ICGA and was quantified with both relative and absolute value units of fluorescence. Tissue with observed values less than 25% to 30% relative value units was resected. Postoperative outcomes and fat necrosis incidence were collected.

RESULTS

Three hundred fifty-five DIEP flaps were included in the study, 187 (52.7%) of which were assessed intraoperatively with ICGA. Thirty-nine patients (10.9%) experienced operable fat necrosis. No statistically significant difference in incidence of postoperative fat necrosis was found between the 2 groups (P = 0.732). However, a statistically significant relationship was found between fat necrosis incidence and body mass index as both a continuum (P = 0.001) and when categorized as greater than 35 (P = 0.038).

CONCLUSIONS

Although ICGA is useful for a variety of plastic surgery procedures, our retrospective review did not show a reduction in operable fat necrosis when using this technology.

Preoperative Computed Tomography Angiography for ALT Flaps Optimizes Design and Reduces Operative Time

BACKGROUND

 Computed tomography angiography (CTA) has been widely used for perforator mapping in abdominal-based reconstruction, but it is less widespread in the anterolateral thigh (ALT) flap. However, CTA may be quite useful for ALT planning, as this flap has demonstrated substantial variability in intrapatient bilateral vascular anatomy. This study investigated whether standard use of preoperative CTA resulted in selection of the donor extremity with preferential perforator anatomy, and whether this affected operative time and postoperative outcomes.

METHODS

 A retrospective review of 105 patients who underwent proposed ALT flap reconstruction was performed. Seventy-nine patients received bilateral lower extremity CTAs, which were evaluated for dominant perforator anatomy (septocutaneous, musculoseptocutaneous, or musculocutaneous). Donor extremity selection was noted, and predicted perforator anatomy was compared with that encountered intraoperatively.

RESULTS

 Among the 73 patients who received bilateral imaging and ultimately received an ALT, congruent findings between imaging and surgical exploration were observed in 51 (69.8%) patients. Thirty (37.9%) patients had asymmetric perforator anatomy between their bilateral extremities on imaging. Among these, the leg with optimal perforator anatomy was selected in 70% of cases. There were no significant reductions among postoperative complication rates, but selection of the donor site with preferential anatomy was associated with a decrease in operative time (p = 0.049) among patients undergoing extremity reconstruction.

CONCLUSION

 CTA is a useful tool for optimizing donor site selection for ALT flaps and reducing operative time. We believe that standard use of preoperative CTA in ALTs warrants further consideration.

Mapping 216 Perforator Flaps Using Highly Portable Tablet-Based Color Doppler Ultrasound (PT-CDU)

BACKGROUND

 The first reports of using color Doppler ultrasound for evaluation of the microvasculature were in the 1990s. Despite the early reports of its efficacy, color Doppler ultrasound did not achieve popularity nor general usage in part due to the cumbersome size, cost and poor resolution. This is the first study to demonstrate the potential utility of a new, highly portable, tablet-based color Doppler ultrasound (PT-CDU) system for imaging perforator flaps.

METHODS

 The deep inferior epigastric artery (DIEP), lateral arm (LA), anterolateral thigh (ALT), thoracodorsal artery (TDAP), and the medial sural artery (MSAP) perforator flaps were imaged within classic topographic landmarks to visualize and measure variables related to perforator flap anatomy. The Philips Lumify L12-4 linear array probe attached to the Samsung Galaxy Tab A tablet was the system used for all examinations.

RESULTS

 A total of 216 flaps were scanned in 50 healthy adult volunteers: 44 DIEP, 44 LA, 40 ALT, 48 TDAP, and 40 MSAP. Precise anatomic information regarding perforator size, number, and location was obtained. Overall, the percent of flaps having at least 1 perforator within the specified topographical landmarks was 89% for the DIEP, 84.1% for the LA, 72.5% for the ALT, 50% for the TDAP, and 30% for the MSAP (p = 2.272e-09). The percent of patients having an asymmetry (right versus left) in the number of perforators was 72.7% (ALT), 65% (DIEP), 59.1% (LA), 41.7% (TDAP), and 30% (MSAP) (p = 0.0351).

CONCLUSIONS

 Portable, tablet-based color Doppler ultrasound offers high-resolution images of perforators and represents a facile technology that may be of interest to microsurgeons in the planning of perforator flaps. Variations in vascular anatomy were well-demonstrated. This surgeon-driven imaging technology may represent an excellent alternative to other imaging modalities.

Use of the Vertical Profunda Artery Perforator Flap to Capture the Dominant Perforator: A Cadaver Dissection and Imaging Study

INTRODUCTION

 While the originally described transverse profunda artery perforator (tPAP) flap is designed to capture the first profunda perforator, our group hypothesized the dominant perforator may not always be captured in this configuration. This study maps the location of dominant profunda perforators using imaging and cadaveric dissections to determine the probability of capturing dominant perforators with the transverse flap design versus the vertical PAP (vPAP) variant.

METHODS

 Fifty preoperative magnetic resonance angiogram or computed tomographic angiogram scans (100 total extremities) were examined from autologous breast reconstruction patients between 2015 and 2019. Profunda perforator characteristics that were examined included the distance from the pubic tubercle to the infragluteal fold (IGF), the distance of the perforators from the IGF, distance posterior to the gracilis, the diameter of the perforator at fascial exit, and total number of perforators present. Profunda perforator dissection was performed in 18 cadaveric extremities. Analysis included mean distance from pubic tubercle, distance posterior to the gracilis, diameter at fascial exit, and total number of perforators.

RESULTS

 In imaging analysis, the mean distance from the IGF to the fascial exit of all dominant perforators was 7.04 cm. The mean diameter of the dominant perforator at the fascial exit was 2.61 mm. Twenty-six thighs (26%) demonstrated dominant perforators that exited the fascia greater than 8 cm below the IGF. In cadaver dissections, the mean distance from the pubic tubercle to the fascial exit of all the dominant perforators was 10.17 cm. Nine cadaver specimens (50%) demonstrated perforators that exited the fascia greater than 8 cm below the estimated IGF.

CONCLUSION

 The dominant perforator can often be missed in the traditional tPAP design. The vPAP incorporates multiple perforators with a long pedicle, excellent vessel diameter, and favorable donor-site.

Stratification of Surgical Risk in DIEP Breast Reconstruction Based on Classification of Obesity

BACKGROUND

 From both a medical and surgical perspective, obese breast cancer patients are considered to possess higher risk when undergoing autologous breast reconstruction relative to nonobese patients. However, few studies have evaluated the continuum of risk across the full range of obesity. This study sought to compare surgical risk between the three World Health Organization (WHO) classes of obesity in patients undergoing deep inferior epigastric perforator (DIEP) flap breast reconstruction.

METHODS

 A retrospective review of 219 obese patients receiving 306 individual DIEP flaps was performed. Subjects were stratified into WHO obesity classes I (body mass index [BMI]: 30-34), II (BMI: 35-39), and III (BMI: ≥ 40) and assessed for risk factors and postoperative donor and recipient site complications.

RESULTS

 When examined together, the rate of any complication between the three groups only trended toward significance (p = 0.07), and there were no significant differences among rates of specific individual complications. However, logistic regression analysis showed that class III obesity was an independent risk factor for both flap (odds ratio [OR]: 1.71, 95% confidence interval [CI]: 0.91-3.20, p = 0.03) and donor site (OR: 2.34, 95% CI: 1.09-5.05, p = 0.03) complications.

CONCLUSION

 DIEP breast reconstruction in the obese patient is more complex for both the patient and the surgeon. Although not a contraindication to undergoing surgery, obese patients should be diligently counseled regarding potential complications and undergo preoperative optimization of health parameters. Morbidly obese (class III) patients should be approached with additional caution, and perhaps even delay major reconstruction until specific BMI goals are met.

Primary Resection and Immediate Autologous Reconstruction of Fronto-orbital Infantile Myofibromatoses

Infantile myofibromatosis is an unusual and rare lesion of the bone and soft tissue, which can be seen in the craniofacial skeleton. These complex tumors present a challenge to craniofacial surgeons regarding diagnosis, management, and safe and effective surgical treatment, frequently requiring complex reconstruction. We present the case of a 7-month-old girl with multicentric infantile myofibromatosis of the right parietal and fronto-orbital region, the associated clinical presentation, histopathologic findings, and surgical management, along with a review of the relevant literature.

Multistage surgical repair for split notochord syndrome with neuroenteric fistula: case report

Split notochord syndrome (SNS) is a rare congenital defect of the central nervous system and has been associated with several anomalies affecting multiple organ systems. One association has been communication with the gastrointestinal tract and the spine, previously identified as a neuroenteric fistula (NEF). Here, the authors describe the unique case of a female infant with SNS and NEF treated with a multistage surgical repair. The three-stage operative plan included a two-stage repair of the defect and temporary subgaleal shunting followed by delayed ventriculoperitoneal shunt placement. The infant recovered well postsurgery and over a 5-year follow-up. A case description, surgical techniques, and rationale are reported. Additionally, a systematic review of the literature utilizing the MEDLINE database was performed.Treatment of SNS with NEF using a multidisciplinary multistaged approach to repair the intestinal defect, close the neural elements, and divert cerebrospinal fluid to the peritoneum is shown to be a safe and viable option for future cases.

Ultrasound Imaging of the Superficial Fascial System Can Predict the Subcutaneous Strength of Abdominal Tissue Using Mean Gray Value Quantification

BACKGROUND

This study is the first to correlate sonographic findings of subcutaneous tissue to structural and biomechanical properties.

METHODS

Precisely sized tissue specimens (59 samples) were collected from five abdominoplasty procedures. A Philips Lumify L12-4 linear array probe, connected to an Android tablet, was used to obtain ultrasound images of the superficial fascial system. A no. 1 Vicryl suture on a CTX needle placed though a needle guide within a three-dimensionally printed template ensured equal bites of subcutaneous tissue across specimens. Suture pull-out strength was measured until failure at a displacement rate of 2.12 mm/second using an Admet MTEST Quattro. Mean gray value for the superficial fascial system in associated ultrasonographic images was quantified by CellProfiler.

RESULTS

Superficial fascial system visualization can be accomplished using high-resolution portable ultrasound. Comparing multiple specimens' imaging, interpatient and intrapatient variability of superficial fascial system quantity and structural characteristics are apparent. The superficial fascial system is highly abundant in some patients, but has limited presence in others. Individual-specimen mean gray value and whole-patient mean gray value positively correlated with tissue tensile strength (p = 0.006) and patient-average tissue tensile strength (p = 0.036), respectively. Whole-patient mean gray value accounted for 98.5 percent of the variance seen in patient-average tensile strength, making it a strong predictor for tensile strength.

CONCLUSIONS

Portable ultrasound and image-processing technology can visualize, quantify, and predict subcutaneous tissue strength of the superficial fascial system. The superficial fascial system quantity correlates with suture tensile strength. Clinically, preoperative superficial fascial system quantification may aid in outcome predictions, manage patient expectations, and potentially lower complication rates.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Diagnostic, V.

Timing of Free Flaps for Traumatic Wounds of the Lower Extremity: Have Advances in Perioperative Care Changed the Treatment Algorithm?

BACKGROUND

 Despite the landmark study by Godina 30 years ago, opinions still vary within the literature about the management of complex traumatic wounds in the lower extremity. We present a large series of lower extremity reconstructions with vascularized free tissue and examine the perioperative factors that influenced the success of these cases.

METHODS

 We reviewed 88 patients with free flap reconstruction of traumatic lower extremity wounds over 8 years. Primary outcomes were flap infections, flap loss, total flap-specific complications, and total recipient site complications. Independent variables specific to perioperative care including time to flap coverage, injury classification, exposed or infected hardware, prior osteomyelitis, use of wound vacuum-assisted closure (VAC) therapy, and concurrent polytrauma were investigated to establish their influence on primary outcomes. Each independent variable was assessed using Chi-square or Fisher's exact test and was included in a logistic regression analysis to establish significance.

RESULTS

 Of the 88 patients, 8 had flap loss, 8 had flap infections, and a total of 23 had primary adverse outcomes. Timing of the reconstruction, VAC use, injury classification, prior hardware or wound status, or presence of polytrauma had no statistically significant impact on the primary outcomes. Injury classification/severity on total recipient site complications (p = 0.051) and flap-specific complications (p = 0.073) trended toward significance; however, subgroup analysis did not achieve significance. Logistic regression of any recipient site complication including all independent variables similarly showed no significance.

CONCLUSION

 Although the original study by Godina suggests early coverage is critical to optimize outcomes, in the modern era of advanced wound care, our study adds to a growing body of evidence that supports the de-emphasis of the 72-hour reconstruction interval. Our current management is focused on more effectively coordinating efficient peritraumatic and perioperative care on an individualized basis in the often very complicated polytrauma patient.

Novel De Novo EFTUD2 Mutations in 2 Cases With MFDM, Initially Suspected to Have Alternative Craniofacial Diagnoses

We report 2 cases of mandibulofacial dysostosis with microcephaly (MFDM) with different and novel de novo mutations in the elongation factor Tu GTP binding domain containing 2 gene. Both cases were initially thought to have alternative disorders but were later correctly diagnosed through whole-exome sequencing. These cases expand upon our knowledge of the phenotypic spectrum in patients with MFDM, which will aid in defining the full phenotype of this disorder and increase awareness of this condition.

Sandwiched White Adipose Tissue: A Microphysiological System of Primary Human Adipose Tissue

White adipose tissue (WAT) is a critical organ in both health and disease. However, physiologically faithful tissue culture models of primary human WAT remain limited, at best. In this study we describe a novel WAT culture system in which primary human WAT is sandwiched between tissue-engineered sheets of adipose-derived stromal cells. This construct, called "sandwiched white adipose tissue" (SWAT), can be defined as a microphysiological system (MPS) since it is a tissue-engineered, multicellular, three-dimensional organ construct produced using human cells. We validated SWAT against the National Institutes of Health MPS standards and found that SWAT is viable in culture for 8 weeks, retains physiologic responses to exogenous signaling, secretes adipokines, and engrafts into animal models. These attributes position SWAT as a powerful tool for the study of WAT physiology, pathophysiology, personalized medicine, and pharmaceutical development.

The Fleur-de-PAP Flap for Bilateral Breast Reconstruction

The authors present the case of a 42-year-old female patient who underwent autologous breast reconstruction using a new perforator flap designed from the medial and posterior thigh. Due to a prior abdominoplasty, the patient's abdominal donor site was unavailable to reconstruct her large, ptotic breasts, so an alternate approach was undertaken. The fleur-de-PAP flap is based on the same perforators employed by the standard profunda artery perforator (PAP) flap, but simultaneously incorporates tissue from both the transverse and vertical PAP flap skin paddles. This design maximizes flap volume at a single donor site and provides a reasonable secondary option for autologous reconstruction in large-breasted patients in whom the abdomen is not available.

The Impact of Chemotherapy on Complications Associated with Mastectomy and Immediate Autologous Tissue Reconstruction

We performed this study to evaluate the impact of chemotherapy on the outcomes associated with immediate autologous tissue reconstruction (IATR) in the treatment of breast cancer. Patients were divided into two groups: Group 1 received chemotherapy before surgery and Group 2 did not receive chemotherapy. Records were reviewed to identify demographics, comorbidities, histology, and wound healing complications. Groups were compared using Kruskal-Wallis and Fisher exact tests as appropriate. A total of 128 patients were identified: 29 received chemotherapy before surgery (Group 1) and 99 did not receive chemotherapy (Group 2). Group 1 patients were more likely to have diabetes 27 per cent versus 6 per cent (P = 0.005) despite both groups having a mean body mass index of 30. Group 2 patients had less advanced stage disease as expected because they did not receive chemotherapy; 37 per cent of Group 2 patients had stage 0 breast cancer (P < 0.001). The incidence of wound complications was 17 per cent in Group 1 and 12 per cent in Group 2 (P = NS). Preoperative chemotherapy for breast cancer followed by IATR was associated with no increased risk of healing complications. IATR can be offered to patients who require preoperative chemotherapy, and their healing will not be impaired as a result of the chemotherapy.

Versatility of subscapular chimeric free flaps in the secondary reconstruction of composite posttraumatic defects of the upper face

High energy injuries to the upper face present challenging reconstructive problems. In some cases, initial reconstructive efforts result in unfavorable outcomes that require secondary intervention. Chimeric free flaps based on the subscapular system offer the tissue components and volume needed for these complex reconstructions. This is a series of five patients who underwent secondary reconstruction of the middle and upper face following traumatic injury. Mechanism of injury, prior attempts at reconstruction, and characteristics of the tissue defects and the flaps used in their reconstruction are described. Two patients were female and three were male. Three injuries resulted from gunshot wounds, and two from motor vehicle accidents. All patients had multiple prior failed attempts at reconstruction using local/regional tissue. Defects included symptomatic oronasal or oro-orbital fistulas, enophthalmos, and forehead contour deformities. Two of the flaps used included scapular bone and latissimus muscular components, and three included scapular bone and thoracodorsal artery perforator-based skin paddle components. All free tissue transfers were successful, and no patients suffered significant complications. Chimeric free flaps based on the subscapular system offer a valuable secondary strategy for reconstruction of composite defects of the upper face when other options have been exhausted through previous efforts.

Juvenile ossifying fibroma of the middle turbinate

Juvenile ossifying fibroma is a rare, benign tumor that may present in the sinonasal area but has never been described arising from the middle turbinate. The lesion's locally aggressive behavior and close proximity to orbit and anterior skull base create a significant challenge for the patient and practitioner. This is a case presentation of a 7-year-old female with an invasive recurrent juvenile ossifying fibroma arising from the middle turbinate.

Persistent oro-nasal fistula after primary cleft palate repair: minimizing the rate via a standardized protocol

OBJECTIVES

Multiple methods are described for cleft palate repair. Similarly, a wide range of postoperative oro-nasal fistula rates are described, depending on technique and series examined. We describe long-term outcomes and fistula rates for primary cleft palate repair for a single surgeon using a standardized protocol. Furlow palatoplasty was used for clefts limited to the soft palate, and two-flap palatoplasty was used for clefts involving both the hard and soft palate.

METHODS

Retrospective review of prospectively gathered data.

RESULTS

Eighty-two patients underwent cleft palate repair within the study period. Average age at time of repair was 1.69 years (range 0.47-12.1 years), 19 patients had cleft palate as a part of a known genetic syndrome, and male:female ratio was 1.05:1. Overall fistula rate requiring repair was 5.5%, and fistula development was not significantly associated with type of cleft repair or use of AlloDerm in the repair.

CONCLUSIONS

A very low rate of oro-nasal fistula and good postoperative outcomes were achieved utilizing this protocol for cleft palate repair. It is effective both in isolated cleft palate, as well as in more complicated syndromic patients. It is possible that significant associations between repair technique and fistula rate exist that were not elucidated in this study as a result of the small number of oro-nasal fistulas.

Treatment of submucous cleft palate with selective use of the Furlow Z-palatoplasty

PURPOSE

Submucous cleft is an uncommon entity that can be complicated by functional abnormalities, specifically velopharyngeal incompetence (VPI), secondary to abnormal palatal muscular insertion. This study aims to characterize our experience using the Furlow Z-palatoplasty for the treatment of VPI in patients with submucous clefts.

METHODS

A retrospective chart review was conducted looking at 24 patients diagnosed with symptomatic submucous clefts between 2000 and 2007 at Children's Hospital of New Orleans. Demographics such as age, gender, diagnosis, need for surgical correction, type of operation, complications, presence of genetic syndromes, need for secondary surgery, and need for myringotomy tubes were examined.

RESULTS

The average age at initial surgery for the entire study population was 6.2 years. The success rate of our Furlow procedure was 66.7%, with 33.3% requiring secondary pharyngeal flaps. The genetic syndromic patient population had an average age at initial surgery of four years and experienced a lower primary success rate of 50%. The non-syndromic patient population had an average age at initial surgery of 7.3 years, with an 85.7% primary success rate.

CONCLUSIONS

Our data supports the notion that Furlow Z-palatoplasty is an effective procedure in the treatment of submucous cleft palate with VPI, frequently without the need for secondary surgical procedures in the majority of patients, particularly those patients without syndromes.

Long-Term Culture of Human Gingival Keratinocyte Progenitor Cells by Down-regulation of 14-3-3σ

Human gingival keratinocytes in culture stop proliferating after a limited number of passages. This limitation is associated with a gradual depletion of the stem cell compartment of the cell population. Human skin keratinocytes have a three- to five-fold higher proliferation capacity under similar culture conditions, and previous studies indicated that stable down-regulation of the 14-3-3 sigma protein in these cultures prevents stem cell differentiation and generates immortal cell lines without the effects of tumorigenic transformation, e.g., genotypic alterations. In this report, we demonstrate the creation of an immortalized human gingival keratinocyte stem cell line by stable down-regulation of the 14-3-3 sigma protein. Keratinocyte cultures were generated from human subjects ranging from 17 to 92 years of age and retrovirally transduced with a 14-3-3 sigma antisense RNA expression construct. In contrast to the control cultures, which propagated for only 2-5 passages and 25-35 cell doublings, the 14-3-3 sigma-transduced cultures propagated for 11 passages and 110 cell doublings so far. The percentage of stem cells measured by clonal analysis, which gradually decreased in the control cultures, increased to a steady level of over 90% in the 14-3-3 sigma down-regulated culture. This gingival keratinocyte stem cell line and others, which can be generated using the same procedure, have the potential to be useful for studies on stem cell differentiation, for developing gene therapy procedures that target the gingival epithelium, as well as a stable platform for testing oral hygiene products and as potential material for preprosthetic surgery.

Percutaneous liver biopsy complicated by hemobilia-associated acute cholecystitis

Liver biopsy is generally considered a safe and highly useful procedure. It is frequently performed in an outpatient setting for diagnosis and follow-up in numerous liver disorders. Since its introduction at the end of the 19^th century, broad experience, new imaging techniques and special needles have significantly reduced the rate of complications associated with liver biopsy. Known complications of percutaneous biopsy of the liver include hemoperitoneum, subcapsular hematoma, hypotension, pneumothorax and sepsis. Other intra-abdominal complications are less common. Hemobilia due to arterio-biliary duct fistula has been described, which has only rarely been clinically expressed as cholecystitis or pancreatitis. We report a case of a fifteen year-old boy who developed severe acute cholecystitis twelve days after a percutaneous liver biopsy performed in an outpatient setting. The etiology was clearly demonstrated to be hemobilia-associated, and the clinical course required the performance of a laparoscopic cholecystectomy. The post operative course was uneventful and the patient was discharged home. Percutaneous liver biopsy is a safe and commonly performed procedure. However, severe complications can occasionally occur. Both medical and surgical options should be evaluated while dealing with these rare incidents.