Devra Becker

Volumetric analysis of simulated alveolar cleft defects and bone grafts using cone beam computed tomography

Background: Cone beam computed tomography allows for a significantly lower radiation dose than conventional computed tomographic scans, with generation of accurate images of the maxillofacial skeleton. The authors investigated its accuracy in the volumetric analysis of alveolar cleft defects and simulated bone grafts. Methods: Five simulated alveolar clefts were created using a burr drill in three dry pediatric skulls and filled with simulated bone grafts. Pregrafting and postgrafting cone beam computed tomographic scanning of skulls was performed using specialized imaging software. The authors compared actual volumes of the simulated bone grafts obtained using a water displacement technique with scan-derived volumes of both the grafts and the defects. Results: The average of the five simulated bone grafts calculated by cone beam computed tomography scanning was 0.380 ml, which was lower than their mean volume of 0.392 ml calculated by water displacement. The percentage difference between measurements ranged from 2.9 to 8.6 percent (mean, 4.86 percent). The mean of the simulated defects of 0.399 ml derived from scanning was higher than the actual mean volume of 0.392 ml derived by water displacement. The mean difference in defect comparison was 2.52 percent. There was no statistically significant difference between real volume and scan-derived graft and defect volume. Conclusions: Cone beam computed tomography calculation of simulated alveolar cleft and bone graft volume is precise and accurate. The volume of bone graft needed to fill alveolar defects can be accurately predicted using volume measurements of the bony defect. These findings further validate its use in the perioperative assessment of alveolar grafting.

Beyond Beauty: Onobotulinumtoxin A (BOTOX®) and the Management of Migraine Headaches

Based on the conducted anatomic studies at our institutions as well as clinical experience with migraine surgery, we have refined our onobotulinumtoxin A (BOTOX®) injection techniques. Pain management physicians are in unique position to be able to not only treat migraine patient, but also to be able to collaborate with neurologists and peripheral nerve surgeons in identifying the migraine trigger sites prior to surgical deactivation. The constellation of migraine symptoms that aid in identifying the migraine trigger sites, the potential pathophysiology of each trigger site, the effective methods of botulinumtoxin and nerve block injection for diagnostic and treatment purposes, as well as the pitfalls and potential complications, will be addressed and discussed in this paper.

Keeping abreast of axillary masses

In October, 2010, a previously healthy 48-year-old woman with textured saline breast implants placed subpectorally 8 years ago for aesthetic purposes, presented with 2-month history of a painless mass underneath her left arm. Physical examination showed symmetrical breasts with no overlying skin or nipple changes. There were two large mobile nodes palpable in the left axilla. Initial breast mammography and ultra sonography confi rmed left axillary lymphadenopathy but did not show any periimplant fl uid collection. Biopsy of the left axillary mass showed fi ndings most consistent with classic Hodgkin’s lymphoma, nodular sclerosing type. It lacked two typical stains—CD15 and Pax5. PET-CT showed a 5-cm area of PET-avid left axillary lymphadenopathy. Hodgkin’s lymphoma stage IA was diagnosed. Our patient then had two cycles of adriamycin, bleomycin, vinblastine, and dacarbazine (ABVD) and 2000 Gy of fi eld radiation to the left axilla. Her initial treatment was completed in March, 2011. Follow-up CT scan in June, 2011, showed a decrease in the size of the left axillary lymphadenopathy. Unilateral fl uid collection, however, was noted around the left breast implant (fi gure). The fl uid increased in size and she presented 6 months later with leakage of serous fl uid from her left breast. Cytology of the peri-implant fl uid showed CD30+ lymphoma cells of indeterminate lineage. Diff erential diagnosis included recurrent Hodgkin’s lymphoma or implant-associated anaplastic large-cell lymphoma. Re peat PET-CT showed PET-avid areas in bilateral axillary lymph nodes. Both implants were removed with capsu lectomies. In October, 2011, she was treated with four cycles of salvage chemotherapy with gemcitabine and cisplatin for assumed recurrent Hodgkin’s lymphoma. Follow-up sonography of the left

Social and Support Services Offered by Cleft and Craniofacial Teams: A National Survey and Institutional Experience.

Background:A multidisciplinary approach to patients with craniofacial abnormalities is the standard of care by the American Cleft Palate-Craniofacial Association (ACPA). The standards of team care, however, do not require provision of social support services beyond access to a social worker. The purpose of this investigation is to study social support services provided by ACPA teams, funding sources for services, and family interest in services. Methods:A survey was submitted to ACPA cleft and craniofacial team leaders (N = 161), which evaluated the provision of potentially beneficial social support services, and their funding sources. A second survey administered to patient families at our institution gauged their level of interest in these services. Statistical analysis evaluated the level of interest among services. Results:Seventy-five of 161 (47%) teams and 39 of 54 (72%) families responded to the surveys. Services provided included scholarships (4%), summer camp (25%), social media (32%), patient support groups (36%), parties (42%), parent support groups (46%), other opportunities (56%), and social workers (90%). The majority of funding for social workers was by the institution (61%) whereas funding for ancillary services varied (institution, team, fundraisers, grants, and other sources). Families indicated an average interest of 2.4 ± 1.41 for support groups, 2.5 ± 1.63 for summer camps, 2.92 ± 1.66 for parties, 3.16 ± 1.65 for social media, and 3.95 ± 1.60 for scholarships (P value <0.05). Conclusions:The ACPA standards of team care do not require teams to provide social support services beyond access to a social worker. Among our survey respondents, the authors found that in addition to a social worker, teams offered social support services, which were not required. The social worker position is usually institutionally funded, whereas funding sources for additional services varied. Respondents at our center desired additional social support services. The authors recommend a hybrid model of hospital and nonhospital funding to provide social and support services to patients with craniofacial deformities.

Nasal Reconstruction and Aesthetic Rhinoplasty

The nose is one of the most prominent features on the human face, and rhinoplasty has preoccupied surgeons for centuries. The nose is often divided into thirds, each third has its own features. Nasal analysis begins with a frank discussion with the patient and includes a thorough history taking, including prior surgeries and any drug use. Analysis of the nose consists of the relationship of the nose to the face in the facial horizontal thirds, vertical fifths, and facial angles. It also includes an assessment of harmony between the nasal segments, nasal length, tip shape, projection, and rotation, and the alar—columellar relationship. Deformities of the upper vault include a dorsal hump, which is treated with rasping and occasionally block resection, or dorsal deficiency, which is treated with grafts. The tip can be modified by grafts, resection of alar cartilages, or suture placement. Nasal deviation must be localized to the upper, middle, or lower vault and is treated with either osteotomies for the upper vault or cartilaginous repositioning for the middle and lower vaults. All rhinoplasties require thoughtful planning and preoperative customization.

Treatment of Headaches with Plastic Surgery

Headaches affect millions of people a year and are associated with a great deal of morbidity. Though the causes of headaches are many, a subset of headaches refractory to traditional pharmacologic treatment — namely migraine and cluster headaches — can be treated surgically. All patients should undergo a thorough history and physical examination and evaluation by a headache specialist. Patients who are diagnosed with migraine headaches have potential trigger sites identi-fied by consideration of the constellation of symptoms, intranasal examination, CT scan, and by injection with 12.5 U of botulinum toxin A for each muscle involved. The use of botulinum toxin A as definitive treatment for headaches remains controversial; we use it as a diagnostic aid. Glabellar trigger sites are treated with corrugator supercilii resection, temporal trigger sites are treated with resection of the zygomaticotemporal branch of the trigeminal nerve (ZMTBTN), occipital trigger sites are treated with surgical release of the greater occipital nerve, and patients with intranasal triggers are treated with septo-plasty and inferior turbinate resection. Patients with cluster headaches are treated with resection of the ZMTBTN. Surgery does have a role in the treatment of refractory migraine and cluster headaches.

Innovative Surgical Treatment of Severe Cherubism

Background: Cherubism is an autosomal dominant syndrome characterized by excessive bilateral maxillomandibular bony degeneration and fibrous tissue hyperplasia. Conservative management is the preferred treatment as cherubism has a self-limiting course. Functional or emotional disturbances may, however, demand surgical intervention. We report a patient who underwent surgical intervention. Method/Description: He had significant enlargement of lower cheeks and bilateral lower lid scleral show. On computed tomography of the face, the patient had significant fibrous tissue involving bilateral maxilla and mandible. The mandibular tumor was excised. Given normal inferior border, bilateral sagittal split osteotomy was performed to infracture and inset the outer cortex. During the procedure, patient required blood transfusion intraoperatively, so the maxillary portion of the procedure was delayed until 6 months later. For the maxilla, bilateral transconjunctival approach was used to resect parts of the orbital floors that were concave, resulting in 1 × 2 cm defects bilaterally which were reconstructed using resorbable plates. Then the anterior maxillary tumor was excised. Results: The patient and his parents were satisfied with his appearance after surgery. The patient was noted to have improvement in contour and decreased scleral show. He has most recently followed up 15 months after the initial surgery. There were no long-term complications. Conclusions: Severity of cherubism influences the type of surgical intervention. The present case is innovative because this is the first reported case of recontouring orbital floors with resorbable plates and infracturing of the mandible using sagittal split osteotomies for surgical treatment of cherubism.

Write it in the Script: A Practical Solution to Promote Gender Balance in Educational Programming

METHODS The survey was distributed to all member categories of the ASMS by e-mail and included demographic questions regarding ethnicity, practice type, location, and gender. Information on barriers to conversion to full active membership was solicited and participants were given the opportunity to elaborate in free text comments. The second arm charged the planning committee with placing “a woman on every panel” for the programming of the Preconference Symposium (PCS) and ASMS DAY at the ASPS annual meeting of 2016.

Perceptions of Educational Value: A Survey of American Council of Academic Plastic Surgeons

METHODS A 16-question self-administered electronic survey was distributed to members of ACAPS in February 2015. Questions elicited demographic information as well as valuation questions to determine perceived support for educational activities. Responses to valuation questions were classified based on adapted Net Promoter Score categories: 0–6 as “unsupportive,” 7–8 as “neutral,” and 9–10 as “supportive.”3 Results were analyzed using the Kruskal-Wallis rank sum test and chi-squared test.