Jesse A. Taylor

Body Contouring Following Massive Weight Loss

Background: Obesity and its associated medical morbidities carry substantial health risk. While massive weight loss allows improvement in health status and lifestyle, physical sequelae due to symptomatic skin redundancy still require treatment. Areas affected include the arms, breasts, abdomen, back, and thighs. After open gastric bypass, patients often have poor abdominal support and incisional hernias. To completely address the treatment of patients following massive weight loss, body contouring procedures are performed, often in one stage and tailored to each patient, to rid the functional and esthetic impairment from skin redundancy. Methods: This retrospective study includes 30 patients treated from March 1998 to August 2002 by a single surgeon at an academic hospital. Average weight loss had been 71 kg, and average weight and BMI at the time of contouring surgery were 98.6 kg and 33 kg/m2 respectively. Procedures included abdominal panniculectomy, thighlift, backlift, brachioplasty, mastopexy and incisional hernia repair, performed either alone or in combination. Results: Average weight of resected tissue was 5.9 kg. Average length of stay was 3 days. Complications included seroma, wound breakdown, hematoma requiring surgical drainage, and lymphocele after brachioplasty. One patient died of a pulmonary embolus within weeks after surgery. Conclusion: Patients requiring surgical skin excision after massive weight loss for functional and/or esthetic reasons are challenging, and require individualized approaches with intensive follow-up.

Free flap take-back following postoperative microvascular compromise: predicting salvage versus failure.

Background: The purpose of this study is twofold: (1) to stratify preoperative risk factors that predict successful free flap salvage and (2) to identify perioperative strategies that correlate with successful salvage. Methods: A retrospective chart review was performed on all free flaps performed from January of 2005 to April of 2011. The time until salvage was defined as the end of the initial procedure until the initiation of the salvage attempt. The primary endpoint, successful salvage, was defined as any flap that did not result in total loss. Results: A total of 2260 free flaps were reviewed, and 47 take-backs for delayed microvascular compromise were identified. Twenty-three of 47 flaps (49 percent) were salvaged. The mean time until take-back, presence of thrombophilia, and preoperative platelet counts were factors predictive of unsuccessful salvage. Preoperative platelet counts above 300 were associated with the lowest rates of salvage. Intraoperative maneuvers were examined, and surgeon experience (defined as >5 years in practice) was the only factor that was significant; however, intraoperative heparin anticoagulation and complete mechanical thrombectomy trended toward significance. The type of thrombolytic agent used was not found to result in a statistically significant difference. Conclusions: There is evidence to suggest that there may be preoperative factors predictive of flap salvage success, including thrombophilia and routine preoperative platelet values. Shorter time to take-back and surgeon experience may improve salvage, whereas intraoperative heparin anticoagulation and complete mechanical removal of the thrombus demonstrate preliminary evidence as effective intraoperative strategies. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

An evaluation of complications, revisions, and long-term aesthetic outcomes in nonsyndromic metopic craniosynostosis.

Background: The authors evaluated the complications, revisions, and long-term aesthetic outcomes of patients with isolated metopic synostosis. Methods: A retrospective chart review was performed on consecutive metopic craniosynostosis patients treated from June of 1987 to June of 2012 at The Children’s Hospital of Philadelphia. Patient demographics, operative details, and postoperative data were collected. Outcomes were reported as Whitaker classification and postoperative clinical characteristics assessed before additional interventions. Reoperation in patients with greater than 5 years of follow-up was noted. Appropriate statistical analyses were applied. Results: From 1987 to 2012, 178 patients underwent surgical correction of isolated metopic craniosynostosis, and 147 met inclusion criteria. Average age at surgery was 0.83 year (range, 0.3 to 4.7 years); average follow-up was 5.8 years (range, 1.0 to 17.8 years). There were 13 surgical complications (8.8 percent), three major (2.0 percent), and 10 minor (6.8 percent). At follow-up, 67 patients (56.8 percent) were classified as Whitaker class I, six (5.1 percent) as class II, 43 (36.4 percent) as class III, and two (1.7 percent) as class IV. Patients with greater than 5 years’ follow-up (n = 57) were more likely to have temporal hollowing (OR, 2.9; 95 percent CI, 1.2 to 7.3; p = 0.021), lateral orbital retrusion (OR, 4.9; 95 percent CI, 1.9 to 12.7; p = 0.001), and Whitaker class III or IV classification (OR, 4.0; 95 percent CI, 1.5 to 10.6; p = 0.006) compared with those with less than 5 years’ follow-up. Conclusion: This study reports low complication and reoperation rates in the treatment of isolated metopic craniosynostosis, but demonstrates a clear trend toward worsening aesthetic outcomes over time. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Comparison of spring-mediated cranioplasty to minimally invasive strip craniectomy and barrel staving for early treatment of sagittal craniosynostosis.

The treatment of sagittal craniosynostosis has evolved from early strip craniectomy to total cranial vault remodeling and now back to attempts at minimally invasive correction. To optimize outcomes while minimizing morbidity, we currently use 2 methods of reconstruction in patients younger than 9 months: spring-mediated cranioplasty (SMC) and minimally invasive strip craniectomy with parietal barrel staving (SCPB). The purpose of this study was to compare the safety and efficacy of the 2 methods. Hospital records of our first 7 SMCs and our last 7 SCPBs were analyzed for demographics, the type of operation performed, estimated blood loss, transfusion requirements, operative time, length of stay in the intensive care unit, length of hospital stay, preoperative cephalic index, postoperative cephalic index, and complications. The techniques were then compared using analysis of variance.All 14 patients successfully underwent cranial vault remodeling with significant improvement in cephalic index. Demographics, length of stay in the intensive care unit (P = 0.15), preoperative cephalic index (P = 0.86), and postoperative cephalic index (P = 0.64) were similar between SMC and SCPB. Spring-mediated cranioplasty had statistically significantly shorter operative time (P = 0.002), less estimated blood loss (P < 0.001), and shorter length of hospital stay (P = 0.009) as compared with SCPB. Complications included 1 spring dislodgment in an SMC that did not require additional management and 1 undercorrection in the SCPB group. Both SMC and SCPB are safe, effective means of treating sagittal craniosynostosis. Spring-mediated cranioplasty has become our predominant means of treatment of scaphocephaly in patients younger than 9 months because of its improved morbidity profile.

A craniometric analysis of posterior cranial vault distraction osteogenesis.

Background: Posterior cranial vault distraction osteogenesis has replaced fronto-orbital advancement in some centers as the first-line treatment in patients with syndromic craniosynostosis. Despite this fact, little has been written about its craniometric effects on children with syndromic craniosynostosis. Methods: A retrospective review of all patients who underwent posterior distraction was performed. Patient demographic, perioperative data, and preoperative/postoperative computed tomographic scans were reviewed. Volumetric and craniometric indices were calculated and measured using commercial three-dimensional imaging software. Results: From 2008 to 2012, 22 patients underwent posterior vault distraction osteogenesis for suspected intracranial hypertension or severe turribrachicephaly. In 13 patients, this was the first cranial vault procedure performed, whereas eight had previous fronto-orbital advancement and one had parieto-occipital reshaping. Half of patients underwent posterior cranial vault distraction osteogenesis before age 1 year; the average age at surgery was 2.3 years (range, 0.3 to 14.1 years) and distraction length averaged 27.3 mm (range, 19 to 35 mm). Average length of surgery was 2.9 hours (range, 1.6 to 3.8 hours), and average blood loss was 400 ml (range, 200 to 600 ml). Total treatment length was 91 days (range, 48 to 147 days). Distraction length averaged 27.3 mm (range, 19 to 35 mm). Intracranial volume increase averaged 21.5 percent (range, 7.5 to 70.0 percent; p < 0.0001) and 28.4 percent (range, 10.8 to 66.0 percent; p = 0.01) in the subset of patients younger than 1 year. Posterior cranial height increased 12.2 percent (range, 0 to 35 percent; p = 0.002), and basofrontal angle decrease averaged 3.9 percent (range, 0 to 12 percent; p = 0.003), indicating a decrease in cranial height trajectory and improvement in frontal bossing. Conclusions: Posterior cranial vault distraction is a safe and effective operation that may lower risk of intracranial hypertension and abnormal skull morphology. Interestingly, cranial morphological benefits were seen both anteriorly and posteriorly. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

The Muenke syndrome mutation (FgfR3P244R) causes cranial base shortening associated with growth plate dysfunction and premature perichondrial ossification in murine basicranial synchondroses.

Muenke syndrome caused by the FGFR3P250R mutation is an autosomal dominant disorder mostly identified with coronal suture synostosis, but it also presents with other craniofacial phenotypes that include mild to moderate midface hypoplasia. The Muenke syndrome mutation is thought to dysregulate intramembranous ossification at the cranial suture without disturbing endochondral bone formation in the skull. We show in this study that knock‐in mice harboring the mutation responsible for the Muenke syndrome (FgfR3P244R) display postnatal shortening of the cranial base along with synchondrosis growth plate dysfunction characterized by loss of resting, proliferating and hypertrophic chondrocyte zones and decreased Ihh expression. Furthermore, premature conversion of resting chondrocytes along the perichondrium into prehypertrophic chondrocytes leads to perichondrial bony bridge formation, effectively terminating the postnatal growth of the cranial base. Thus, we conclude that the Muenke syndrome mutation disturbs endochondral and perichondrial ossification in the cranial base, explaining the midface hypoplasia in patients. Developmental Dynamics 240:2584–2596, 2011.

Mandibular Microsurgical Reconstruction in Patients with Hemifacial Microsomia

Background: Although hemifacial microsomia is a relatively common craniofacial malformation, there is some debate regarding the ideal treatment of severe mandibular hypoplasia. Traditionally, patients with severe mandibular deficits have been treated with iliac or costochondral bone grafts followed by distraction osteogenesis, with mixed results. The authors present their experience with the use of the fibula osteocutaneous free flap for mandibular reconstruction in severe hemifacial microsomia patients. Methods: From 1999 to 2006, 10 patients aged 3 to 10 years (mean, 7.2 years) underwent 10 free flap reconstructions. Of the 10 patients, six were girls and four were boys. Data were collected retrospectively from the patients’ records, photographs, and radiographs. The authors report the surgical technique used, complications, and long-term outcome. Results: Nine of 10 flaps were successful, for a flap survival rate of 90 percent. Donor bone length was 5 to 10 cm, with a mean of 6.3 cm. Skin paddles ranged from 8 to 36 cm2, with a mean size of 18.7 cm2. Mean operation time was 412 minutes and mean follow-up was 45.4 months (range, 12 to 94 months). Two patients underwent successful distraction osteogenesis subsequent to their free flap mandible reconstruction. All patients demonstrated stable bony union of the free flap by physical and radiographic examination. One major complication (a failed free flap) and two minor complications were observed. Conclusion: The free flap is safe and effective, and should be considered as a first choice in mandibular reconstruction in severe cases of hemifacial microsomia where distraction osteogenesis is not possible.

A critical evaluation of long-term aesthetic outcomes of fronto-orbital advancement and cranial vault remodeling in nonsyndromic unicoronal craniosynostosis.

Background: This study reports long-term aesthetic outcomes with fronto-orbital advancement and cranial vault remodeling in treating unicoronal synostosis over a 35-year period. Methods: Retrospective review was performed on patients with isolated unicoronal synostosis from 1977 to 2012. Demographic, preoperative phenotypic, and long-term aesthetic outcomes data were analyzed with chi-squared and Fisher’s exact test for categorical data and Wilcoxon rank-sum and Kruskal-Wallis rank for continuous data. Results: A total of 238 patients were treated; 207 met inclusion criteria. None underwent secondary intervention for intracranial pressure. At definitive intervention, there 96 (55 percent) Whitaker class I patients, 11 (6 percent) class II, 62 (35 percent) class III, and six (3 percent) class IV. Nasal root deviation and occipital bossing each conferred an increased risk of Whitaker class III/IV [OR, 4.4 (1.4 to 13.9), p = 0.011; OR, 2.6 (1.0 to 6.8), p = 0.049]. Patients who underwent bilateral cranial vault remodeling with extended unilateral bandeau were less likely Whitaker class III/IV at latest follow-up compared with those undergoing strictly unilateral procedures [OR, 0.2 (0.1 to 0.7), p = 0.011]. Overcorrection resulted in decreased risk of temporal hollowing [OR, 0.3 (0.1 to 1.0), p = 0.05]. Patients with 5 years or more of follow-up were more likely to develop supraorbital retrusion [OR, 7.2 (2.2 to 23.4), p = 0.001] and temporal hollowing [OR, 3.7 (1.5 to 9.6), p = 0.006] and have Whitaker class III/IV outcomes [OR, 4.9 (1.8 to 12.8), p = 0.001]. Conclusion: Traditional fronto-orbital advancement and cranial vault remodeling appears to mitigate risk of intracranial pressure but may lead to aesthetic shortcomings as patients mature, namely fronto-orbital retrusion and temporal hollowing. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, 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.

Plastic Surgery Residency Websites: A Critical Analysis of Accessibility and Content

BackgroundMedical students applying for plastic surgery residency utilize the Internet to manage their residency applications. Applicants often apply to many programs and rely on advice from colleagues, mentors, and information gathered from plastic surgery residency websites (PSRWs). The purpose of the present study was to evaluate integrated and combined PSRWs with respect to accessibility, resident recruitment, and education. MethodsWebsites from all 63 integrated and combined plastic surgery residencies available to graduating medical students during the 2013 academic year were available for study inclusion. Databases from national bodies for plastic surgery education were analyzed for accessibility of information. PSRWs were evaluated for comprehensiveness in the domains of resident education and recruitment. Residency programs were compared according to program characteristics using the Student t test and ANOVA with Tukey method. ResultsOf the 63 residencies available to graduating medical students, only 57 had combined or integrated program information on their PSRWs (90.5%). In the domain of resident recruitment, evaluators found an average of 5.5 of 15 content items (36.7%). As a whole, 26.3% of PSRWs had academic conference schedules, 17.5% had call schedules, and only 8.8% had operative case listings. For resident education, PSRWs provided an average of 4.6 of 15 content items (30.7%). Only 31.6% of PSRWs had interview schedules, 24.6% had graduate fellowship information, and 5.3% had information on board exam performance. Upon comparison, programs in the Midwest had more online recruitment content than programs in the West (47.1% vs. 24.2%, P < 0.01). Additionally, programs with a larger class of incoming residents (2 vs. 1) had greater online recruitment content (40.0% vs. 26.7%, P < 0.05). Larger programs with 3 integrated spots had more online education content than smaller programs with only 1 integrated spot (40.0% vs. 19.4%, P < 0.01). ConclusionPSRWs are often not readily accessible and do not provide basic information that allow residency applicants to use this recruitment tool effectively. The paucity of online content suggests PSRWs are underutilized as an educational and recruitment tool. These findings have implications for applicants and plastic surgery residency programs, and there may be future opportunity to utilize this tool more effectively.