Perspectives on Cybersecurity and Plastic Surgery: A Survey of Plastic Surgeons and Scoping Review of the Literature

BACKGROUND

Data breach costs in the United States are among the highest in the world, making robust cybersecurity an important bulwark of national defense. Healthcare is a popular target for cyber threats, and there is increasing emphasis on cybersecurity safeguards to protect sensitive patient data.

OBJECTIVES

The objective of this national survey and scoping review is to (1) identify cybersecurity awareness, preparedness, and practices among plastic surgeons, and (2) to provide guidelines to mitigate the threat of cyberattacks.

METHODS

A 16-question, anonymous online survey was developed and distributed to The Aesthetic Society registrants to ascertain plastic surgeons' cybersecurity practices. Utilizing PubMed, CINAHL, and Embase databases, eligible articles were identified as part of this scoping review.

RESULTS

Of 89 individuals who began the survey, 69 completed it (77.5%). Sixty respondents agreed or strongly agreed that cybersecurity is an important issue in plastic surgery. The greatest perceived limitations for protection against cyberattacks were insufficient expertise (41.7%), followed by lack of funding and insufficient time to dedicate to this goal. Most respondents (78.7%) had cybersecurity policies incorporated into their practice. Those who agreed or strongly agreed they had technology to prevent data theft/breach were significantly more likely to be older than 54 years of age (P < .001). No articles identified in the literature specifically addressed cybersecurity in plastic surgery; however, 12 articles detailing cybersecurity in healthcare were identified and included.

CONCLUSIONS

Despite possessing adequate technology and procedures in place to prevent cyberattacks, plastic surgeons perceive significant barriers to cybersecurity protection, including insufficient expertise and lack of dedicated funding. It is imperative that our field establishes standards and protocols to protect our patients.

Meta-Analysis and Meta-Regression of Complications and Failures of Autologous Heterotopic Cranial Bone versus Alloplastic Cranioplasties

BACKGROUND

Fresh autologous cranial bone graft has been traditionally regarded as the ideal cranioplasty material, however long-term comparisons of outcomes with modern alloplastic materials are absent in the literature. In this work, we evaluated complications and failures among cranioplasties performed with fresh, heterotopic, cranial bone graft versus three common alloplastic materials.

METHODS

Random-effects meta-analyses of logit-transformed proportions were performed on studies published between 1971-2021 to evaluate complications and failures of cranioplasties performed with fresh, autologous, heterotopic cranial bone, polyetheretherketone (PEEK), polymethylmethacrylate (PMMA), or titanium with a mean follow-up ≥12 months. Generalized mixed model meta-regressions were performed to account for heterogeneity and to evaluate the contributions of moderators to outcomes variables.

RESULTS

1490 patients (mean age 33.9±10.8 years) were included. Pooled, all-cause complications were 6.2% for fresh, heterotopic, autologous cranial bone (95% confidence interval [CI]:2.1-17.0%; I2=55.0%, p=0.02), 18.5% for PEEK (95%CI:14.0-24.0%; I2=0.0%, p=0.58), 26.1% for titanium (95%CI:18.7-35.1%; I2=60.6%, p<0.01), and 28.4% for PMMA (95%CI:12.9-51.5%; I2=88.5%, p<0.01). Pooled all-cause failures were 2.2% for fresh, autologous cranial bone (95%CI:0.4-10.6%; I2=0.0%, p=0.45), 6.3% for PEEK (95%CI:3.2-12.3%; I2=15.5%, p=0.31), 11.4% for titanium (95%CI:6.7-18.8%; I2=60.8%, p<0.01), and 12.7% for PMMA (95%CI:6.9-22.0%; I2=64.8%, p<0.01). Meta-regression models indicated that each alloplastic subtype significantly and independently predicted higher complications, while titanium and PMMA were significant predictors for all-cause failures compared to autologous bone. All three subtypes were predictive of higher cranioplasty failures secondary to infection compared to autologous bone.

CONCLUSIONS

Cranioplasties performed with fresh, autologous heterotopic cranial bone grafts resulted in lower complications and failures compared to alloplastic materials.

Effective Local Anesthetic Use in Nasal Surgery: A Systematic Review and Meta-analysis of Randomized Controlled Studies

Intraoperative nerve blocks have shown promise in managing pain after nasal surgery. The purpose of this systematic review and meta-analysis was to analyze existing level I and II evidence on intraoperative nerve blocks in nasal surgery to optimize postoperative recovery.

Methods

The primary outcome of this systematic review and meta-analysis was postoperative pain scores; secondary outcomes included perioperative opioid requirements, patient satisfaction scores, and time to first analgesic requirement. PubMed, Embase, and MEDLINE databases were searched, and two independent reviewers conducted article screening. Methodological quality assessment of studies utilized the Jadad instrument, and interrater reliability was assessed using Cohen kappa. An inverse-variance, fixed-effects model was used for meta-analysis with Cohen d used to normalize effect size between studies. I2 and Q statistics were used to assess interstudy variability.

Results

Four studies were included for meta-analysis, totaling 265 randomized patients. The nerve blocks assessed included infraorbital nerve, sphenopalatine ganglion, external nasal nerve, central facial nerve blocks, and total nerve blocks. All demonstrated significantly reduced postoperative pain compared with controls, with a large effect size (P < 0.001). Opioid requirements were lower in the nerve block groups (P < 0.001), and patient satisfaction scores were higher (P < 0.001). Supplemental meta-analyses showed a longer time to first analgesic requirement for patients who received a nerve block (P < 0.001).

Conclusions

These findings support the efficacy of nerve blocks in providing postoperative pain relief and enhancing patient satisfaction with pain management. Perioperative nerve blocks, in combination with general anesthesia, should be considered for postoperative pain control.

A Three-Dimensional-Based Morphometric Analysis of a Standardized Overcorrection Technique for Fronto-Orbital Advancement in Metopic Craniosynostosis

INTRODUCTION

The concept of "overcorrection" for trigonocephaly has been reported to achieve both anterior cranial fossa expansion and normalization of craniofacial form. The purpose of this study is to describe in detail a standardized technique to fronto-orbital advancement utilizing the concept of "overcorrection" and objectively evaluate intermediate results.

METHODS

This retrospective study included patients with isolated metopic synostosis who underwent surgery via the proposed surgical technique and age and sex-matched unaffected controls. Craniofacial morphometric analysis was performed on pre-, immediate post-, and intermediate postoperative (>2 years) three-dimensional (3D)-rendered computed tomographic (CT) scans and photographs. Key CT-based measurements included interzygomaticofrontal suture distance (IZFS), endocranial bifrontal angle (ECA), and temporal expansion. 3D photogrammetry was performed using established measurements and associated Z-scores converted. A Paired t-test and analysis of variance were performed when appropriate.

RESULTS

Forty-one patients were included. A comparison of pre- and immediate postoperative CT scans demonstrated statistically significant increases in all measurements. Subset analysis of 12 patients with intermediate follow-up (age: 39.6 ± 3.6 months) demonstrated significant differences from preoperative values except for IZFS, which decreased from immediate postoperative values and was smaller than age- and sex-matched controls. 3D photogrammetry demonstrated a mean Z-score above the norm for frontal breath. 3D photogrammetry is also positively correlated with CT-based measurements.

CONCLUSIONS

This standardized "overcorrection" approach for trigonocephaly can provide the appropriate changes to maintain a normal ECA despite a reduction in bifrontal width over time. 3D photogrammetry positively correlated with CT-based measurements and may provide useful information when following patients clinically. Long-term follow-up assessment to determine the necessary degree of overcorrection at skeletal mature is needed.

Mandibular Measurements at the 20-Week Anatomy Ultrasound as a Prenatal Diagnostic Predictor of Pierre Robin Sequence

BACKGROUND

Pierre Robin Sequence (PRS) is characterized by micrognathia, glossoptosis, and upper airway obstruction. Early recognition and appropriate perinatal management is crucial for optimizing outcomes. This study aimed to evaluate 20-week fetal ultrasounds to determine if specific mandibular measurements could predict PRS diagnosis and disease severity.

METHODS

A retrospective case-control study of 48 patients with PRS and gender-matched controls was performed. Medical records were reviewed for respiratory and surgical interventions. Three parameters to assess micrognathia were measured on mid-sagittal profile ultrasound images: frontal nasal-mental angle (FNMA), facial-maxillary angle (FMA), and alveolar overjet. Student's t-test and univariate logistic regression was performed. P ≤ 0.05 was considered statistically significant.

RESULTS

Patients with PRS demonstrated a significantly smaller mean FNMA compared to the control group, 129.3 ± 8.6° and 137.4 ± 3.2°, respectively (p < 0.0001), as well as significantly smaller mean FMA, 63.2 ± 9.2° and 74.8 ± 6.1°, respectively (p < 0.0001). The PRS group also demonstrated significantly larger mean alveolar overjet compared to the control group, 3.9 ± 1.4 mm and 2.1 ± 0.9 mm, respectively (p < 0.0001). The odds of respiratory intervention increased among cases when FMA was <68°. Additionally, there was a significant difference in median overjet between patients with PRS who did and did not require respiratory intervention.

CONCLUSIONS

Mandibular features on the 20-week ultrasound can be measured to predict diagnosis and severity of PRS. This is an important first step to prepare for potential respiratory intervention at delivery to minimize perinatal hypoxia. Alveolar overjet, previously not described in prenatal ultrasound literature, is measurable and has utility in prenatal screening for PRS, as do FMA and FNMA.

The Clinical Significance of Clinocephaly in Late-Presentation Sagittal Craniosynostosis

The diagnosis of late-presentation sagittal suture craniosynostosis (SCS) can be challenging, especially in the setting of subtle physical exam findings. The clinical significance of clinocephaly-a retro-coronal concavity along the midvault-in this context remains unknown. The aim of this study is to evaluate the predictive value of clinocephaly in identifying late-presentation SCS.

A retrospective chart review of all patients >1 year old presenting to the craniofacial clinic with a concern for SCS was performed. The presence or absence of SCS in the setting of clinocephaly was recorded following diagnostic imaging. Student's t test, Chi Square test, and multivariate logistic regression analysis were performed to determine predictors for SCS.

75 patients met inclusion criteria. 32 patients (42.7%, 6% female) were diagnosed with SCS. No difference in age between patients with and without SCS was detected. Stratification of patients by age (1-2, 2-4, and >4 years) revealed a higher rate of SCS in younger patients (P = 0.04). The cephalic index (C.I.) of those with sagittal synostosis was significantly smaller but within the normal range, indicating a more scaphocephalic shape (P = 0.003). Logistic regression analysis revealed that C.I. was a strong predictor for SCS (P = 0.003). Of those with SCS, a mix of complete and partial fusion of the sagittal suture was appreciated.

This study found that 42.7% of patients with clinocephaly had SCS. C.I. was the only predictor for SCS and unique suture fusion patterns were identified in those with SCS. This study suggests that clinocephaly should be considered a core component of the exam and work-up for SCS. Future studies aimed at evaluating the positive predictive value of this exam finding and identifying risk factors associated with late-presentation SCS are underway.

3D Photography to Quantify the Severity of Metopic Craniosynostosis

This study aims to determine the utility of 3D photography for evaluating the severity of metopic craniosynostosis (MCS) using a validated, supervised machine learning (ML) algorithm.

This single-center retrospective cohort study included patients who were evaluated at our tertiary care center for MCS from 2016 to 2020 and underwent both head CT and 3D photography within a 2-month period.

The analysis method builds on our previously established ML algorithm for evaluating MCS severity using skull shape from CT scans. In this study, we regress the model to analyze 3D photographs and correlate the severity scores from both imaging modalities.

14 patients met inclusion criteria, 64.3% male (n = 9). The mean age in years at 3D photography and CT imaging was 0.97 and 0.94, respectively. Ten patient images were obtained preoperatively, and 4 patients did not require surgery. The severity prediction of the ML algorithm correlates closely when comparing the 3D photographs to CT bone data (Spearman correlation coefficient [SCC] r = 0.75; Pearson correlation coefficient [PCC] r = 0.82).

The results of this study show that 3D photography is a valid alternative to CT for evaluation of head shape in MCS. Its use will provide an objective, quantifiable means of assessing outcomes in a rigorous manner while decreasing radiation exposure in this patient population.

Tissue Augmenting Palatoplasty for the Treatment of Velopharyngeal Insufficiency

PURPOSE

Persistent velopharyngeal insufficiency (VPI) following primary palatoplasty remains a difficult problem to treat. This study evaluates speech outcomes following revision palatoplasty with tissue augmentation using buccal myomucosal flaps (BMF) as an alternative to pharyngoplasty for patients with VPI.

METHODS

A retrospective single-center review of revision palatoplasty with tissue augmentation at a tertiary pediatric hospital Cleft-Craniofacial Center between January 2017 and March 2021 was conducted. Patients with a history of previous palatoplasty, a diagnosis of persistent or recurrent VPI, and comprehensive pre- and postoperative speech evaluations who underwent revision palatoplasty with BMF were included.

RESULTS

Twenty patients met inclusion criteria (35% female, 20% syndromic). Mean age at the time of revision palatoplasty with BMF was 9.7 years. Preoperatively, all patients had stigmatizing speech and received the recommendation for speech surgery; the mean Pittsburgh Weighted Speech Score (PWSS) was 14.3 ± 4.9. The mean postoperative PWSS at the most recent assessment was 4.2 ± 2.3, representing a statistically significant improvement from preoperative scores (P < .001). Mean follow-up time was 8.9 months. Following revision palatoplasty with BMF, only one patient has received the recommendation for further speech surgery. No complications were noted.

CONCLUSION

In patients with VPI following primary palatoplasty, revision palatoplasty with tissue augmentation offers an alternative to pharyngoplasty. This approach preserves dynamic velopharyngeal function, improves speech outcomes, and should be considered an option when treating patients with post-primary palatoplasty VPI.

The Effect of Functional Nasal Surgery on Olfactory Function

BACKGROUND

Functional and aesthetic nasal operations are some of the most common plastic surgery procedures performed in the United States. The purpose of the study was to evaluate the effects of septoplasty, septorhinoplasty, and rhinoplasty procedures on postoperative olfactory function and their relationship to nasal airflow and quality of life.

METHODS

A systematic review and meta-analysis was performed evaluating olfactory function following nasal surgery. Preoperative and postoperative values for olfaction, nasal airflow, and quality of life/nasal symptoms were analyzed. The effect size was calculated from each study and used for meta-analysis. As studies evaluated patients at different points in the postoperative period, the latest time point reported by each study was used in the meta-analysis. The 95 percent confidence interval of the effect size was calculated for each study. Study quality was assessed using the Jadad and Methodological Index for Nonrandomized Studies instruments. All included studies were Level of Evidence II.

RESULTS

There were 25 included studies. Following nasal surgery, patients experienced significant improvements in olfaction (p < 0.001), nasal airflow (p < 0.001), and quality of life/nasal symptoms (p < 0.001). Patients often experienced a transient decrease in olfaction immediately after surgery, followed by improvement postoperatively. Preoperative olfactory dysfunction rates were low and postoperative dysfunction was equally low. Olfaction improvement was directly correlated with improvement in nasal airflow and quality of life.

CONCLUSIONS

Functional and aesthetic nasal operations appear to significantly improve olfaction, which is directly correlated with nasal airflow. Some studies report a transient worsening of these measures in the immediate postoperative period, which subsequently improved at later time points.

The Impact of the COVID-19 Pandemic on Cleft Care

Background

The COVID-19 pandemic had multiple effects on the provision of health care, including the suspension of elective and nonessential surgeries. The objective of this study was to determine the early effect of the COVID-19 pandemic on the surgical care of patients with cleft lip and/or palate at a high-volume cleft center.

Methods

A retrospective comparative cohort study of patients with cleft lip and/or palate undergoing lip adhesion, cleft lip and nose repair, and palatoplasty before and during the pandemic was conducted. There were 50 patients in the prepandemic cohort and 53 in the pandemic cohort.

Results

Mean age at lip adhesion was 3.1 ± 1.1 months prepandemic (n = 8) and 3.5 ± 2.5 months in the pandemic cohort (n = 8) (P = 0.75). One lip adhesion was delayed by 1.6 months. Mean age at cleft lip and nose repair was 6.6 ± 1.9 months prepandemic (n = 23) and 8.0 ± 2.1 months in the pandemic cohort (n = 23) (P = 0.03). Six pandemic cleft lip and nose repairs were delayed; the mean delay was 2.6 ± 1.8 months. The mean age at palatoplasty was 13.9 ± 2.2 months prepandemic (n = 26) and 14.1 ± 2.9 months in the pandemic cohort (n = 26) (P = 0.79). Seven pandemic palatoplasties were delayed; the mean delay was 3.3 ± 1.4 months.

Conclusions

The COVID-19 pandemic caused delays at each stage of repair for cleft lip and/or palate-related procedures; however, only cleft lip and nose repair were significantly affected. This study emphasizes the importance of remaining vigilant regarding the care of this vulnerable population during this challenging time.

Oral Flora and Perioperative Antimicrobial Interventions in Cleft Palate Surgery: A Review of the Literature

BACKGROUND

The role of perioperative antibiotics in cleft palate remains a topic of debate. Advocates stress their importance in preventing local and systemic infections and decreasing the incidence of oronasal fistula formation. However, few studies to date have directly evaluated the role of antibiotics and other antimicrobial measures in cleft palate surgery.

OBJECTIVE

The aim of this review is to evaluate the evidence surrounding the use of perioperative antibiotics and other antimicrobial interventions in cleft palate surgery. Additionally, we review the literature on the oral flora unique to the cleft palate patient population.

METHODS

This was accomplished utilizing PubMed, Medline, and the Cochrane Library with MeSH and generic terms. Articles were selected based on predefined inclusion and exclusion criteria.

RESULTS

This review highlights the lack of higher level evidence on perioperative antibiotic use and other antimicrobial interventions in cleft palatoplasty and calls for further research on the matter.

CONCLUSIONS

The literature appears to support the use of preoperative antibiotics for cleft palatoplasty, but the benefits of prolonged postoperative antibiotic use remain questionable.

Tumor suppressor protein p53 negatively regulates ischemia-induced angiogenesis and arteriogenesis

OBJECTIVE

The tumor suppressor protein p53 regulates angiogenesis and is a key regulatory mediator of cellular apoptosis, proliferation, and growth. p53 expression is induced in response to ischemia; however, its role in regulating ischemia-induced angiogenesis and arteriogenesis remains undefined. The objective of this study was to define the role of p53 in regulating ischemia-induced angiogenesis and arteriogenesis and to identify mechanisms by which this regulation occurs in vivo.

METHODS

Surgically induced hindlimb ischemia or mesenteric artery ligation was performed in wild-type (p53+/+) and p53 knockout (p53-/-) mice. Limb perfusion and revascularization were assessed by laser Doppler perfusion imaging, capillary density, and collateral artery development. Mesenteric collateral artery flow and development were determined by arterial flow measurement and by histologic analysis, respectively. An in vitro aortic ring assay was performed on p53+/+ and p53-/- aortic tissue to evaluate endothelial function. The p53 inhibitor and activator pifithrin-α and quinacrine, respectively, were used to modulate p53 activity in vivo after ischemia.

RESULTS

Absence of p53 in mice resulted in increased limb perfusion (P < .05), capillary density (P < .05), and collateral artery development (P < .05) after induction of hindlimb ischemia. In the nonischemic mesenteric artery ligation model of arteriogenesis, p53 expression was induced in collateral arteries and increased arterial blood flow in mice lacking p53 (P < .05). Lack of p53 decreased apoptosis in ischemic hindlimb tissue (P < .05) and increased proangiogenic factors hypoxia-inducible factor 1α and vascular endothelial growth factor (VEGF). Endothelial cell outgrowth in vitro increased in the absence of p53 (P < .05). Pharmacologic augmentation of p53 expression after ischemia impaired perfusion and collateral artery formation and decreased VEGF levels (P < .05). Conversely, inhibition of p53 with pifithrin-α augmented limb perfusion (P < .05) and collateral artery formation (P < .05) and increased protein levels of hypoxia-inducible factor 1α and VEGF. Pharmacologic augmentation and inhibition of p53 had no significant effect in mice lacking p53.

CONCLUSIONS

p53 negatively regulates ischemia-induced angiogenesis and arteriogenesis. Inhibition of p53 increases ischemia-induced arteriogenesis and limb perfusion and thus represents a potential therapeutic strategy for arterial occlusive disease.

FGFR2c-mediated ERK-MAPK activity regulates coronal suture development

Fibroblast growth factor receptor 2 (FGFR2) signaling is critical for proper craniofacial development. A gain-of-function mutation in the 2c splice variant of the receptor's gene is associated with Crouzon syndrome, which is characterized by craniosynostosis, the premature fusion of one or more of the cranial vault sutures, leading to craniofacial maldevelopment. Insight into the molecular mechanism of craniosynostosis has identified the ERK-MAPK signaling cascade as a critical regulator of suture patency. The aim of this study is to investigate the role of FGFR2c-induced ERK-MAPK activation in the regulation of coronal suture development. Loss-of-function and gain-of-function Fgfr2c mutant mice have overlapping phenotypes, including coronal synostosis and craniofacial dysmorphia. In vivo analysis of coronal sutures in loss-of-function and gain-of-function models demonstrated fundamentally different pathogenesis underlying coronal suture synostosis. Calvarial osteoblasts from gain-of-function mice demonstrated enhanced osteoblastic function and maturation with concomitant increase in ERK-MAPK activation. In vitro inhibition with the ERK protein inhibitor U0126 mitigated ERK protein activation levels with a concomitant reduction in alkaline phosphatase activity. This study identifies FGFR2c-mediated ERK-MAPK signaling as a key mediator of craniofacial growth and coronal suture development. Furthermore, our results solve the apparent paradox between loss-of-function and gain-of-function FGFR2c mutants with respect to coronal suture synostosis.

Component approach to the temporomandibular joint and coronoid process

Reconstruction of the temporomandibular joint (TMJ) region is challenging. The conventional direct preauricular incision permits only limited access to the TMJ and surrounding structures, therefore risking injury to the facial nerve during retraction. The ideal approach allows sufficient exposure, preservation of underlying neurovascular structures, and achieves an optimal aesthetic outcome. We describe a preauricular posttragal incision with a superficial musculoaponeurotic system flap to allow wide exposure of the zygomatic arch, TMJ, condyle, and coronoid process. We postulate that this approach improves access, lessens the amount of retraction required, and creates a more inconspicuous scar.

Craniofacial dermoid cysts: histological analysis and inter-site comparison

INTRODUCTION

Dermoid cysts are common, benign, embryologically derived soft tissue cysts that can arise at a variety of craniofacial sites. It is not known whether specific histological variations exist between the different craniofacial sites. This study aims to establish whether inter-site histologic differences exist between periorbital, nasal, scalp, and postauricular dermoid cysts and analyze these in context of their distinct embryological origin and varied clinical presentation.

METHODS

A retrospective review of craniofacial dermoid cysts was performed. Using light microscopy with hematoxylin and eosin staining, histological appearance was directly compared between craniofacial sites.

RESULTS

All (n = 16) cysts contained keratinizing, stratified squamous epithelial lining, intraluminal keratin, and hair. Sebaceous glands were commonly present (n = 13). Eccrine (sweat) glands were less common (n = 3). Structures of mesodermal origin were seen in three periorbital cysts. Only the six ruptured cysts showed evidence of inflammation.

CONCLUSIONS

Histological properties of dermoid cysts are conserved between craniofacial sites (periorbital, nasal, scalp, and postauricular). This reflects the consistency of ectodermal inclusion during early embryological development, which is independent of specific craniofacial site or surrounding anatomical structures.

Mandibular volumetric increase following distraction osteogenesis

INTRODUCTION

Mandibular distraction osteogenesis (MDO) for the treatment of Pierre Robin sequence (PRS) enables mandibular lengthening and improves airway and feeding function. It remains unknown how the post-distracted mandibular volume compares to a normal control population. The aim of this study was to analyze mandibular volume and symmetry following bilateral MDO and compare post-distraction measurements to a non-distracted, normal age- and sex-matched control cohort.

METHODS

Demographic information and three dimensional-computed tomographic (CT) images were obtained from normal control and distracted PRS patients. Mandibular volume and symmetry indices were calculated and results statistically analyzed. P values ≤0.05 were considered statistically significant.

RESULTS

24 CT scans and 48 hemimandibles were analyzed (8 control patients: mean age = 5.6 months, 3 females; 8 distracted patients: mean age pre-distraction = 1.8 months, mean age post-distraction = 5.3 months, 3 females). No complications were encountered in the distracted group. The mean pre- and post-distraction volume in the MDO group measured 7238.1 mm(3) and 15,360.6 mm(3), respectively (P = 0.0003) and the mean percent increase in mandibular volume following distraction was 113.3%. The mean symmetry index increased after distraction from 0.91 to 0.95 (P = 0.31). Matched normal control mandibles measured 13,488.6 mm(3) versus post-distraction mandibles at 15,360.6 mm(3) (P = 0.40). Normal control and post-distraction symmetry indices were 0.99 and 0.95, respectively (P = 0.68).

CONCLUSION

Distraction resulted in a significantly increased mandibular volume and an observed preservation in mandibular symmetry. Post-distraction volume was increased compared to normal controls but remained less symmetrical.

PDE-5 inhibition improves skin flap viability in rats that are exposed to nicotine

INTRODUCTION

Nicotine causes ischemia and necrosis of skin flaps. Phosphodiesterase-5 (PDE-5) inhibition enhances blood flow and vasculogenesis. This study examines skin flap survival in rats exposed to nicotine that are treated with and without PDE-5 inhibition.

MATERIALS AND METHODS

Eighty six rats were divided into five groups. Group 1 received saline subcutaneous (SC) once per day. Group 2 received nicotine SC 2 mg/kg day. Group 3 received sildenafil intraperitoneal (IP) 10 mg/kg day. Group 4 received nicotine SC 2 mg/kg and sildenafil IP 10 mg/kg day. Group 5 received nicotine SC 2 mg/kg day and sildenafil IP 10 mg/kg two times daily. After 28 days of treatment, modified McFarlane flaps were created, silicone sheets were interposed, and flaps were sutured. Photographs were taken on postoperative days 1, 3, and 7 and fluorescence angiography was used on day 7, both to evaluate for skin flap necrosis. Rats were euthanized and flaps were harvested for Vascular Endothelial Growth Factor (VEGF) Western blot analysis. Images were analyzed by three blinded observers using ImageJ, and necrotic indices were calculated.

RESULTS

The nicotine and PDE-5 inhibition twice-daily group showed a 46% reduction in flap necrosis when compared to saline only (P < 0.05) and a 54% reduction when compared to nicotine only (P < 0.01). Fluorescence angiographic image analysis revealed reductions in flap necrosis (P < 0.01). VEGF analysis trended toward increased VEGF for all sildenafil-treated groups (P > 0.05).

CONCLUSIONS

PDE-5 inhibition exhibits a dose-dependent reduction in skin flap necrosis in rats exposed to nicotine. This suggests that PDE-5 inhibition may mitigate the ill effects of smoking on skin flaps.

Use of the ostomy baseplate in negative pressure wound therapy

The advent of the negative pressure wound therapy (NPWT) has been a significant advancement in wound-healing practices. However, as the therapy has gained popularity and increased usage in all areas of the body, obstacles have arisen. In certain areas of the body, namely those with crevices and folds, or an abundance of apocrine glands, the application of NPWT can be problematic. This study presents a novel technique for the application of the NPWT in the treatment of wounds in areas difficult to achieve an appropriate vacuum seal. This method eliminates the traditional problems encountered when applying the NPWT to areas with clefts and folds by utilising an ostomy baseplate to provide a more secure and accessible surface area. The patient is an 84-year-old male with a category IV sacral decubitus ulcer. Traditional methods of NPWT application initially proved inadequate due to difficulty sustaining negative pressure; however, subsequent use of an ostomy baseplate with NPWT successfully secured a seal and allowed for wound healing. Our technique allows for the preservation of a proper seal near clefted areas, provides ease of application, reduces the burden of dressing changes and reduces cost, benefiting both the patient and health care providers.

Bridge of bone canthopexy: technique and morphologic assessment

INTRODUCTION

Malposition of the lower eyelid may disrupt facial aesthetics and impair proper eyelid function. Multiple techniques have been proposed to restore lower eyelid position. The purpose of this study is to report on a modified bridge of bone canthopexy technique and assess its effect on lower eyelid and palpebral fissure restoration.

METHODS

A retrospective chart review was conducted. Pre- and post-operative photographs of patients were evaluated by a blinded observer. Pair-wise and chi-square tests were conducted with an observed p-value of 0.05 or less considered statistically significant.

RESULTS

12 patients (7 females) with a mean age of 42 (range = 7-87) were included. Canthal tilt and scleral show decreased significantly following surgery (p = 0.05), and the eye fissure index and inferior coverage of the iris approached significance (p = 0.16 and p = 0.07, respectively). Two minor complications were encountered in our series.

CONCLUSION

The modified bridge of bone canthopexy is a safe and effective technique for alteration of the lower eyelid and is broadly applicable to all causes of negative canthal angulation. Further studies are necessary to test the longevity and stability of this procedure.

Computer-enhanced digital angiography: correlation of clinical assessment of left ventricular ejection fraction and regional wall motion

We compared computer-enhanced digital angiography (CEDA) following pulmonary injection of 20 ml Renografin-76 (5 ml/sec) to conventional directly injected left ventriculography (LV) in 13 patients undergoing routine diagnostic catheterization. Left ventricular ejection fraction (LVEF) was determined by planimetry from end-diastolic and end-systolic images by two independent angiographers. The correlation coefficient for LVEF (CEDA vs. LV) was r = 0.75 (p less than 0.005) for observer 1 and r = 0.85 (p less than 0.0005) for observer 2. The interobserver variability for LVEF was very low, resulting in a high correlation coefficient (r = 0.91, p less than 0.0005). Three angiographers independently reviewed both the conventional and CEDA images in a random order for assessment of anterior, apical, and inferior regional wall motion, using a 6-point subjective grading system (198 determinations). The interobserver correlation for subjective assessment of regional wall motion by both LV and CEDA was poor (49% for LV and 59% for CEDA, p = NS). These poor correlations were not improved by excluding any region or angiographer from the analysis. The agreement of regional motion assessments between the two techniques was only 40%. To improve reproducibility of wall motion interpretation, an automated analysis program was developed. First the range of normal contraction was defined from pooled literature data. The movement of any segment of the left ventricular wall could then be determined in millimeters and referenced to the normal range. This method eliminated interobserver variability. In the absence of an acceptable standard of segmental wall motion to which this measurement can be compared, the accuracy of this objective format could not be determined. We conclude that CEDA images allow accurate determination of ejection fraction and that the large interobserver variability of subjective regional wall motion analysis can be overcome by employing more objective formats.