Joseph M. Firriolo

Abstract: Surgical Treatment of Breast Asymmetry Improves Quality of Life in Adolescents and Young Women

RESULTS: The mean ages of breast subjects (n=42) at surgery and controls (n=103) at baseline were 17.4 and 16.7 years, respectively. All asymmetry forms were included (most frequent size difference was two cups; mean volume difference was 213 mL). At baseline, asymmetry subjects performed significantly worse than controls in the role-emotional SF-36 domain and on the RSES and EAT-26. Postoperatively asymmetry subjects experienced significant improvements in three SF-36 domains (social functioning, role emotional, mental health) and on the EAT-26. These results largely did not vary by age, BMI category, and asymmetry severity. Postoperative asymmetry patients performed equally to controls in all eight SF-36 domains, and on the RSES and EAT-26.

Abstract 115: Effect of Surgical Complications on Health-Related Quality of Life Outcomes in Adolescents and Young Women Following Reduction Mammaplasty

METHODS: We retrospectively reviewed 542 breast reconstructions, performed by two surgeons (SST,NTH) at one tertiary care academic hospital from January 2012 to February 2016. Patients choosing implants and completing reconstruction (n=269) were split into 4 groups based on GCR status and combined gynecologic procedures (GYN) status: GCR+, GYN+ (Group1,n=26); GCR+, GYN(Group2,n=41); GCR-, GYN+ (Group3,n=5); GCR-, GYN(Group4,n=197). GCR included mutations in BRCA, CHEK2, PALB2, Li-Fraumeni Syndrome, and others. Oneway ANOVA (df between groups = 3, df within groups = 265) and Tukey HSD was performed to compare differences in the percentages of patients with necrosis requiring surgery, infection requiring IV antibiotics, seroma, and device exchange.

Central Coalition Osteotomy of Phalangeal Synostoses in the Management of the Type III Apert Hand

PURPOSE We report a technique in the management of the type III Apert hand. The proposed approach facilitates the creation of a 5-fingered hand in 3 stages. METHODS We reviewed records of patients with Apert syndrome and type III hands surgically treated at our institution from 1995 through 2014. In all cases, syndactyly release was performed in 3 stages with prioritization of the border digits. In addition, limited retrograde, axial osteotomies between the phalangeal segments of the conjoined index, middle, and ring fingers were performed during the first stage. Medical records were reviewed for demographics, clinical presentation, operative findings, and postoperative outcomes. RESULTS Twelve pediatric patients with type III hands underwent syndactyly release. Median patient age was 10.0, 15.8, and 29.6 months at operative stages 1, 2, and 3, respectively. A thumb and 4 fingers were achieved for all but 1 hand. The median duration of hospital stay was 2 days for each stage. No infections or major complications were observed. CONCLUSIONS We demonstrate this method as a safe and effective means of creating 5 digits in the Apert patient with type III hands. Our opinion is that the additional aesthetic and functional gains offset the requirement of a 3-stage approach. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic IV.

The Effect of Surgical Treatment for Gynecomastia on Quality of Life in Adolescents

PURPOSE Despite the psychosocial deficits associated with gynecomastia, surgical treatment of adolescent gynecomastia remains controversial. This longitudinal cohort study measures changes in health-related quality of life following surgical treatment of gynecomastia in adolescents. METHODS The following surveys were administered to adolescents with gynecomastia and male controls, aged 12-21 years: Short-Form 36v2 (SF-36), Rosenberg Self-Esteem Scale (RSES), and Eating-Attitudes Test-26. Subjects completed surveys at baseline and postoperatively/at follow-up at 6 months, 1 year, 3 years, and 5 years. RESULTS From 2008 to 2017, 44 patients undergoing surgical treatment of gynecomastia and 64 unaffected male controls participated in our study. At baseline, gynecomastia patients scored significantly worse than controls on the RSES and in five SF-36 domains: general health, vitality, social functioning, role-emotional, and mental health. Scores significantly improved postoperatively on the RSES, and in four SF-36 domains: physical functioning, role-physical, bodily pain, and social functioning. Postoperatively, gynecomastia subjects scored similarly to controls in all SF-36 domains and the RSES. Young and overweight/obese patients and those with severe gynecomastia had the greatest postoperative improvement across survey measures. CONCLUSIONS Surgical treatment of gynecomastia significantly improves the quality of life of adolescents, with measurable improvements in physical and psychosocial functioning. Postoperatively, gynecomastia patients performed comparably to unaffected controls. Surgical treatment of gynecomastia in adolescents and young men has the potential to significantly improve quality of life, particularly in younger and overweight/obese patients and those with moderate to severe gynecomastia. Concerns regarding patient age and body mass index alone should not contraindicate surgery.

Abstract 17: Reduction Mammaplasty Improves Quality-of-Life in Adolescents with Macromastia: A Longitudinal Cohort Study

METHODS: Mice carrying the floxed FOP mutation (ACVR1 R206H) received a simultaneous hindlimb injection of Ad.cre to induce gene transformation and cardiotoxin to induce local injury (Ad.cre/CTX). Mice were treated with either daily vehicle control or rapamycin (5 mg/kg) administered i.p. (n=10/group). The presence of mesenchymal cells at the injury site was determined using immunofluorescent staining for PDGFRa and Sca-1 five days after injury. Ectopic cartilage and bone were determined using histology and microCT imaging 21 days after injury. PLGA microparticles were synthesized to deliver rapamycin as a slow-release; flow cytometry was used to quantify release time profile. Finally, a separate set of mice underwent Ad.cre/CTX injection with resection of formed HO 3 weeks after injury and subsequent treatment with or without rapamycin to eliminate recurrence.

Abstract: Long-Term Outcomes Following Flap Reconstruction in Pediatric Pressure Ulcers

Long-Term Outcomes Following Flap Reconstruction in Pediatric Pressure Ulcers The Harvard community has made this article openly available. Please share how this access benefits you. Your story matters Citation Firriolo, Joseph M., Ingrid M. Ganske, Carolyn M. Pike, Catherine Caillouette, Heather R. Faulkner, and Brian I. Labow. 2017. “Abstract: Long-Term Outcomes Following Flap Reconstruction in Pediatric Pressure Ulcers.” Plastic and Reconstructive Surgery Global Open 5 (9 Suppl): 166-167. doi:10.1097/01.GOX.0000526404.47863.87. http:// dx.doi.org/10.1097/01.GOX.0000526404.47863.87. Published Version doi:10.1097/01.GOX.0000526404.47863.87 Citable link http://nrs.harvard.edu/urn-3:HUL.InstRepos:34492185 Terms of Use This article was downloaded from Harvard University’s DASH repository, and is made available under the terms and conditions applicable to Other Posted Material, as set forth at http:// nrs.harvard.edu/urn-3:HUL.InstRepos:dash.current.terms-ofuse#LAA

Abstract 37. Pediatric Orbital Floor Fractures: Clinical and Radiological Predictors of Tissue Entrapment and the Effect of Operative Timing on Ocular Outcomes

37. Pediatric Orbital Floor Fractures: Clinical and Radiological Predictors of Tissue Entrapment and the Effect of Operative Timing on Ocular Outcomes The Harvard community has made this article openly available. Please share how this access benefits you. Your story matters Citation Firriolo, Joseph M., Nicole C. Ontiveros, Carolyn M. Pike, John G. Meara, Arin K. Greene, Oren Ganor, Amir Taghinia, and Brian I. Labow. 2017. “Abstract 37. Pediatric Orbital Floor Fractures: Clinical and Radiological Predictors of Tissue Entrapment and the Effect of Operative Timing on Ocular Outcomes.” Plastic and Reconstructive Surgery Global Open 5 (2 Suppl): 40-41. doi:10.1097/01.GOX.0000513452.31374.f3. http:// dx.doi.org/10.1097/01.GOX.0000513452.31374.f3. Published Version doi:10.1097/01.GOX.0000513452.31374.f3 Citable link http://nrs.harvard.edu/urn-3:HUL.InstRepos:32072205 Terms of Use This article was downloaded from Harvard University’s DASH repository, and is made available under the terms and conditions applicable to Other Posted Material, as set forth at http:// nrs.harvard.edu/urn-3:HUL.InstRepos:dash.current.terms-ofuse#LAA

The Effect of Reduction Mammaplasty on Quality of Life in Adolescents With Macromastia

By using validated surveys, this study prospectively evaluates the long-term physical and psychosocial effects of breast reduction in an adolescent population. OBJECTIVES: To measure changes in health-related quality of life and breast-related symptoms after reduction mammaplasty in adolescents. METHODS: In this longitudinal cohort study, we administered the Short-Form 36v2 (SF-36), Rosenberg Self-Esteem Scale (RSES), Breast-Related Symptoms Questionnaire (BRSQ), and Eating Attitudes Test-26 to 102 adolescents with macromastia and 84 female controls, aged 12 to 21 years. Patients with macromastia completed surveys preoperatively and after reduction mammaplasty at 6 months and 1, 3, and 5 years. Controls completed baseline and follow-up surveys at the same intervals. RESULTS: Patients with macromastia demonstrated significant score improvements postoperatively from baseline on the RSES, BRSQ, and in 7 out of 8 SF-36 domains: physical functioning, role-physical, bodily pain, vitality, social functioning, role-emotional, mental health (P < .001, all). By the 6-month follow-up visit, postoperative subjects scored similarly to or more favorably than controls on the RSES, BRSQ, Eating Attitudes Test-26 , and SF-36; these benefits persisted for at least 5 years and were not significantly affected by BMI category or age. CONCLUSIONS: Reduction mammaplasty was significantly associated with improvements in health-related quality of life and breast-related symptoms of adolescent patients, with measureable improvements in physical and psychosocial well-being evident by 6 months postoperatively and still demonstrable after 5-years. These results largely do not vary by BMI category or age. Patients and providers should be aware of the potential positive impact that reduction mammaplasty can provide adolescents with symptomatic macromastia. Historic concerns regarding age and BMI category at the time of surgery should be reconsidered.

Pediatric Orbital Floor Fractures: Clinical and Radiological Predictors of Tissue Entrapment and the Effect of Operative Timing on Ocular Outcomes

Abstract Orbital floor fractures can produce acute constitutional symptoms and poor ocular outcomes. This study aims to determine the clinical and radiological predictors of tissue entrapment in pediatric orbital floor fractures and to explore the effect of operative timing on ocular outcomes. The authors reviewed medical records from pediatric patients with orbital floor fractures from 2007 to 2015. One hundred fifty-two patients with 159 orbital floor fractures were included. One hundred twenty-two (80.3%) patients were male, and the mean age was 12.2 years. Twelve patients sustained orbital floor fractures with tissue entrapment. At presentation extraocular movement (EOM) restriction, diplopia, nausea, and vomiting were all associated with tissue entrapment (P < 0.001). Among patients with trapdoor fractures (determined by facial computed tomography), the presence of nausea and/or vomiting was predictive of tissue entrapment: positive predictive value 80%, negative predictive value 100%. For all the patients, regardless of fracture configuration, the presence of nausea and/or vomiting was valuable in ruling out tissue entrapment: sensitivity 83.3%, negative predictive value 98.1%. In tissue entrapment patients, poorer ocular outcomes (EOM restriction and diplopia) were associated with the length of operation (P = 0.007), but not the time interval to operation (P = 0.146). The authors conclude that nausea and vomiting are valuable predictors of tissues entrapment, particularly when EOM restriction and diplopia are equivocal. In the authors’ study, radiological findings were also predictive of entrapment, but inconsistent language in this area limits the external validity of these results. The authors’ study draws attention to the relationship between operation length and poorer ocular outcomes, suggesting that case severity/complexity and surgeon technique/experience may influence outcomes.

Long-term Outcomes After Flap Reconstruction in Pediatric Pressure Ulcers

Background Pressure ulcers refractory to nonoperative management may undergo flap reconstruction. This study aims to evaluate the long-term outcomes and recurrence rates of flap reconstruction for pediatric pressure ulcers. Methods We reviewed the records of patients who underwent flap reconstruction for pressure ulcer(s) from 1995 to 2013. Results Twenty-four patients with 30 pressure ulcers, requiring 52 flaps were included. Ulcers were stages III and IV and mostly involved either the ischia (15/30) or sacrum (8/30). Flaps were followed for a median of 4.9 years. Twenty-three patients were wheelchair dependent, and 20 had sensory impairment at their ulcer site(s). Ten patients had a history of noncompliance with preoperative management, 8 of whom experienced ulcer recurrence. Twenty-one ulcers had underlying osteomyelitis, associated with increased admissions (P = 0.019) and cumulative length of stay (P = 0.031). Overall, there was a 42% recurrence rate in ulceration after flap reconstruction. Recurrence was associated with a preoperative history of noncompliance with nonoperative therapy (P = 0.030), but not with flap type or location, age, sex, body mass index, osteomyelitis, or urinary/fecal incontinence (P > 0.05, all). Conclusions Flap reconstruction can be beneficial in the management of pediatric pressure ulcers. Although high rates of long-term success with this intervention have been reported in children, we found rates of ulcer recurrence similar to that seen in adults. Poor compliance with nonoperative care and failure to modify the biopsychosocial perpetuators of pressure ulcers will likely eventuate in postoperative recurrence. Despite the many comorbidities observed in our patient sample, compliance was the best indicator of long-term skin integrity and flap success.