Russell E. Ettinger

Obstructive sleep apnea after dynamic sphincter pharyngoplasty

IntroductionIn patients who require additional surgery for velopharyngeal insufficiency (VPI), a higher incidence of obstructive sleep apnea (OSA) may be incurred. Although this phenomenon has been demonstrated with the posterior pharyngeal flap, the effect of dynamic sphincter pharyngoplasty (DSP) on OSA is less clear. The purposes of this case series were to (1) determine the incidence of OSA after DSP, (2) assess the changes in polysomnography after DSP, and (3) identify risk factors for the development of OSA after DSP. Our global hypothesis is that OSA and VPI exist on a continuum and that speech outcomes should not be considered in isolation. MethodsFor a 13-year period, 146 patients with idiopathic VPI, submucous cleft palate, cleft palate only, or cleft lip and palate underwent DSP for VPI. The diagnosis of OSA was defined as the prescription of continuous positive airway pressure therapy by a pediatric sleep medicine physician. The incidence of OSA preoperatively and postoperatively was compared using Fisher exact test. When available, preoperative and postoperative apnea–hypopnea indices (AHIs) were compared using the pairwise, 2-tailed, Student’s t-test. Patient factors, such as obesity (body mass index ≥ 95th percentile), the presence of a craniofacial syndrome, surgical history, and a preexisting OSA diagnosis, were noted. A multiple logistic regression was performed to elucidate risk factors for the development of OSA. ResultsThe average age at surgery was 9.2 years (range, 4–40 y), and the mean follow-up time was 4.5 years (range, 1 mo to 12 y). The incidence of OSA increased after DSP, from 2 to 33 patients (1.4%–22%, respectively; P = 0.05). In 23 patients (16%), both preoperative and postoperative AHIs were available. There was a significant increase in AHI after DSP, from 3.1 to 8.4 episodes per hour of sleep (P = 0.001). Previous tonsillectomy/adenoidectomy was predictive of OSA after DSP (relative risk = 2.4; P = 0.04). ConclusionsWe report an increased incidence of OSA and higher-than-average AHIs postoperatively after DSP. Preoperative tonsillectomy/adenoidectomy predicted the development of OSA after DSP. A high index of suspicion for development of OSA must be maintained in patients who undergo secondary speech operations for VPI. Clinical screening for OSA should be used in this population, with a low threshold for polysomnographic evaluation. The surgeon must be wary that improvements in speech after DSP may change airway dynamics and increase the risk of OSA.

Timing of Furlow Palatoplasty for Patients With Submucous Cleft Palate

Background: Submucous cleft palate (SMCP) is the most common form of cleft involving the posterior palate, resulting in variable degrees of velar dysfunction and speech disturbance. Although early surgical intervention is indicated for patients with true cleft palate, the indications for palatoplasty and timing of surgical intervention for patients with SMCP remain controversial. Methods: Twenty-nine patients with SMCP were retrospectively reviewed. Patients treated with Furlow palatoplasty were dichotomized based on patient age at the time of surgical correction into early speech development and late speech development. Primary outcome measures included standardized assessments of hypernasal resonance and quantitative pre- and postoperative nasometry scores. Patients managed nonoperatively were included for comparison of early and late speech outcomes. Results: Both early and late groups demonstrated improvement in qualitative assessment of hypernasal resonance following Furlow palatoplasty. Early and late groups also had significant improvement in pre- to postoperative nasometry scores from 7.4 to 2.3 SD from norm (P = .01) and 6.0 to 3.6 SD from norm (P = .02), respectively. There was no difference in postoperative nasometry scores between early and late groups, 2.3 and 3.6 SD (P = .12). Conclusion: Furlow palatoplasty significantly improves the degree of hypernasality in patients with SMCP based on pre- and postoperative nasometry scores and on qualitative assessment of hypernasality. There were no differences in speech outcomes based on early compared with late operative intervention. Therefore, early palatal repair is not obligatory for optimal speech outcomes in children with SMCP and palatoplasty should be deferred until the emergence of overt velopharyngeal insufficiency.

Cohort study of immediate implant exchange during acute infection in the setting of breast reconstruction

BACKGROUND Implant infections in the setting of breast reconstruction present a significant setback for patients with breast cancer. Traditional management of implant infections is predicated on the operative removal of the implant and delayed replacement. Another option for implant infection management has emerged in which the soft tissue infection is neutralized, the implant is removed, the surgical site is washed out, and a new implant replaced immediately. In this study, we present our findings with the implementation of this technique and an algorithm for choosing which patients are the most appropriate candidates on the basis of a retrospective review. METHODS A retrospective chart review of patients who underwent operative removal of infected expanders from January 1, 2010 to December 31, 2015 was performed at the University of Michigan by the senior authors. The final reconstructive outcome, time to reconstruction, and infection recurrence were evaluated. RESULTS Twenty patients with clinical signs of implant infections were identified. Of them, 16 patients with clinical signs of implant infection underwent immediate implant exchange; 15 remained infection free, while 1 patient developed recurrent infection within a month, which was treated with device removal. The mean time to final reconstruction in the 15 infection free patients was 207 days, and the 4 patients who underwent removal without immediate replacement had a 75% rate of non-completion at over 500 days. CONCLUSIONS Our findings demonstrate that immediate implant exchange safely offers patients the opportunity to remain on a path toward reconstruction. These findings offer support for a paradigm shift in our management of implant infections in breast reconstruction patients who already face challenges associated with breast cancer care.

Abstract 69: Stem Cells Harvested from Bone Marrow and Adipose Tissue Demonstrate Equivalent Healing but Through Different Mechanisms in a Murine Model of Irradiated Mandibular Fracture Healing

METHODS: Immunocompromised nude-mice underwent external beam irradiation of the scalp. Five weeks later, mice either received seven deferoxamine treatments (1mg in 100ul) or saline subcutaneously to the irradiated area every other day. Laser Doppler analysis (LDA) was recorded prior to irradiation, following irradiation, and 24 hours following each treatment. Human fat grafts were then injected in the subcutaneous plane of the scalp and volume retention measured by CT scan over 8 weeks. Finally, skin and fat samples were evaluated histologically for vasculature, dermal thickness, and fat graft quality.

Abstract 48. Stem Cells Harvested from Bone Marrow and Adipose Tissue Demonstrate Differential Healing Mechanisms and Union Rates in a Murine Model of Irradiated Mandibular Fracture Repair

METHODS: Custom 3DBC scaffolds were either coated with collagen (control) or coated with collagen and immersed in 100 μM dipyridamole (DIPY). Sheep (n=5) were subjected to 4 trephine-induced (12 mm diameter) calvarial defects with immediate scaffold placement via two separate operations: anteriorly (control) and posteriorly (DIPY) on the right (3 weeks healing) and left (6 weeks healing) sides of the calvarium. Following sacrifice, defects were evaluated through microcomputed tomography and histologic analysis for bone, scaffold, and soft tissue quantification as a function of time in vivo. Statistical analysis was performed by a mixed model and significance was defined by p<0.05.

Remediation of Radiation-Associated Vasculopathy Utilizing a Novel Angiogenic Nanotechnology

RESULTS: 4 cm long full-thickness skin wounds were incised on the back of mice. The mice were locally treated by subcutaneous injections of CD24 derivatives from either bacterial or mammalian cell sources and compared to untreated mice. Wounds were histologically analyzed and scored, based on the degree of cellular invasion, granulation tissue formation, vascularity, and re-epithelialization. In the treated mice the wounds closed significantly faster then the untreated mice. No statistically significant difference was seen between bacterial and mammalian origin derivatives.

Abstract: Stem Cells Harvested from Bone Marrow and Adipose Tissue Demonstrate Equivalent Healing Potential in a Murine Model of Irradiated Mandibular Fracture Healing

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