Noopur Gangopadhyay

Pierre Robin Sequence

Pierre Robin sequence (PRS) is classically described as a triad of micrognathia, glossoptosis, and airway obstruction. Infants frequently present at birth with a hypoplastic mandible and difficulty breathing. The smaller mandible displaces the tongue posteriorly, resulting in obstruction of the airway. Typically, a wide U-shaped cleft palate is also associated with this phenomenon. PRS is not a syndrome in itself, but rather a sequence of disorders, with one abnormality resulting in the next. However, it is related to several other craniofacial anomalies and may appear in conjunction with a syndromic diagnosis, such as velocardiofacial and Stickler syndromes. Infants with PRS should be evaluated by a multidisciplinary team to assess the anatomic findings, delineate the source of airway obstruction, and address airway and feeding issues. Positioning will resolve the airway obstruction in ~70% of cases. In the correct position, most children will also be able to feed normally. If the infant continues to show evidence of desaturation, then placement of a nasopharyngeal tube is indicated. Early feeding via a nasogastric tube may also reduce the amount of energy needed and allow for early weight gain. A proportion of PRS infants do not respond to conservative measures and will require further intervention. Prior to considering any surgical procedure, the clinician should first rule out any sources of obstruction below the base of the tongue that would necessitate a tracheostomy. The two most common procedures for treatment, tongue-lip adhesion and distraction osteogenesis of the mandible, are discussed.

The impact of chemotherapy and radiation therapy on the remodeling of acellular dermal matrices in staged, prosthetic breast reconstruction

Background: An acellular dermal matrix will typically incorporate, in time, with the overlying mastectomy skin flap. This remodeling process may be adversely impacted in patients who require chemotherapy and radiation, which influence neovascularization and cellular proliferation. Methods: Multiple biopsy specimens were procured from 86 women (n = 94 breasts) undergoing exchange of a tissue expander for a breast implant. These were divided by biopsy location: submuscular capsule (control) as well as superiorly, centrally, and inferiorly along the paramedian acellular dermis. Specimens were assessed for cellular infiltration, cell type, fibrous encapsulation, scaffold degradation, extracellular matrix deposition, neovascularization, mean composite remodeling score, and type I and III collagen. Patients were compared based on five oncologic treatment groups: no adjuvant therapy (untreated), neoadjuvant chemotherapy with or without radiation, and chemotherapy with or without radiation. Results: Biopsy specimens were procured 45 to 1805 days after implantation and demonstrated a significant reduction in type I collagen over time. Chemotherapy adversely impacted fibrous encapsulation (p = 0.03). Chemotherapy with or without radiation adversely impacted type I collagen (p = 0.02), cellular infiltration (p < 0.01), extracellular matrix deposition (p < 0.04), and neovascularization (p < 0.01). Radiation exacerbated the adverse impact of chemotherapy for several remodeling parameters. Neoadjuvant chemotherapy also caused a reduction in type I (p = 0.01) and III collagen (p = 0.05), extracellular matrix deposition (p = 0.03), and scaffold degradation (p = 0.02). Conclusion: Chemotherapy and radiation therapy limit acellular dermal matrix remodeling. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Industry Financial Relationships in Plastic Surgery: Analysis of the Sunshine Act Open Payments Database.

Background: Limited data exist regarding industry financial relationships in plastic surgery. The Sunshine Act Open Payments Database currently represents the largest repository of these data, but is limited primarily to queries of individual providers. The purpose of this study was to analyze these data and present them in a manner that better delineates these relationships, and to compare plastic surgery with other surgical subspecialties. Methods: A review of the Open Payments Database was performed for the period from January 1, 2014, to December 31, 2014. These data were analyzed with respect to types of payments, characteristics of plastic surgeons and companies, and comparison with other surgical subspecialties. Results: A total of 49,053 payments from 274 companies were identified that were made to 4812 plastic surgeons (475 academic and 4337 private practice). The total value of payments was

Remodeling Characteristics and Collagen Distributions of Biologic Scaffold Materials Biopsied From Postmastectomy Breast Reconstruction Sites

17,091,077. Food and beverage represented the most common type of payment (82.2 percent). Royalties and licensing represented the highest valued type of payment (35.7 percent), but were received by only a minority of plastic surgeons (0.5 percent). No significant differences were identified between academic and private practice plastic surgeons in the value or quantity of payments. Plastic surgery (54.5 percent) exhibited the lowest prevalence of industry financial relationships compared with otolaryngology (57.9 percent), orthopedics (62.4 percent), neurosurgery (87.8 percent), and urology (63.1 percent) (p < 0.001). Conclusions: Approximately half of all plastic surgeons have industry financial relationships. The prevalence of these relationships is comparatively less than in other surgical subspecialties.

Liquid latex molding: A novel application of 3D printing to facilitate flap design

ObjectiveThe study purpose was to evaluate the associations between patient characteristics and the histologic remodeling scores of acellular dermal matrices (ADMs) biopsied from breast reconstruction sites in the first attempt to generate a multivariable risk prediction model of nonconstructive remodeling. It was hypothesized that host characteristics and surgical site assessments predict the degree of graft remodeling for ADMs used during breast reconstruction. MethodsThe ADMs were biopsied from the breast reconstruction sites of n = 62 patients during a subsequent breast procedure, stained with hematoxylin-eosin, and evaluated according to a semi-quantitative scoring system for remodeling characteristics (cell types, cell infiltration, extracellular matrix deposition, scaffold degradation, fibrous encapsulation, and neovascularization) and a mean composite score. Biopsies were stained with Sirius Red and Fast Green, and analyzed to determine the collagen I:III ratio. Based on univariate analyses between subject clinical characteristics and the histologic remodeling scores, cohort variables were selected for multivariable regression models using a P value of 0.20 or less. ResultsThe composite score model yielded 3 variables: pack-year history, corticosteroid use, and radiation timing (r2 pseudo = 0.81). The model for collagen I yielded 2 variables: corticosteroid use and reason for reoperation (r2 pseudo = 0.78). The model for collagen III yielded 1 variable: reason for reoperation (r2 pseudo = 0.35). ConclusionsThese preliminary results constitute the first steps in generating a risk prediction model that predicts the patients and clinical circumstances most likely to experience nonconstructive remodeling of biologic grafts used to reconstruct the breast.

Point of maximum width: a new measure for anthropometric outcomes in patients with sagittal synostosis.

The approach to bony craniofacial reconstruction has been significantly enhanced with the development of patient-specific, computer-aided designed and manufactured (CAD/CAM) implants. This technology, however, has not yet been widely employed for soft tissue reconstruction. While algorithmic approaches based on the size, location, and etiology of the defect are effective in most cases, a patient-specific CAD/CAM approach has benefits in complex reconstructive problems. In this study, we present a patient-specific approach to preoperative flap planning: using three-dimensional (3D) printing and liquid latex to create a flexible model of a flap, and demonstrate its application in planning a complex scalp reconstruction.

Ultrapulse carbon dioxide laser versus traditional deepithelialization in reduction mammoplasty and mastopexy: Clinical outcomes and cost analysis

Abstract The esthetic success of sagittal synostosis reconstruction is measured by cephalic index (CI). This limited measure does not fully account for the abnormal head shape in sagittal synostosis. In this retrospective study, we investigate a new objective measure, point of maximum width (PMW) of the skull from a vertex view, to determine where the head is widest for children with sagittal synostosis as compared with normal controls. Preoperative computed tomography (CT) scans of 27 children with sagittal synostosis and 14 postoperative CT scans at least 8 months after surgery were obtained. Normal CT scans were matched for age, sex, and race. Three-dimensional renderings were standardized for orientation. Mean (SE) PMW in patients with sagittal synostosis was 53% (1%) compared with 57% (1%) in controls (P < 0.001). Mean (SE) CI in patients with sagittal synostosis was 66.8% (0.8%) compared with 83.3% (1.0%) in controls (P < 0.001). The correlation between PMW and CI was weak in both controls (r 2 = 0.002, P = 0.824) and uncorrected cases (r 2 = 0.083, P = 0.145). After surgical correction, both CI and PMW significantly improved. Mean (SE) PMW in patients after surgical release of sagittal synostosis was 58% (1%) compared with 58% (1%) in controls (P = 0.986). The PMW is not a surrogate for CI but is a novel, valid measure of skull shape, which aids in quantifying the widest region of the skull. It is significantly more anterior in children with sagittal synostosis and exhibits a consistent posterior shift along the cranium after surgery, showing no difference compared with healthy children.

Single Z-Plasty Versus Double-Opposing Z-Plasty: A Cadaveric Study of Palatal Lengthening.

Skin deepithelialization is a component of many procedures in plastic surgery. Although simple in concept, traditional technique with a scalpel or scissor has been shown to result in an uneven depth of excision. This can have potential clinical effects, such as in reduction mammoplasty or reconstruction of radiated wounds, where preservation of vascularized dermis is desired. Conversely, retained epidermis can result in inclusion cysts that can be symptomatic or mistaken for malignancy. The carbon dioxide (CO2) laser has been previously described as an alternative technique. However, potential downsides of laser-assisted deepithelialization that have been cited include epidermal inclusion cysts, seroma, and impaired wound healing. While prior histologic studies and case series have been presented, limited data exists of clinical outcomes and operative efficiency following deepithelialization with the ultrapulse CO2 laser. 5 The purpose of this study was to compare clinical outcomes between laser-assisted and traditional deepithelialization in patients undergoing reduction mammoplasty and mastopexy, and to identify risk factors, if any, for complications. Second, we sought to objectively corroborate a perceived time-savings advantage with the laser. Finally, the cost-savings achieved with shorter operative times were then compared to the additional operating room supply costs associated with use of the laser to achieve an overall cost comparison. A retrospective review was performed of a consecutive series of patients who underwent reduction mammoplasty or mastopexy with or without use of the ultrapulse CO2 laser for deepithelialization between June 2008 and

Combining Preoperative CTA Mapping of the Peroneal Artery and Its Perforators with Virtual Planning for Free Fibula Flap Reconstruction of Mandibulectomy Defects.

Objective: The double-opposing Z-plasty is an effective method of repairing the cleft palate due to its reorientation of the palatal musculature and lengthening of the soft palate. A technique for lengthening the palate with a single oral Z-plasty has also been described. The authors hypothesize that these 2 techniques have equivalent effects on palate length. Methods: A cadaver study was performed. Ten fresh adult cadaver heads were used. All palates were divided in the midline. In 5 specimens, a modified double-opposing Z-plasty technique was used; 5 other specimens underwent an oral Z-plasty with a straight-line repair of the nasal mucosa. In both groups, the levator veli palatini muscles were separately dissected and reapproximated with an intravelar veloplasty. The velar length, defined in this study as the distance from the posterior nasal spine to the tip of uvula, was measured before and after the surgical procedure. Results: The double-opposing Z-plasty produced a mean increase of 1.0 ± 0.6 cm in velar length (P = 0.023). The single Z-plasty repair resulted in a mean gain of 1.1 ± 0.3 cm (P = 0.001). There was no difference in change in palate length between the 2 procedures (P = 0.941), and no difference in the percentage of soft palate lengthening (24% vs 29%, respectively; P = 0.565). Conclusions: A single oral Z -plasty provides palatal lengthening equivalent to that of a double-opposing Z-plasty procedure.

Outcomes of laparoscopic paraesophageal hernia repair in elderly and high-risk patients.

8 up of 3.5 years (range 6.5 – 0.5 years), improvements in all functional outcomes were noted. Progressive re-innervation of facial skin and muscles improved or enabled eating, speaking and the ability to produce facial expressions and experience facial sensation. There was significant increase in upper airway volumes, leading to improvements in breathing and smelling. All artificial airways and feeding tubes were removed. In the remaining FT recipients from the peer-reviewed literature, the abilities to smell, eat and feel were improved in 100% of cases, whereas the abilities to breath, speak and grimace were ameliorated in 93%, 71% and 76%, respectively. Almost 60% of outcomes were not reported in the scientific literature.