Raj M. Vyas

Risk factors for abdominal donor-site morbidity in free flap breast reconstruction.

Background: The lower abdomen is the most popular donor site for autologous tissue breast reconstruction. Several studies have reported abdominal morbidity following pedicled and free flap reconstructions using this donor site, yet few studies have compared the various types of free flaps and investigated specific operative and patient-related factors that are associated with higher rates of abdominal complications. Methods: The authors conducted a retrospective review of all free flap breast reconstructions performed at University of California Los Angeles Medical Center between July of 2002 and July of 2005. Results: A total of 279 patients underwent 211 unilateral and 68 bilateral reconstructions, totaling 347 flaps. Eleven percent were free transverse rectus abdominis myocutaneous (TRAM) flaps, 52 percent were muscle-sparing free TRAM flaps, and 37 percent were deep inferior epigastric perforator (DIEP) flaps. Mean follow-up was 29.9 months. There were 30 total abdominal complications (10.9 percent of patients), including 17 rectus bulges and five hernias. Free TRAM reconstructions had a significantly higher rate of donor-site complications than did DIEP reconstructions. Bilateral flap harvests and obesity (body mass index >30) were significant risk factors for (1) any donor-site complication and (2) rectus bulge/hernia formation. There was no significant increase in donor-site complications associated with various prior abdominal operations. Conclusions: Donor-site complications are not uncommon, but paying careful attention to patient comorbidities when selecting an operative approach (bilateral versus unilateral, free TRAM versus DIEP, and so on) can minimize postoperative abdominal complications. Furthermore, the results corroborate the recent literature suggesting there is little functional difference in patients receiving muscle-sparing free TRAM versus DIEP reconstructions.

Economic advantages to a distraction decision tree model for management of neonatal upper airway obstruction.

Background: Neonatal upper airway obstruction demands urgent attention. Tracheostomy can prove to be lifesaving but has morbidities. Recently, the authors found reduced morbidity/mortality when using a distraction decision tree model compared with conventional “case-by-case” management. In this current study, the authors assess the long-term costs of (1) a decision tree model versus conventional treatment and (2) tracheostomy versus distraction osteogenesis. Methods: An inpatient cost-matrix analysis study on neonates with upper airway obstruction and micrognathia was performed (n = 149). In Part I, conventionally treated neonates managed on a case-by-case basis received home monitoring or a tracheostomy. Decision tree model–managed newborns had specialist consultations and diagnostic testing to determine whether home monitoring, tracheostomy, or distraction osteogenesis would be implemented. In Part II, tracheostomy treatment was compared directly to distraction osteogenesis. Results: In Part I (conventional versus decision tree model), taking into account the costs of the distraction, tracheostomy, hospital stay, diagnostic studies, physician fees, and emergency department visits, the total per patient treatment cost was 1.5 greater in the conventional treatment group (

The reconstructive matrix: a new paradigm in reconstructive plastic surgery.

332,673) compared with the decision tree model (

Primary Premaxillary Setback and Repair of Bilateral Complete Cleft Lip: Indications, Technique, and Outcomes.

225,998) (p < 0.05). In Part II (tracheostomy versus distraction osteogenesis), the total per-patient treatment cost in the tracheostomy group was two times greater than in the distraction group (

Adult Cleft Lip Repair Under Local Anesthesia: An Effective Technique in Resource-Poor Settings

382,246 versus

Breast Milk Feeding Rates in Patients With Cleft Lip and Palate at a North American Craniofacial Center.

193,128) (p < 0.05). Conclusions: In treating newborns with micrognathia and upper airway obstruction, a decision tree model with mandibular distraction decreases long-term health care costs compared with conventional treatment. Furthermore, when comparing distraction to tracheostomy, similar decreases in long-term health care costs occurred.

Is Craniosynostosis Repair Keeping Up With the Times? Results From the Largest National Survey on Craniosynostosis.

Technology has dramatically altered paradigms and doctrines in modern medicine. In plastic surgery, there has been an explosion of medical knowledge and innovation resulting in a myriad of potential reconstructive options. Since the Edwin Smith Papyrus,1 treatment paradigms have facilitated the decision-making process of the reconstructive surgeon. In 1982, Mathes and Nahai proposed the reconstructive ladder, which emerged as a very useful guiding framework for decision-making in plastic surgery.2 As one goes up the rungs of the ladder, an increasingly complex choice of surgical procedures is described to treat a specific problem. The surgeon should consider using the simplest procedure that effectively solves the problem. Improved surgical techniques increase the reliability of complex reconstruction options that contribute to better functional and aesthetic outcomes. Several articles2–9 refine the concept of the reconstructive ladder, reflecting dissatisfaction with its simplicity. In 1994, Gottlieb and Krieger3 proposed an “elevator” that bypasses rungs of the ladder, emphasizing form and function in decisionmaking. The elevator allows surgeons to select the rung of the ladder that best suits these requirements, regardless of the complexity of the chosen technique. Attempting to emphasize the increasingly popular techniques of microsurgery and tissue expansion, Mathes and Nahai proposed the reconstructive triangle.10 This model emphasizes judgment, experience, and familiarity with reconstructive techniques to select from any of the three corners of the triangle: flap transposition, microsurgery, or tissue expansion. Although it acknowledges the role of the surgeon and the increasing reliability of traditionally difficult reconstructive techniques, the triangle paradigm is criticized as being too “flat”7 because it considers neither the varied complexity of reconstructive procedures nor the aesthetic and functional requirements of each patient. The constant evolution of medical knowledge and the introduction of new technologies are not well incorporated into these models. To provide plastic surgeons with a model that better accounts for today’s constantly evolving technological, medical, and social environments, we propose the concept of the reconstructive matrix.

Use of Safety Measures, Including the Modified World Health Organization Surgical Safety Checklist, During International Outreach Cleft Missions

Objective To analyze indications and outcomes for primary premaxillary setback. Design Retrospective. Setting Academic childrens hospital. Patients All children with bilateral complete cleft lip age ≤2 years of age who had premaxillary setback by one surgeon (1992 to 2011). Results Twenty-five patients with bilateral complete cleft lip underwent primary premaxillary setback at an average age of 9 months; the mean follow-up was 47 months. There were three indications: failed dentofacial orthopedics (n = 9), delayed referral precluding manipulation (n = 10), and intact secondary alate (n = 6). Of 19 patients with bilateral complete cleft lip/palate, primary setback was combined with nasolabial repair (n = 11), adhesions (n = 2), or palatoplasty (n = 6). Patients who had nasolabial closure and setback were significantly younger than those who had combined palatal closure and setback (6.5 versus 16 months, P = .01). No patient exhibited postoperative premaxillary instability. Serial anthropometry showed similar growth of nasolabial features after both primary setback (n = 9) and active dentofacial orthopedics (n = 35). Conclusions Primary premaxillary ostectomy and setback permits synchronous bilateral nasolabial-alveolar closure or alveolar-palatal repair in a child with intact secondary palate. This procedure should be considered whenever dentofacial orthopedics cannot be accomplished. Speech is paramount in an older child; setback with palatal closure is scheduled before nasolabial repair. Disturbance of midfacial growth is likely following primary premaxillary ostectomy and setback in patients with bilateral complete cleft lip/palate; however, most already need maxillary advancement. Furthermore, premaxillary setback permits proper primary nasolabial design and construction in appreciation of expected changes with growth.

Management of Rhinophyma: Outcomes Study of the Subunit Method

Objective In developing countries there are many adults with unrepaired cleft lip deformities. These countries often lack the equipment and personnel to provide general anesthesia for all patients; therefore, a technique for repair under local anesthesia would be useful. Method A retrospective review was performed of 22 adolescent/adult patients on whom primary cleft lip repair was performed under local anesthesia in Bamako, Mali, in 2008 and 2009. Inclusion criteria for this technique were age greater than 12 with unilateral or bilateral deformity and ability to understand and tolerate the procedure under local anesthesia alone. Exclusion criteria included cardiopulmonary disease or inability to tolerate the procedure while awake. Demographic information and outcome data were collected including total time in the operating room, surgical time, and day of discharge. Results Twenty-two primary cleft lip repairs were completed in 12 male and 10 female patients. Mean age was 22.3 years and mean weight was 50 kg. Overall, mean total operating room time was 145 minutes. Mean operating room time was significantly (p < .01) longer in 2008 (159 minutes) than in 2009 (114 minutes). Although mean surgical time was 110 minutes, there was a similar significant (p = .03) decrease from 2008 (119 minutes) to 2009 (91 minutes). All patients tolerated the procedure without requiring intubation or intravenous sedation, and all were discharged the same day. Conclusion Cleft lip repair in adults under local anesthesia is safe and effective. Improvements in technique and efficiency have made this valuable in developing countries.

Reply: Transdiaphragmatic Omental Harvest

Objective Our study goal was to evaluate the rates of breast milk feeding among patients with oral clefts at a large North American Craniofacial Center. Methods Parents of patients with oral clefts born from 2000 to 2012 and treated at our center were interviewed regarding cleft diagnosis, counseling received for feeding, and feeding habits. Results Data were obtained from parents of 110 patients with oral clefts. Eighty-four percent of parents received counseling for feeding a child with a cleft. Sixty-seven percent of patients received breast milk for some period of time with a mean duration of 5.3 months (range 0.25 to 18 months). When used, breast milk constituted the majority of the diet with a mean percentage of 75%. Breast milk feeding rates increased successively over the 13-year study period. The most common method of providing breast milk was the Haberman feeder at 75% with other specialty cleft bottles composing an additional 11%. Parents who received counseling were more likely to give breast milk to their infant (P = .02). Duration of NasoAlveolar Molding prior to cleft lip repair did not affect breast milk feeding length (P = .72). Relative to patients with cleft lip and palate, patients with isolated cleft lip had a breast milk feeding odds ratio of 1.71. Conclusion We present breast milk feeding in the North American cleft population. Although still lower than the noncleft population, breast milk feeding with regards to initiation rate, length of time, and proportion of total diet is significantly higher than previously reported.