James E. Clune

Inlay cranioplasty: an experimental comparison of particulate graft versus bone dust.

Background: Cranioplasty in children is difficult because autologous bone is limited. To expand the calvarial donor site, surgeons have used bone dust harvested with a power drill and particulate bone taken with a bit and brace. The purpose of this study was to compare bone dust and particulate bone for inlay cranioplasty. Methods: A critical-size defect was made in the parietal bone of rabbits and managed in three ways: group I (n = 5), no implant; group II (n = 6), bone dust implant; and group III (n = 6), particulate graft implant. Bone dust and particulate graft were obtained using a power burr or brace and bit, respectively. Bone dust and particulate graft volume was calculated using a micrometer. Computed tomography was performed 4, 8, and 16 weeks after cranioplasty to determine ossification; histology also was studied. Results: The average volume of particulate bone fragments (6.2 × 104 mm3) was 344-fold greater than bone dust particles (1.8 × 102 mm3) (p < 0.0001). Four weeks postoperatively, the filled volume of the experimental defect was 6.8 ± 4.9 percent in group I, 8.4 ± 7.4 percent in group II, and 43.0 ± 7.2 percent in group III. Eight weeks postoperatively, the filled volume was 22.3 ± 3.9 percent in group I, 29.1 ± 6.7 percent in group II, and 80.0 ± 8.9 percent in group III. Sixteen weeks postoperatively, the defect was closed 38.6 ± 11.1 percent in group I, 41.3 ± 11.2 percent in group II, and 99.3 ± 1.5 percent in group III (p < 0.0001). Conclusions: Particulate bone graft ossifies full-thickness cranial defects. Bone dust is ineffective and resorbs, possibly because of its smaller particle size and/or thermal injury during harvesting. Particulate graft, and not bone dust, is suitable for inlay cranioplasty.

Autologous cranial particulate bone grafting reduces the frequency of osseous defects after cranial expansion.

Primary autologous particulate bone grafting has been demonstrated to heal osseous defects after fronto-orbital advancement. We sought to determine if this technique was equally effective for larger defects resulting from major cranial expansion procedures. We studied children who underwent cranial expansion (other than fronto-orbital advancement) between 1989 and 2008. Defects either were left to heal spontaneously (group 1) or had autologous cranial particulate bone graft placed over dura at the time of cranial expansion (group 2). Particulate bone graft was harvested from the endocortical or ectocortical surface using a hand-driven brace and bit. Outcome variables were ossification and need for revision cranioplasty. The study included 53 children. Mean (SD) age at procedure was 12.2 (8.1) months (range, 1.0-36.0 months) for group 1 (n = 15) and 20.2 (15.1) months (range, 3.3-78.6 months) for group 2 (n = 38) (P = 0.06). There were palpable bony defects in 33.0% (n = 5) of group 1 patients versus 7.9% (n = 3) of group 2 patients (P = 0.03). Corrective cranioplasty was needed in 26.7% of group 1 patients and only 5.3% of those in group 2 (P = 0.04). Primary cranial particulate bone grafting significantly reduced the frequency of osseous defects and secondary cranioplasty following cranial remodeling.

Malignant Melanoma: Beyond the Basics.

Learning Objectives: After reading this article, the participant should be able to: 1. Discuss the initial management of cutaneous malignant melanoma with regard to diagnostic biopsy and currently accepted resection margins. 2. Be familiar with the management options for melanoma in specific situations such as subungual melanoma, auricular melanoma, and melanoma in the pregnant patient. 3. Discuss the differentiating characteristics of desmoplastic melanoma and its treatment options. 4. List the indications for sentinel lymph node biopsy and be aware of the ongoing trials and current literature. 5. Discuss the medical therapies available to patients with metastatic melanoma. Summary: Management of the melanoma patient is a complex and evolving subject. Plastic surgeons should be aware of the recent changes in the field. Excisional biopsy remains the gold standard for diagnosis, although there is no evidence that use of other biopsy types alters survival or recurrence. Wide local excisions should be carried out with margins as recommended by National Comprehensive Cancer Network guidelines according to lesion Breslow depth, with sentinel lymph node biopsy being offered to all medically suitable candidates with intermediate thickness melanomas (1.0 to 4.0 mm), and with sentinel lymph node biopsy being considered for high-risk lesions (ulceration and/or high mitotic figures) with melanomas of 0.75 to 1.0 mm. Melanomas diagnosed during pregnancy can be treated with preoperative lymphoscintigraphy and wide local excision under local anesthesia, with sentinel lymph node biopsy under general anesthesia delayed until after delivery. Management of desmoplastic melanoma is currently controversial with regard to the indications for sentinel lymph node biopsy and the efficacy of postoperative radiation therapy. Subungual and auricular melanoma have evolved from being treated by amputation of the involved appendage to less radical procedures—ear reconstruction is now attempted in the absence of gross invasion into the perichondrium, and subungual melanomas may be treated with wide local excision down to and including the periosteum, with immediate full-thickness skin grafting over bone. Although surgical treatment remains the current gold standard, recent advances in immunotherapy and targeted molecular therapy for metastatic melanoma show great promise for the development of medical therapies for melanoma.

Cranial particulate bone graft ossifies calvarial defects by osteogenesis.

Background: Cranial particulate bone graft heals inlay calvarial defects and can be harvested as early as infancy. The purpose of this study was to test the hypothesis that particulate bone promotes ossification primarily by osteogenesis. Methods: Freshly harvested particulate bone, devitalized particulate bone, and high-speed drilled bone dust from rabbit calvaria were assayed for metabolic activity (resazurin) and viable osteoblasts (alkaline phosphatase). A rabbit cranial defect model was used to test the effect of devitalizing particulate bone on in vivo ossification. A parietal critical-size defect was created and managed in three ways: (1) no implant (n = 6); (2) particulate bone implant (n = 6); and (3) devitalized particulate bone implant (n = 6). Micro–computed tomographic scanning was used to measure ossification 16 weeks later; histology also was studied. Results: Particulate bone contained more viable cells (0.94 percent transmittance per milligram) compared with devitalized particulate bone (0.007 percent) or bone dust (0.21 percent) (p = 0.01). Particulate bone had greater alkaline phosphatase activity (0.13 &mgr;U/&mgr;g) than devitalized particulate bone (0.000) or bone dust (0.06) (p = 0.01). Critical-size defects treated with particulate bone had more ossification (99.7 percent) compared with devitalized particulate bone implants (42.2 percent) (p = 0.01); no difference was found between devitalized particulate bone and the control (40.8 percent) (p = 0.9). Conclusions: Particulate bone graft contains living cells, including osteoblasts, that are required to heal critical-size cranial defects. These data support the hypothesis that particulate bone promotes ossification primarily by osteogenesis.

On Bernard Sarnat's 100th birthday: pathology and management of craniosynostosis.

Abstract The focus on nonsyndromic craniosynostosis, the most common type of isolated craniosynostosis, is sagittal, followed by unilateral coronal, bilateral coronal, metopic, and lambdoid, in order of decreasing frequency. Certain forms of craniosynostosis display a sex predilection. For example, boys outnumber girls in a 4:1 ratio in sagittal synostosis, but girls outnumber boys in a 3:2 ratio in unilateral coronal synostosis. Other forms, such as metopic, lambdoid, and bilateral coronal synostosis, demonstrate no sex dominances tract.

Comprehensive cleft center: a paradigm shift in cleft care.

ing a blunt-tip filling needle attached to a syringe into the proximal end of the blood vessel and securing it circumferentially with a 5-0 Vicryl suture. Normal saline is gently infused and the patency of the anastomosis is assessed under the microscope (Fig. 2). With limited resources and time during residency, a model that is cost-effective, efficient, valid, and reliable is needed. The standard rat femoral vessel model requires extensive institutional review board approval, coordination of multiple attending physicians and residents, ethical considerations, and the need for anesthetization, possibly rendering a less than favorable cost-to-benefit ratio. Advantages of chicken feet include minimal cost, ready availability, and easy disposal without concern for biohazard or institutional review board compliance. An obvious disadvantage of the chicken foot model is the inability to assess the anastomosis in the circulatory state; however, the injection of saline into the vessel with a blunt-tip syringe does offer some evaluation of the repair (Fig. 2). To further supplement the educational value of our model, feedback should be implemented from expert surgeons to novice surgeons. At our institution, we will conduct observed graded sessions using the Global Rating Scale we are currently validating. Because the chicken foot is readily accessible, residents and trainees can work on their own, maximizing the number of times they practice to hone their microsurgical skills. DOI: 10.1097/PRS.0b013e318278d760

Perioperative corticosteroid reduces hospital stay after fronto-orbital advancement.

Facial swelling is common after fronto-orbital advancement. Edema and closure of the palpebral fissures can lead to prolonged hospitalization. The purpose of this study was to determine if perioperative corticosteroid shortens hospital stay after this procedure.We retrospectively studied consecutive children younger than 2 years who underwent primary fronto-orbital advancement between 1990 and 2008. Patients were categorized into 2 groups: group 1 patients were not given corticosteroid; group 2 patients received tapered perioperative dexamethasone. Primary outcome variables included length of hospital stay and infection rate.A total of 161 patients were included in the study. Hospitalization was significantly shorter (P = 0.008) for group 2 (n = 65; median duration, 3.0 d) than group 1 (n = 96; median duration, 5.0 d). Infection rates did not differ between groups (group 1, 2.1%; group 2, 1.5%; P = 0.8).Perioperative corticosteroid shortens hospitalization after fronto-orbital advancement without increasing the incidence of postoperative infection. The cost of postoperative hospital care was reduced by 27.2%.

Nipple adenoma in infancy.

We report the first patient with a nipple adenoma presenting in infancy. Nipple adenoma is a benign lesion typically affecting women between 45 and 55 years of age. This lesion can occur in the pediatric population and should be included in the differential diagnosis of an infantile breast lesion. Management of children with nipple adenoma requires consideration for breast development; excision before maturity may cause nipple-areola deformity or injury to the breast bud.

Disseminating surgery effectively and efficiently in Haiti.

The need for surgical care in Haiti remains vast despite the enormous relief efforts after the earthquake in 2010. As the poorest country in the Western hemisphere, Haiti lacks the necessary infrastructure to provide surgical care to its inhabitants. In light of this, a multidisciplinary approach led by Partners In Health and Dartmouth-Hitchcock Medical Center is improving the access to surgical care and offering treatment of a broad spectrum of pathology. This article discusses how postearthquake Haiti partnerships involving academic institutions can alleviate the surgical burden of disease and, in the process, serve as a profound educational experience for the academic community. The lessons learned from Haiti prove applicable in other resource-constrained settings and invaluable for the next generation of surgeons.

Autologous cranial particulate bone graft: an experimental study of onlay cranioplasty.

The purpose of this study was to determine whether particulate bone graft maintains its volume when used for onlay cranioplasty. Twenty-five adult, male, New Zealand white rabbits were divided into 5 groups (n = 5/group). Groups 1 to 3 were controls: group 1, untreated; group 2, sham procedure; and group 3, burring the cortical surface. Group s 4 and 5 had augmentation of the parietal bones with particulate graft harvested from the frontal bone with a brace and bit. The particulate graft was placed on native parietal bone (group 4) or on parietal bone that had been abraded to punctuate bleeding with an electric burr (group 5). Volume maintenance and osseointegration of the grafts were determined by micro-computed tomography and histology. At 16 weeks postoperatively, the mean (SD) volumes of the parietal bones in control groups 1, 2, and 3 were 555.8 (29.2), 550.8 (36.8), and 539.0 (39.0) mm3, respectively. Immediately after cranioplasty, the mean (SD) volumes of augmented parietal bone were 846.0 (10.8) mm3 for group 4 and 831.8 (11.8) mm3 for group 5. Sixteen weeks postoperatively, 100% of the group 4 grafts had resorbed (551.8 [SD, 24.0] mm3), and parietal volume was no different from controls (P = 0.89). Group 5 maintained 54.2% of volume (695.6 [SD, 22.0] mm3), which was greater than those of the controls (P < 0.0001). Particulate graft may be used for onlay cranioplasty if the recipient site is burred. Approximately one half of the onlay graft is resorbed, and its original shape is not maintained.