Isotretinoin Use in Transmasculine Patients and Its Implication on Chest Masculinization Surgery: Scoping Review of the Literature

BACKGROUND

Acne often worsens in transmasculine patients who are on prolonged testosterone therapy. Isotretinoin is an oral retinoid used in the treatment of severe or refractory cases of acne, but it has the potential to cause delayed wound healing. Transmasculine patients may potentially be prescribed treatment for acne with isotretinoin while also planning to undergo chest masculinization surgery.

OBJECTIVE

This scoping review aims to determine whether isotretinoin has a negative impact on postoperative healing in transmasculine patients undergoing chest masculinization surgery.

METHODS

A scoping review was performed using the PubMed and Ovid databases. A total of 16 publications were selected for inclusion.

RESULTS

Acne tends to peak in transmasculine patients 6 months after initiation of testosterone treatment. Severe cases can be treated with isotretinoin; however, acne may recur once treatment is discontinued, given ongoing hormone therapy. There is little to no evidence in the medical literature regarding perioperative use of isotretinoin specifically among transmasculine patients undergoing chest masculinization surgery. In general, however, recent studies have found no evidence of increased hypertrophic scars or keloids in patients taking isotretinoin.

CONCLUSIONS

Further studies are required to strengthen the current evidence that suggests that isotretinoin does not need to be discontinued before or after incisional or excisional surgeries, including chest masculinization surgery in transmasculine patients.

Autologous Heterogeneous Skin Construct Closes Traumatic Lower Extremity Wounds in Pediatric Patients: A Retrospective Case Series

Lower extremity traumatic wounds pose unique challenges in pediatric patients, including vessel caliber, compliance with postoperative instructions, parental concerns about multiple operations, and long-term function. An autologous heterogeneous skin construct (AHSC) has demonstrated the ability to cover avascular structures and regenerate full-thickness functional skin. The objective of this study is to report our experience using AHSC in a cohort of pediatric trauma patients. This study is a noncontrolled, retrospective cohort analysis of all pediatric patients (<19 years of age) treated with AHSC for lower extremity traumatic wounds with at least one exposed deep structure (tendon, bone, and/or joint) at a single institution between May 1, 2018, and April 1, 2019. Seven patients with 10 traumatic wounds met inclusion criteria. The median follow-up time was 11.8 months. Five patients were male (71%); the median age was 7 years (range = 2-15 years). Average wound size was 105 cm². All wounds achieved coverage of exposed structures and epithelial closure in a median of 13 and 69 days, respectively. There were no donor site complications and no reoperations required. All patients returned to normal activity, ambulate without limp, can wear shoes normally, and have normal tendon gliding. AHSC covered exposed structures and achieved closure within a single application in complex traumatic lower extremity wounds in a pediatric cohort.

The Impact of Exogenous Testosterone on Breast Cancer Risk in Transmasculine Individuals

BACKGROUND

Exogenous testosterone is vital to gender-affirming therapy for transmasculine individuals. Testosterone may be implicated in breast cancer (BCa) because it can activate androgen and estrogen receptors. To further explore this risk, we performed a systematic review to investigate the impact of exogenous testosterone on BCa risk in transmasculine individuals.

METHODS

We searched PubMed/MEDLINE and Ovid/Embase for clinical and preclinical studies assessing BCa and testosterone therapy and screened 6125 articles independently. We ascertained level of evidence using a modified tool from Cook et al (Chest. 1992;102:305S-311S) and risk of bias using a modified Joanna Briggs Institute's Critical Appraisal Tool.

RESULTS

Seventy-six studies were included. Epidemiological data suggested that BCa incidence was higher in transmasculine individuals compared with cisgender men but lower compared with cisgender women. Histological studies of transmasculine breast tissue samples also demonstrated a low incidence of precancerous lesions. Interestingly, cases demonstrated that BCa occurred at a younger average age in transmasculine individuals and was predominantly hormone receptor positive. The mechanism for BCa in transmasculine individuals may be related to androgen receptor stimulation or conversion to estradiol. Serum studies reported varied estradiol levels associated with exogenous testosterone. Animal and in vitro studies demonstrated that testosterone was growth inhibitory but may induce proliferation at higher doses or with low estradiol levels.

CONCLUSIONS

Plastic surgeons play a critical role in providing gender-affirming care for transmasculine patients. The limited studies available suggest that this patient population has decreased risk for BCa when compared with cisgender women; however, any BCa that does occur may have different clinical presentations and underlying mechanisms compared with cisgender women and men. Overall, the limitations for clinical studies and discrepancies among preclinical studies warrant further investigation.

Large Animal Models of Vascularized Composite Allotransplantation: A Review of Immune Strategies to Improve Allograft Outcomes

Over the past twenty years, significant technical strides have been made in the area of vascularized composite tissue allotransplantation (VCA). As in solid organ transplantation, the allogeneic immune response remains a significant barrier to long-term VCA survival and function. Strategies to overcome acute and chronic rejection, minimize immunosuppression and prolong VCA survival have important clinical implications. Historically, large animals have provided a valuable model for testing the clinical translatability of immune modulating approaches in transplantation, including tolerance induction, co-stimulation blockade, cellular therapies, and ex vivo perfusion. Recently, significant advancements have been made in these arenas utilizing large animal VCA models. In this comprehensive review, we highlight recent immune strategies undertaken to improve VCA outcomes with a focus on relevant preclinical large animal models.

Regeneration and expansion of autologous full-thickness skin through a self-propagating autologous skin graft technology

New autologous skin regeneration technology yielded full-thickness skin as evidenced by clinical observation and skin biopsy 5 months after surgery, providing relief for debilitating split-thickness skin graft contracture in a pediatric burn case.

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.

Does Fracture Pattern Influence Functional Outcomes in the Management of Bilateral Mandibular Condylar Injuries?

The purpose of this study was to compare the functional outcomes of different types of bilateral mandibular condylar fractures. This was a retrospective study of patients with bilateral mandibular condylar fractures at a level-1 trauma center over a 15-year period. The primary predictor variable was fracture pattern, classified as type I (bilateral condylar), type II (condylar-subcondylar), or type III (bilateral subcondylar). Secondary predictor variables were demographic, injury-related, and treatment factors. Bivariate associations between the predictors and complication rates were computed; a multiple logistic regression model was utilized to adjust for confounders and effect modifiers. Thirty-eight subjects with bilateral condylar injuries met the inclusion criteria. The sample's mean age was 37.6 + 18.2 years, and 16% were female. The most common mechanisms of injury were motor vehicle collisions (53%) and falls (29%). Seventy-four percent had associated noncondylar mandibular fractures, and 32% of cases had concomitant midface fractures. Fifty-three percent of cases were classified as type I, 21% as type II, and 26% as type III. Ten subjects (26%) were managed with open reduction and internal fixation. The average length of follow-up was 4.5 + 6.3 months. After adjusting for confounders and effect modifiers, the type of fracture was a significant predictor of functional complications with type II injuries having the highest likelihood of a poor functional outcome (odds ratio: 7.77, 95% confidence interval: 1.45-41.53, p  = 0.02). Asymmetric bilateral mandibular condylar fractures may be associated with an increased risk of poor functional outcomes.

Facial Fracture Patterns Associated with Traumatic Optic Neuropathy

Traumatic optic neuropathy (TON) is rare. The heterogeneity of injury patterns and patient condition on presentation makes diagnosis difficult. Fracture patterns associated with TON have never been evaluated. Retrospective review of 42 patients diagnosed with TON at the R. Adams Cowley Shock Trauma Center from May 1998 to August 2010 was performed. Thirty-three patients met criteria for study inclusion of fracture patterns. Additional variables measured included patient demographics and mechanism. Cluster analysis was used to form homogenous groups of patients based on different fracture patterns. Fracture frequency was analyzed by group and study population. Visual depiction of fracture patterns was created for each group. Cluster analysis of fracture patterns yielded five common "groups" or fracture patterns among the study population. Group 1 ( n  = 3, 9%) revealed contralateral lateral orbital wall (100%), zygoma (67%), and nasal bone (67%) fractures. Group 2 ( n  = 7, 21%) demonstrated fractures of the frontal bone (86%), nasal bones (71%), and ipsilateral orbital roof (57%). Group 3 ( n  = 14, 43%) involved fractures of the ipsilateral zygoma (100%), lateral orbital wall (29%), as well as frontal and nasal bones (21% each). Group 4 ( n  = 5, 15%) consisted of mid- and upper-face fractures; 100% fractured the ipsilateral orbital floor, medial and lateral walls, maxilla, and zygoma; 80% fractured the orbital roof and bilateral zygoma. Group 5 ( n  = 4, 12%) was characterized by fractures of the ipsilateral orbital floor, medial and lateral orbital walls (75% each), and orbital roof (50%). A notably high 15 of 33 patients (45%) sustained penetrating trauma. Our study demonstrates five fracture pattern groups associated with TON. Zygomatic, frontal, nasal, and orbital fractures were the most common. Fractures with a combination of frontal, nasal, and orbital fractures are particularly concerning and warrant close attention to the eye.

Subcranial and orthognathic surgery for obstructive sleep apnea in achondroplasia

PURPOSE

Obstructive sleep apnea (OSA) is a common problem in patients with achondroplasia. The purpose of this study was to assess changes in airway volumes following various degrees of facial skeletal advancement.

METHODS

This was a retrospective evaluation of patients with achondroplasia who underwent facial skeletal advancement for obstructive sleep apnea. Patients were treated with either an isolated Le Fort III distraction (LF3) or Le Fort II distraction with or without subsequent Le Fort I and bilateral sagittal split osteotomies (LF2 ± LF1/BSSO). Demographic, cephalometric, volumetric, and polysomnographic variables were recorded pre- and postoperatively.

RESULTS

Six patients with achondroplasia underwent midface advancement for treatment of OSA (2 LF2 + LF1/BSSO, 2 LF2, 2 LF3). Patients undergoing LF2 + LF1/BSSO had consistent volumetric improvements at the nasopharyngeal and oropharyngeal levels (Δ ≥ +347% and ≥+253%, respectively). Patients undergoing LF2 alone had consistent improvement in the nasopharyngeal airway alone (Δ ≥ +214%). Patients undergoing LF3 alone had consistent, but less dramatic, changes in nasopharyngeal volume (Δ ≥ +97.1%). All patients undergoing LF2 distraction (with or without LF1/BSSO) had a ≥50% reduction in the apnea-hypopnea index (AHI) postoperatively; there was no improvement in AHI with LF3 alone.

CONCLUSION

In patients with achondroplasia-associated OSA there are variable improvements in airway volume. This preliminary report suggests that LF2 distraction, with or without subsequent LF1/BSSO, may provide consistent reductions in AHI relative to LF3 distraction.

Nasal Unit Transplantation: A Cadaveric Anatomical Feasibility Study

Background The science and technical acumen in the field of vascularized composite allotransplantation has progressed rapidly over the past 15 years, and transplantation of specialized units of the face, such as the nose, appears possible. No study to date has evaluated the technical feasibility of isolated nasal unit transplantation (NUT). In this study, we explore the anatomy and technical specifics of NUT. Methods In this study, four fresh cadaver heads were studied. Bilateral vascular pedicle dissections were performed in each cadaver. The facial artery was cannulated and injected with food dye under physiologic pressure in two cadavers, and with lead oxide mixture in two cadavers to evaluate perfusion territories supplied by each vascular pedicle. Results The facial artery and vein were found to be adequate pedicles for NUT. Divergent courses of the vein and artery were consistently identified, which made for a bulky pedicle with necessary inclusion of large amounts of subcutaneous tissue. In all cases, the artery remained superficial, while the vein coursed in a deeper plane, and demonstrated consistent anastomoses with the superior transverse orbital arcade. While zinc oxide injection of the facial artery demonstrated filling of the nasal vasculature across the midline, dye perfusion studies suggested that unilateral arterial inflow may be insufficient to perfuse contralateral NUT components. Discrepancies in these two studies underscore the limitations of nondynamic assessment of nutritive perfusion. Conclusion NUT based on the facial artery and facial vein is technically feasible. Angiosome evaluation suggests that bilateral pedicle anastomoses may be required to ensure optimal perfusion.

Timing of cranial vault remodeling in nonsyndromic craniosynostosis: a single-institution 30-year experience

OBJECTIVE Due to the changing properties of the infant skull, there is still no clear consensus on the ideal time to surgically intervene in cases of nonsyndromic craniosynostosis (NSC). This study aims to shed light on how patient age at the time of surgery may affect surgical outcomes and the subsequent need for reoperation. METHODS A retrospective cohort review was conducted for patients with NSC who underwent primary cranial vault remodeling between 1990 and 2013. Patients' demographic and clinical characteristics and surgical interventions were recorded. Postoperative outcomes were assessed by assigning each procedure to a Whitaker category. Multivariate logistic regression analysis was performed to determine the relationship between age at surgery and need for minor (Whitaker I or II) versus major (Whitaker III or IV) reoperation. Odds ratios (ORs) for Whitaker category by age at surgery were assigned. RESULTS A total of 413 unique patients underwent cranial vault remodeling procedures for NSC during the study period. Multivariate logistic regression demonstrated increased odds of requiring major surgical revisions (Whitaker III or IV) in patients younger than 6 months of age (OR 2.49, 95% CI 1.05-5.93), and increased odds of requiring minimal surgical revisions (Whitaker I or II) in patients older than 6 months of age (OR 2.72, 95% CI 1.16-6.41). CONCLUSIONS Timing, as a proxy for the changing properties of the infant skull, is an important factor to consider when planning vault reconstruction in NSC. The data presented in this study demonstrate that patients operated on before 6 months of age had increased odds of requiring major surgical revisions.

Calf Augmentation and Reshaping with Autologous Fat Grafting

BACKGROUND

Despite multiple advantages of fat grafting for calf augmentation and re-shaping over traditional silicone calf implants, few reports have been published.

OBJECTIVES

To report our technique and results with autologous fat grafting for calf augmentation and reshaping.

METHODS

A retrospective review of the senior author's (JEV) experience with autologous fat grafting for calf augmentation was performed. Medial and lateral calf augmentation was accomplished with injection of prepared autologous lipoaspirate intramuscularly and subcutaneously.

RESULTS

Over a 5-year period, 13 patients underwent calf augmentation and reshaping with the described technique. Ten cases were bilateral (77%), and 3 cases (23%) were performed for congenital leg discrepancies. Mean 157 cc of prepared lipoaspirate was transferred per leg, with roughly 60% and 40% transferred into the medial and lateral calf, respectively. Four patients (31%) underwent a second round of autologous fat injection for further calf augmentation because they desired more volume. At mean 19.6 month follow-up, durable augmentation and improvement in calf contour was documented by comparison of standardized preoperative and postoperative photographs.

CONCLUSIONS

Autologous calf fat grafting is a viable alternative to traditional implant-based calf augmentation for congenital calf discrepancies and the aesthetic pseudo-varus deformity. This technique provides results comparable to those obtainable with traditional methods. LEVEL OF EVIDENCE 4: Therapeutic.

Optimizing Reconstruction with Periorbital Transplantation: Clinical Indications and Anatomic Considerations

Complex periorbital subunit reconstruction is challenging because the goals of effective reconstruction vary from one individual to another. The purpose of this article is to explore the indications and anatomic feasibility of periorbital transplantation by reviewing our institutional repository of facial injury.

METHODS

Institutional review board approval was obtained at the R Adams Cowley Shock Trauma Center for a retrospective chart review conducted on patients with periorbital defects. Patient history, facial defects, visual acuity, and periorbital function were critically reviewed to identify indications for periorbital or total face (incorporating the periorbital subunit) vascularized composite allotransplantation. Cadaveric allograft harvest was then designed and performed for specific patient defects to determine anatomic feasibility. Disease conditions not captured by our patient population warranting consideration were reviewed.

RESULTS

A total of 7 facial or periorbital transplant candidates representing 6 different etiologies were selected as suitable indications for periorbital transplantation. Etiologies included trauma, burn, animal attack, and tumor, whereas proposed transplants included isolated periorbital and total face transplants. Allograft recovery was successfully completed in 4 periorbital subunits and 1 full face. Dual vascular supply was achieved in 5 of 6 periorbital subunits (superficial temporal and facial vessels).

CONCLUSIONS

Transplantation of isolated periorbital structures or full face transplantation including periorbital structures is technically feasible. The goal of periorbital transplantation is to re-establish protective mechanisms of the eye, to prevent deterioration of visual acuity, and to optimize aesthetic outcomes. Criteria necessary for candidate selection and allograft design are identified by periorbital defect, periorbital function, ophthalmologic evaluation, and defect etiology.

Abstract presentations by residents at an intramural research day: what factors affect publication?

OBJECTIVE

To assess the rate of conversion of scientific abstracts presented at an intramural resident research day to published articles and identify the factors associated with successful conversion.

DESIGN

Retrospective cohort study.

SETTING

Johns Hopkins Hospital, Department of Plastic Surgery.

PARTICIPANTS

Evaluation of 78 abstracts presented by plastic surgery residents as part of an intramural research day over a 5-year period.

RESULTS

A total of 78 abstracts were presented by residents over the study period. Most abstracts (49, 63%) were presented by senior residents (postgraduate year ≥4). Fifty-six abstracts (72%) were clinical studies. The majority (54, 69%) of primary investigators had an academic rank of associate professor or professor. Fifty abstracts (64%) were subsequently published in a peer-reviewed journal. The mean time to publication was 15.6 ± 13.6 months. In a logistic regression model, abstract conversion was inversely associated with increasing postgraduate year (odds ratio = 0.56, 95% CI: 0.36-0.85, p = 0.007) and directly associated with primary investigator academic rank (odds ratio = 3.3, 95% CI: 1.1-10.5, p = 0.047).

CONCLUSIONS

The conversion rate of abstracts to published articles from an intramural resident research day is >50% and is associated with increased time until graduation and primary investigator academic rank. These results suggest that research exposure early in surgical training and experienced mentorship are key elements to successful education in surgical research.

Antibiotics and facial fractures: evidence-based recommendations compared with experience-based practice

Efficacy of prophylactic antibiotics in craniofacial fracture management is controversial. The purpose of this study was to compare evidence-based literature recommendations regarding antibiotic prophylaxis in facial fracture management with expert-based practice. A systematic review of the literature was performed to identify published studies evaluating pre-, peri-, and postoperative efficacy of antibiotics in facial fracture management by facial third. Study level of evidence was assessed according to the American Society of Plastic Surgery criteria, and graded practice recommendations were made based on these assessments. Expert opinions were garnered during the Advanced Orbital Surgery Symposium in the form of surveys evaluating senior surgeon clinical antibiotic prescribing practices by time point and facial third. A total of 44 studies addressing antibiotic prophylaxis and facial fracture management were identified. Overall, studies were of poor quality, precluding formal quantitative analysis. Studies supported the use of perioperative antibiotics in all facial thirds, and preoperative antibiotics in comminuted mandible fractures. Postoperative antibiotics were not supported in any facial third. Survey respondents (n = 17) cumulatively reported their antibiotic prescribing practices over 286 practice years and 24,012 facial fracture cases. Percentages of prescribers administering pre-, intra-, and postoperative antibiotics, respectively, by facial third were as follows: upper face 47.1, 94.1, 70.6; midface 47.1, 100, 70.6%; and mandible 68.8, 94.1, 64.7%. Preoperative but not postoperative antibiotic use is recommended for comminuted mandible fractures. Frequent use of pre- and postoperative antibiotics in upper and midface fractures is not supported by literature recommendations, but with low-level evidence. Higher level studies may better guide clinical antibiotic prescribing practices.

Surgical excision of multiple penile syringomas with scrotal flap reconstruction

OBJECTIVE

Penile syringomas are rare lesions usually occurring in isolation. We report the excision and reconstruction of multiple synchronous penile shaft syringomas with local scrotal flaps.

METHODS

We report a rare case of excision of multiple penile syringomas and reconstruction with scrotal flaps in a 29-year-old man.

RESULTS

Penile syringomas were excised and reconstructed with scrotal flaps in a single-stage procedure.

CONCLUSIONS

In addition to providing wound coverage, this reconstructive option allowed for excellent functional results with regard to shaft alignment and erectile function, and it should be considered in the reconstructive armamentarium for penile shaft lesions.

Reconstruction of porcine critical-sized mandibular defects with free fibular flaps: the development of a craniomaxillofacial surgery model

Vascularized bone flaps are the well-known standards of care for reconstruction of segmental mandibular defects ≥ 6 cm. We developed a large animal critical-sized mandibular defect model in which osseous free fibula flaps were used for reconstruction.In this study a total of eight 3-month-old Yorkshire pigs underwent 6 cm full-thickness resection of the left hemimandible. An osseous free fibula flap from the left leg was harvested and contoured to the mandibular defect. Bone placement and plate position was confirmed with fluoroscopy. Animals were followed with serial radiographs and clinical evaluations.Free fibulas were transferred successfully in all eight animals. The average operative time was 346 minutes, and the average flap ischemia time was 86 minutes. The average volume ratio of reconstructed hemimandibles to nonoperated control hemimandibles was 0.72 ± 0.33. The average maximum fracture load was 689 ± 262 N, and the average ratio of biomechanical fracture load for these samples compared with contralateral control hemimandibles was 0.88 ± 0.25.It is concluded that the porcine osseous free fibula flaps can be reliably harvested and viably transferred to critical-sized posterior mandibular defects with acceptable long-term results. The described microsurgical large animal model is acceptable for use in craniomaxillofacial experimentation.

Found in space: computer-assisted orthognathic alignment of a total face allograft in six degrees of freedom

PURPOSE

Full facial osteomyocutaneous transplantation requires correct 3-dimensional (3D) alignment of donor osseous structures to a new cranial base with minimal reference points and 6 degrees of potential movement. We investigated whether computer-assisted design and manufacturing (CAD/CAM) could enable accurate placement of the facial skeleton.

MATERIALS AND METHODS

A prospective single-cohort study of Le Fort III-based maxillary-mandibular segment allotransplantation was performed in 5 cadaver pairs and 1 clinical pair. The osteotomies were modeled using computed tomography (CT) data and 3D modeling software and then translated to the donor-recipient pairs using surgical navigation and osteotomy cutting guides. The predicted values were calculated about all rotational axes (pitch, yaw, and roll) and along all translational axes (vertical, horizontal, and anteroposterior) and used as the independent variable. The primary outcome variable of the actual postoperative CT values was compared for fidelity to the prediction using the intraclass correlation coefficient (ICC). The similarity to the donor versus recipient values was calculated as a secondary independent variable, and both predicted and actual measurements were compared with it as a percentage.

RESULTS

The postoperative fidelity to the plan was adequate to excellent (ICC 0.520 to 0.975) with the exception of lateral translation (2.94 ± 1.31 mm predicted left vs 3.92 ± 2.17 mm right actual displacement; ICC 0.243). The predicted and actual values were not consistently skewed toward the donor or recipient values.

CONCLUSIONS

We have demonstrated a novel application of CAD/CAM that enables orthognathic alignment of a maxillary-mandibular segment to a new cranial base. Quantification of the alignment in all 6 degrees of freedom delivers precise control compared with the planned changes and allows postoperative quality control.

Simultaneous double-opposing Z-plasty and posterior pharyngeal flap

PURPOSE

Strategies to address severe anteroposterior palatal shortening with velopharyngeal insufficiency include palatal lengthening or manipulation of posterior pharyngeal tissue as a flap or sphincter. In some cases, a single procedure alone is not sufficient to achieve dynamic velopharyngeal closure. The objective of this study was to determine whether double-opposing Z-plasty coupled with a posterior pharyngeal flap would achieve adequate palatal length in severe velopharyngeal dysfunction.

MATERIALS AND METHODS

Six patients, 3 with previously unrepaired cleft palate and 3 children with previous straight-line repairs and significant anteroposterior shortening, were included. Demographic and perioperative information was tabulated. Subjective and objective speech data were gathered, if available. Complications, follow-ups, and postoperative nasometric results were compiled. Statistical analysis involved the paired t test.

RESULTS

There were no perioperative complications. Follow-up was at least 1 year. No postoperative fistulas or nasal obstruction developed. Hypernasal speech and nasal emission were subjectively improved in all patients. Nasometric data showed a statistically significant improvement in nasal air escape with speech.

CONCLUSIONS

Simultaneous double-opposing Z-plasty and posterior pharyngeal flap can be performed effectively. This strategy is useful for severe velopharyngeal dysfunction secondary to anteroposterior palatal shortening or a previously unrepaired cleft palate, and the technique optimizes palatal function and creates a mechanical blockade to nasal air escape.

Engineering bone grafts with enhanced bone marrow and native scaffolds

The translation of tissue engineering approaches to the clinic has been hampered by the inability to find suitable multipotent cell sources requiring minimal in vitro expansion. Enhanced bone marrow (eBM), which is obtained by reaming long bone medullary canals and isolating the solid marrow putty, has large quantities of stem cells and demonstrates significant potential to regenerate bone tissues. eBM, however, cannot impart immediate load-bearing mechanical integrity or maintain the gross anatomical structure to guide bone healing. Yet, its putty-like consistency creates a challenge for obtaining the uniform seeding necessary to effectively combine it with porous scaffolds. In this study, we examined the potential for combining eBM with mechanically strong, osteoinductive trabecular bone scaffolds for bone regeneration by creating channels into scaffolds for seeding the eBM. eBM was extracted from the femurs of adult Yorkshire pigs using a Synthes reamer-irrigator-aspirator device, analyzed histologically, and digested to extract cells and characterize their differentiation potential. To evaluate bone tissue formation, eBM was seeded into the channels in collagen-coated or noncoated scaffolds, cultured in osteogenic conditions for 4 weeks, harvested and assessed for tissue distribution and bone formation. Our data demonstrates that eBM is a heterogenous tissue containing multipotent cell populations. Furthermore, coating scaffolds with a collagen hydrogel significantly enhanced cellular migration, promoted uniform tissue development and increased bone mineral deposition. These findings suggest the potential for generating customized autologous bone grafts for treating critical-sized bone defects by combining a readily available eBM cell source with decellularized trabecular bone scaffolds.

Le Fort II fractures are associated with death: a comparison of simple and complex midface fractures

PURPOSE

To investigate whether complex midface fractures have a greater association with death and intracranial injury than simple midface fractures.

MATERIALS AND METHODS

A retrospective chart review was performed for patients with blunt-mechanism midface fractures who had presented to an urban trauma center from 1998 to 2010. The survival and intracranial injury status was evaluated for patients with simple and complex midface fractures, including Le Fort, naso-orbitoethmoid, and/or zygomaticomaxillary fractures. Intracranial injury included hemorrhage and brainstem injury. Patients with upper face fractures were excluded to minimize confounding. Adjusted relative risk estimates were obtained using multivariate regression analysis.

RESULTS

Of 3,291 patients with midface fractures, 213 (6.3%) died and 693 (21.3%) had an intracranial injury. The cumulative mortality reached 11.6% in patients with complex midface fractures and 5.1% in those with simple midface fractures (P < .001). Patients with complex midface fractures were 57% more likely to die (relative risk = 1.57; P < .005). Specifically, Le Fort II fractures independently conferred a 94% increased risk of death (relative risk = 1.94; P < .01), but Le Fort I and III fractures were not significantly associated with death. Among patients presenting without neurologic impairment, those with Le Fort II and III fractures remained 2.88-fold (P < .01) and 2.54-fold (P < .001) more likely to have an underlying intracranial injury, respectively.

CONCLUSIONS

Le Fort II fractures are associated with increased mortality. Furthermore, Le Fort II and III fractures are associated with serious intracranial injury, even in the absence of alterations in consciousness. These patients should be monitored with heightened vigilance and followed up closely during hospitalization, regardless of the presenting clinical findings.

Acute mycobacterial flexor tenosynovitis following accidental bacillus calmette-guérin inoculation in a health care worker: case report

Solutions containing bacillus Calmette-Guérin (BCG), a live attenuated form of Mycobacterium bovis or Mycobacterium tuberculosis, commonly are injected intravesically to treat tumors of the urinary bladder. We report a case of acute mycobacterial flexor tenosynovitis in a health care worker who inadvertently inoculated her finger via needlestick while preparing BCG solution for intravesicular administration. She was treated successfully with immediate operative intervention followed by 6 months of antimycobacterial antibiotics. Of 3 previous reports of hand infections following self-inoculation with BCG solutions, this case is unique owing to rapid onset of acute mycobacterial flexor tenosynovitis and positive intraoperative mycobacterial cultures. Needlesticks with BCG-containing solutions, especially into the flexor tendon sheath, should be treated with timely surgical debridement and appropriate antimycobacterial management.

Vascularized bone marrow-based immunosuppression inhibits rejection of vascularized composite allografts in nonhuman primates

Vascularized composite allograft (VCA) transplantation (also referred to as composite tissue allotransplantation) has demonstrated clinical success in cases of hand, arm and face transplantation despite prior belief that skin provides an insurmountable barrier to allograft rejection. These overall good outcomes are facilitated by substantial immunosuppressive requirements in otherwise healthy patients, yet still demonstrate frequent rejection episodes. We developed a nonhuman primate model of facial segment allotransplantation to elucidate the unique pathophysiology and immunosuppressive requirements of VCA with addition of concomitant vascularized bone marrow (VBM). Heterotopically transplanted facial segment VCA with VBM treated only with tacrolimus and mycophenolate mofetil (MMF) demonstrated prolonged rejection-free survival, compared to VCA without VBM that demonstrated early rejection episodes and graft loss. While VCA with VBM demonstrated sporadic macrochimerism, acute and chronic rejection and graft loss occurred after discontinuation of immunosuppression. These data support an immunomodulatory role of VBM in VCA that reduces immunosuppressive requirements while providing improved outcomes.

Severe tracheobronchial stenosis and cervical vertebral subluxation in X-linked recessive chondrodysplasia punctata

Radiologic manifestations of X-linked chondrodysplasia punctata (CDPX1) typically include chondrodysplasia, epiphyseal stippling, punctate calcification of cartilage, distal phalangeal hypoplasia, and nasal/midface hypoplasia. We present an infant with CDPX1 demonstrating calcification and stenosis of the entire trachea and mainstem bronchi, as well as possible anterior C1 subluxation due to progression of congenital vertebral dysplasia.

Proteomic signatures of epidermal growth factor receptor and survival signal pathways correspond to gefitinib sensitivity in head and neck cancer

PURPOSE

Gefitinib targeting of the epidermal growth factor receptor (EGFR) has shown limited activity in clinical trials of head and neck squamous cell carcinoma (HNSCC). To investigate the underlying molecular mechanism, the proteomic signatures and responses of EGFR and downstream signals have been studied in a panel of HNSCC cell lines and tumor specimens pre- and post-gefitinib treatment.

EXPERIMENTAL DESIGN

The IC(50) of gefitinib for HNSCC cell lines were determined using 3-(4,5-dmethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide proliferation assay. The effects of gefitinib on activation of EGFR and downstream signaling molecules were determined by Western blot, ELISA, and reverse-phase protein microarray (RPMA). The biomarkers involved in the signaling pathways were examined in HNSCC tumor specimens from patients in a phase I gefitinib trial.

RESULTS

In vitro, gefitinib inhibited cell proliferation with differing IC(50), and suppressed activation of EGFR and downstream signaling molecules protein kinase B (AKT), extracellular signal-regulated kinase 1/2, signal transducer and activator of transcription 3 (STAT3), and nuclear factor kappaB. The drug sensitivity was statistically correlated with activation of phosphorylated AKT (p-AKT) and phosphorylated STAT3 (p-STAT3) detected by ELISA, and consistent with results measured by RPMA. In patient samples, a broad suppression of activation of EGFR and downstream signaling molecules was observed in a molecular responder patient, in contrast to a lack of inhibition or increased activation of biomarkers in different pathways in nonresponder patients.

CONCLUSIONS

Gefitinib sensitivity is correlated with p-AKT and p-STAT3 activation in HNSCC cell lines and tumor specimens. p-AKT and p-STAT3 could serve as potentially useful biomarkers and drug targets for further development of novel therapeutic agents for HNSCC.

Case report: treatment of severe subcutaneous emphysema with a negative pressure wound therapy dressing

OBJECTIVE

This article describes a patient who developed severe subcutaneous emphysema and a persistent air leak after several attempts at needle thoracostomy for what was thought to be a tension pneumothorax. Subcutaneous emphysema was effectively treated with a topical negative pressure wound therapy dressing applied to a typical subfacial "blowhole" incision. This article aims to describe and contextualize the use of negative pressure wound therapy within the existing treatment options for subcutaneous emphysema.

METHODS

A case report of the clinical course and technique was drafted, and the relevant literature in PubMed was reviewed.

RESULTS

The level of subcutaneous emphysema decreased significantly within 48 hours of negative pressure wound therapy as confirmed with physical examination and computed tomography scans. Negative pressure wound therapy for subcutaneous emphysema has not been previously described in the literature.

CONCLUSIONS

Negative pressure wound therapy applied over subfascial incisions is a novel technique that effectively and rapidly controlled massive subcutaneous emphysema and persistent air leak. This technique may be efficacious in other cases of subcutaneous emphysema.

Case report: full-thickness forehead burn over indwelling titanium hardware resulting from an aberrant intraoperative electrocautery circuit

OBJECTIVE

This study aims to contextualize an unintended intraoperative electrocautery burn that occurred on our service within the spectrum of all intraoperative electrocautery burns.

METHODS

A case report of the incident was drafted, and the relevant literature present in PubMed and industry publications was reviewed.

RESULTS

Intraoperative electrocautery burns can be divided into 4 categories: (1) direct contact burns resulting from inappropriate operator use of the active electrode, (2) burns at the grounding electrode site due to improper attachment or placement, (3) burns resulting from electrode heating of pooled solutions, and (4) burns occurring outside the operative field as a result of circuits generated between the active electrode and an alternate grounding source. We herein report an unintended intraoperative electrocautery burn of the fourth category. An aberrant intraoperative circuit utilized previously placed in-dwelling titanium plating in the patient's right brow as the grounding electrode, resulting in 3 x 3-cm full-thickness skin necrosis overlying the site of hardware implantation.

CONCLUSIONS

Literature recommendations to reduce this type of electrocautery burn suggest avoiding grounding pad placement on the forearm and lateral thigh, although further investigation is needed to determine optimal grounding electrode placement with respect to known indwelling hardware.