Jennifer L. McGrath

Free tissue transfer in the hypercoagulable patient: a review of 58 flaps.

Background: Hypercoagulability or thrombophilia is a group of inherited or acquired conditions associated with a predisposition to thrombosis. Most hypercoagulable states alter the blood itself or affect the vasculature, directly creating a detrimental environment for microsurgery. The authors present their series of hypercoagulable patients who underwent free flap reconstruction. Methods: A retrospective review was conducted of all free flaps performed between January 1, 2005, and October 1, 2010, at the University of Pennsylvania. A total of 2032 flaps were performed. Forty-one patients or 58 free flaps (2.9 percent) were identified as having a diagnosed thrombophilia or previous thromboembolic event. Results: Of the 41 patients, 36 were women and five were men. Diagnosis included factor V Leiden mutation, protein C deficiency, hyperhomocysteinemia, antiphospholipid antibody syndrome, prothrombin gene mutation, factor VIII elevation, anticardiolipin antibody syndrome, and essential thrombocytosis. The group of patients with prior thrombotic events (many with concomitant events and diagnoses) included deep vein thrombosis, pulmonary embolus, myocardial infarction before the age of 50, and embolic stroke. Twelve patients (29.3 percent) were actively followed by a hematologist. The rate of thrombosis was 20.7 percent (12 flaps), including those occurring intraoperatively. The salvage rate for a postoperative thrombosed flap in this group was 0 percent. The flap loss rate was 15.5 percent. Conclusions: Although hypercoagulability produces an unfavorable condition for microvascular reconstruction, free tissue transfer is feasible. In this series, the authors had an 80 percent success rate. Collaboration with a hematologist may be helpful. In this group, flap thrombosis seems to occur in the delayed period. Even with operative reexploration, salvage rates have not been promising. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, IV.

Volumetric changes in cranial vault expansion: comparison of fronto-orbital advancement and posterior cranial vault distraction osteogenesis.

Background: Posterior cranial vault distraction osteogenesis has recently been introduced to treat patients with multisuture syndromic craniosynostosis and is believed to provide greater gains in intracranial volume. This study provides volumetric analysis to determine the gains in intracranial volume produced by this modality. Methods: This was a two-center retrospective study of preprocedure and postprocedure computed tomography scans of two groups of 15 patients each with syndromic multisuture craniosynostosis treated with either fronto-orbital advancement or posterior cranial vault distraction osteogenesis. Scan data were analyzed volumetrically with Mimics software. Volumetric gains attributable to growth between scans were controlled for. Results: The mean advancements were 12.5 mm for fronto-orbital advancement and 24.8 mm for distraction osteogenesis. The mean difference in volume between the preoperative and postoperative scans was 144 cm3 for fronto-orbital advancement and 274 cm3 for (p = 0.009). After controlling for growth, the corrected mean volume difference was 66 cm3 for fronto-orbital advancement and 142 cm3 for distraction osteogenesis (p = 0.0017). The corrected mean volume difference per millimeter of advancement was 4.6 cm3 for fronto-orbital advancement and 5.8 cm3 for distraction (p = 0.357). Conclusions: In this retrospective study, posterior cranial vault distraction osteogenesis provided statistically greater intracranial volume expansion than fronto-orbital advancement. The volume gains per millimeter advancement were similar between groups, with a trend toward greater gains per millimeter with distraction osteogenesis. Gradual expansion of the overlying soft tissues with posterior cranial vault distraction osteogenesis appears to be the primary mechanism for greater volume gains with this technique. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Differential closure of the spheno-occipital synchondrosis in syndromic craniosynostosis

Background: The spheno-occipital synchondrosis is a driver of cranial base and facial growth. Its premature fusion has been associated with midface hypoplasia in animal models. The authors reviewed computed tomographic scans of patients with Apert and Muenke syndrome, craniosynostosis syndromes with midface hypoplasia, to assess premature fusion of the spheno-occipital synchondrosis when compared with normal controls. Methods: Ninety head computed tomographic scans of Apert syndrome patients and 31 head scans of Muenke syndrome patients were assessed, in addition to an equal number of control scans. Spheno-occipital synchondrosis fusion on axial images was graded as open, partially closed, or closed. Analysis focused on ages 7 to 14 years, as no control patient fused before age 7 or had failed to fuse after age 14. Results: All 38 Apert syndrome patients aged 7 to 14 had some degree of spheno-occipital synchondrosis closure, compared with 29 of 38 matched controls (p = 0.0023). Seventeen of 20 Muenke syndrome patients showed closure, compared with 14 of 20 matched controls (p = 0.4506). Partial fusion was seen as early as age 2 in Apert syndrome and age 6 in Muenke syndrome patients; the earliest fusion was seen at age 7 in the control group. Conclusions: Compared with matched controls, the spheno-occipital synchondrosis closes significantly earlier in patients with Apert syndrome but not Muenke syndrome. This correlates well to reported incidences of midface hypoplasia in these syndromes. Although causality cannot be concluded from this study, an association exists between midface phenotype and degree of spheno-occipital synchondrosis closure. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, II.

Delayed autologous breast reconstruction: factors which influence patient decision making.

BACKGROUND Autologous breast reconstruction timing continues to be controversial. The purpose of this study was to examine delayed autologous breast reconstruction at a center favouring immediate reconstruction to better understand factors driving the decision to delay reconstruction. METHODS We performed a retrospective cohort study of all free autologous breast reconstruction patients between 2005 and 2009, focussing on ethnicity, cancer stage, unilateral or bilateral reconstructions, initial management, distance from the institution, and average income. Delayed reconstructions were compared to immediate reconstructions. All delayed reconstructions were surveyed to examine treatment and reconstruction decisions and satisfaction. RESULTS Of 709 patients, 169 (24%) underwent delayed treatment. Delayed reconstruction patients had higher cancer stages (p < 0.001), higher rates of pre-reconstruction radiation therapy (64% vs. 20%, p < 0.0001) and higher rates of unilateral reconstruction (64% vs. 48%, p < 0.001). Seventy delayed patients responded to the survey (41%), with 75% having had their initial mastectomy at an outside health system. Only 51% discussed immediate reconstruction prior to electing delayed treatment and 41% had no discussion regarding advantages or disadvantages to reconstructive options. Approximately 30% noted no choice in their reconstructive timing. Forty five percent would elect immediate reconstruction if given the option. CONCLUSIONS This study demonstrates that women may not be receiving all available information prior to undergoing mastectomy for initial breast cancer treatment. As a significant portion of women electing delayed reconstruction would elect immediate autologous reconstruction if given the option again, there is room for improvement in pre-operative patient education and in the education of our oncology colleagues.

Is nasal mucoperiosteal closure necessary in cleft palate repair

Background: The goals of successful palate repair include optimizing speech and feeding, mitigating adverse maxillary growth effect, and avoiding fistulae. The necessity of vomerine and/or nasal-side mucosa repair has not been tested. The purpose of this study was to compare the outcome of palate repairs with and without nasal mucoperiosteal closure. The authors used the null hypothesis. Methods: This was a retrospective analysis of consecutive cleft palate repairs performed between 2001 and 2004. Group 1 underwent two-layer repair (oral and nasal/vomerine mucoperiosteal flaps), and group 2 underwent one-layer closure (oral mucoperiosteal flaps) only. Both groups underwent double-opposing Z-plasty posteriorly. Demographic and perioperative outcome variables were recorded and compared statistically. Results: Group 1 consisted of 51 children (23 boys and 28 girls), and 80 percent were nonsyndromic. Group 2 included 29 patients (15 boys and 14 girls), and 72 percent were without an associated diagnosis. Age at repair was similar (20.80 and 15.17 months, respectively). Operative time was less for one-layer repair (84 versus 135 minutes) (p = 0.0001). Complications, length of stay, and follow-up length were similar between the two cohorts. Velopharyngeal dysfunction was rare in both groups. A single fistula occurred in each group. Anthropometric data revealed larger maxillary arc and tragus-subnasale lengths in group 2. Growth velocities were similar in both groups. Conclusions: The goals of cleft palate repair can be efficiently achieved using a one-sided oral mucoperiosteal repair only. Omitting the nasal-side and vomer repair does not increase fistula formation or prove detrimental to velopharyngeal function, and may facilitate maxillary growth.

Abstract: Patient-Specific Implants for Cranioplasty

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