Sunil S. Tholpady

Nasal airway and septal variation in unilateral and bilateral cleft lip and palate

Cleft lip and palate (CLP) affects the dentoalveolar and nasolabial facial regions. Internal and external nasal dysmorphology may persist in individuals born with CLP despite surgical interventions. 7–18 year old individuals born with unilateral and bilateral CLP (n = 50) were retrospectively assessed using cone beam computed tomography. Anterior, middle, and posterior nasal airway volumes were measured on each facial side. Septal deviation was measured at the anterior and posterior nasal spine, and the midpoint between these two locations. Data were evaluated using principal components analysis (PCA), multivariate analysis of variance (MANOVA), and post‐hoc ANOVA tests. PCA results show partial separation in high dimensional space along PC1 (48.5% variance) based on age groups and partial separation along PC2 (29.8% variance) based on CLP type and septal deviation patterns. MANOVA results indicate that age (P = 0.007) and CLP type (P ≤ 0.001) significantly affect nasal airway volume and septal deviation. ANOVA results indicate that anterior nasal volume is significantly affected by age (P ≤ 0.001), whereas septal deviation patterns are significantly affected by CLP type (P ≤ 0.001). Age and CLP type affect nasal airway volume and septal deviation patterns. Nasal airway volumes tend to be reduced on the clefted sides of the face relative to non‐clefted sides of the face. Nasal airway volumes tend to strongly increase with age, whereas septal deviation values tend to increase only slightly with age. These results suggest that functional nasal breathing may be impaired in individuals born with the unilateral and bilateral CLP deformity. Clin. Anat. 27:999–1008, 2014.

Helmet Use and Injury Patterns in Motorcycle-Related Trauma.

Administrative, technical, or material support: Holcomb, Graham. Study supervision: Hawn. Conflict of Interest Disclosures: None reported. Funding/Support: This study is supported by a Department of Veterans Affairs Health Services Research and Development Grant (IIR 09-347). Dr Holcomb is supported by grant T32 HS013852-11 from the Agency for Healthcare Research and Quality. Dr Richman is supported by a Department of Veterans Affairs Career Development Award. Role of the Funder/Sponsor: The Department of Veterans Affairs had no role in the design and conduct of the study; collection, management, analysis, or interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication. Previous Presentation: This paper was presented at the 39th Annual Meeting of the Association of VA Surgeons; May 3, 2015; Miami Beach, Florida. 1. Fleisher LA, Fleischmann KE, Auerbach AD, et al; American College of Cardiology; American Heart Association. 2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery: a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines. J Am Coll Cardiol. 2014;64(22):e77-e137. 2. Iversen LH, Antonsen S, Laurberg S, Lautrup MD. Therapeutic delay reduces survival of rectal cancer but not of colonic cancer. Br J Surg. 2009;96(10):1183-1189. 3. Simunovic M, Rempel E, Thériault ME, et al. Influence of delays to nonemergent colon cancer surgery on operative mortality, disease-specific survival and overall survival. Can J Surg. 2009;52(4):E79-E86. 4. Holcomb CN, Graham LA, Richman JS, Itani KM, Maddox TM, Hawn MT. The incremental risk of coronary stents on postoperative adverse events: a matched cohort study [published online April 17, 2015]. Ann Surg. doi:10.1097/SLA .0000000000001246. 5. Jackson GL, Melton LD, Abbott DH, et al. Quality of nonmetastatic colorectal cancer care in the Department of Veterans Affairs. J Clin Oncol. 2010;28(19): 3176-3181. 6. Paulson EC, Fu X, Epstein AJ. Location and timing of care for colon cancer patients in the VA Health System. J Surg Res. 2013;183(2):639-644.

Cone-Beam Computed Tomography Analysis of Mucosal Thickening in Unilateral Cleft Lip and Palate Maxillary Sinuses.

Objective To compare maxillary mucosal thickening and sinus volumes of unilateral cleft lip and palate subjects (UCLP) with noncleft (nonCLP) controls. Design Randomized, retrospective study of cone-beam computed tomographs (CBCT). Setting University. Patients Fifteen UCLP subjects and 15 sex- and age-matched non-CLP controls, aged 8 to 14 years. Main Outcome Measure Following institutional review board approval and reliability tests, Dolphin three-dimensional imaging software was used to segment and slice maxillary sinuses on randomly selected CBCTs. The surface area (SA) of bony sinus and airspace on all sinus slices was determined using Dolphin and multiplied by slice thickness (0.4 mm) to calculate volume. Mucosal thickening was the difference between bony sinus and airspace volumes. The number of slices with bony sinus and airspace outlines was totaled. Right and left sinus values for each group were pooled (t tests, P > .05; n = 30 each group). All measures were compared (principal components analysis, multivariate analysis of variance, analysis of variance) by group and age (P ≤ .016 was considered significant). Results Principal components analysis axis 1 and 2 explained 89.6% of sample variance. Principal components analysis showed complete separation based on the sample on axis 1 only. Age groups showed some separation on axis 2. Unilateral cleft lip and palate subjects had significantly smaller bony sinus and airspace volumes, fewer bony and airspace slices, and greater mucosal thickening and percentage mucosal thickening when compared with controls. Older subjects had significantly greater bony sinus and airspace volumes than younger subjects. Conclusions Children with UCLP have significantly more maxillary sinus mucosal thickening and smaller sinuses than controls.

Decreased Wait Times After Institution of Office-Based Hand Surgery in a Veterans Administration Setting

Carpal tunnel syndrome is a common peripheral nerve compression disorder causing symptoms of numbness, tingling, weakness, and muscle atrophy. Open carpal tunnel release (CTR) is a common treatment modality traditionally performed in the operating room with sedation or general anesthesia. It can also be performed in the surgeon’s office under local anesthesia only. 1 In our study, we examined the number of days from initial consultation and visit to operative intervention in a Veterans Administration (VA) setting. A significant decrease in wait time from initial consultation to operative intervention and from initial visit to operative intervention was hypothesized to occur with the transition to office-based hand surgery procedures, without an increase in complications. Methods | Institutional review board approval from the Richard L. Roudebush VA Medical Center was obtained to construct a database of recent surgical procedures performed for carpal tunnel syndrome by the plastic surgery service. Operations including CTR in conjunction with other procedures were excluded. The minor procedure room is located within the plastic surgery clinic, with a single nurse serving as a circulating nurse. The hand and forearm are prepped and draped, and both monopolar cautery and bipolar cautery are available. A more specific description to a similar configuration can be found in

Hand Surgery Resources Exceed American Health Literacy

Background: The National Institutes of Health, American Medical Association, and US National Library of Medicine recommend that educational material for patients be written at a sixth-grade reading level. The purpose of this study is to assess the complexity of hand surgery information on academic plastic and orthopedic surgery websites. Methods: An online search was performed for all hand surgery patient education materials provided by institutions with plastic and orthopedic surgery training programs. Readability analyses were conducted using the Flesch-Kincaid Reading Ease, Flesch-Kincaid Grade Level, Simple Measure of Gobbledygook Index, Gunning Fog Score, Automated Readability Index, and Coleman-Liau Index. A 2-tailed z test was used to compare means. Results: Seventy-six institutions with both plastic and orthopedic surgery training programs were identified; 42 had educational material available online. The average readability for all hand-related information was at the 11.92 grade reading level. Information regarding de Quervain tenosynovitis had the highest grade level for all plastic surgery procedures (13.45). Hand arthritis had the highest grade level for all orthopedic surgery procedures (12.82). Ganglion cysts had the lowest grade level for both plastic and orthopedic surgery (10.15 and 11.01, respectively; P = .12). Carpal tunnel release was the most commonly described procedure overall. There were no differences in text complexity among geographic regions. Conclusions: Online patient resources for common hand ailments are too complex for the average patient to understand. Efforts should be made to provide materials at the recommended sixth-grade reading level to improve patient education and improve the physician-patient relationship.

Assessing the Necessity of Stopping Antithrombotic Agents Before Wide-Awake Hand Surgery

Assessing the Necessity of Stopping Antithrombotic Agents Before Wide-Awake Hand Surgery Sarah E. Sasor, MD, Tyler A. Evans, MD, Julia A. Cook, MD, Elizabeth A. Lucich, MD, William A. Wooden, MD, Sunil S. Tholpady, MD, PhD, and Michael W. Chu, MD Division of Plastic Surgery, Department of Surgery, Indiana University, Indianapolis Richard L. Roudebush Veterans Affairs Medical Center, Indianapolis, Indiana Corresponding author. Article Information Corresponding Author: Michael W. Chu, MD, Division of Plastic Surgery, Department of Surgery, Indiana University, 545 Barnhill Dr, #232, Indianapolis, IN 46202 (dr.michael.chu@gmail.com). Accepted for Publication: July 2, 2017. Published Online: November 29, 2017. doi:10.1001/jamasurg.2017.3927 Author Contributions: Drs Sasor and Chu had full access to all of the data in the study and take responsibility for the integrity and accuracy of the data analysis. Study concept and design: Sasor, Evans, Wooden, Tholpady, Chu. Acquisition, analysis, or interpretation of data: Sasor, Cook, Lucich, Tholpady. Drafting of the manuscript: Sasor, Evans, Wooden, Tholpady. Critical revision of the manuscript for important intellectual content: All authors. Statistical analysis: Sasor, Cook, Tholpady. Administrative, technical, or material support: Lucich, Wooden, Chu. Study supervision: Sasor, Wooden, Chu. Conflict of Interest Disclosures: None reported. Meeting Presentation: This paper was presented at the Annual Meeting of the Association of VA Surgeons, May 9, 2017, Houston, Texas. Received 2017 May 17; Accepted 2017 Jul 2. Copyright 2017 American Medical Association. All Rights Reserved.

Tourniquet Use in Wide-Awake Carpal Tunnel Release

Background: Carpal tunnel syndrome is a common cause of upper extremity discomfort. Surgical release of the median nerve can be performed under general or local anesthetic, with or without a tourniquet. Wide-awake carpal tunnel release (CTR) (local anesthesia, no sedation) is gaining popularity. Tourniquet discomfort is a reported downside. This study reviews outcomes in wide-awake CTR and compares tourniquet versus no tourniquet use. Methods: Wide-awake, open CTRs performed from February 2013 to April 2016 were retrospectively reviewed. Patients were divided into 2 cohorts: with and without tourniquet. Demographics, comorbidities, tobacco use, operative time, estimated blood loss, complications and outcomes were compared. Results: A total of 304 CTRs were performed on 246 patients. The majority of patients were male (88.5%), and the mean age was 59.9 years. One hundred patients (32.9%) were diabetic, and 92 patients (30.2%) were taking antithrombotics. Seventy-five patients (24.7%) were smokers. A forearm tourniquet was used for 90 CTRs (29.6%). Mean operative time was 24.97 minutes with a tourniquet and 21.69 minutes without. Estimated blood loss was 3.16 mL with a tourniquet and 4.25 mL without. All other analyzed outcomes were not statistically significant. Conclusion: Operative time was statistically longer and estimated blood loss was statistically less with tourniquet use, but these findings are not clinically significant. This suggests that local anesthetic with epinephrine is a safe and effective alternative to tourniquet use in CTR. The overall rate of complications was low, and there were no major differences in postoperative outcomes between groups.

The Veterans Affairs Medical Center’s Contribution to Plastic Surgery Education

This population-based study evaluates the levels of case minimums met by plastic surgery residents in Veterans Affairs hospitals.

Treatment of Dupuytren Contracture With Injectable Collagenase Within the Veterans Affairs System

ASSOCIATION OF VA SURGEONS Treatment of Dupuytren Contracture With Injectable Collagenase Within the Veterans Affairs System Dupuytren contracture is a debilitating disease involving abnormal thickening of the palmar fascia, resulting in pits, nodules, and cords that lead to contracture of the digits. Prevalence in the veteran population is approximately 306 per 100 000 individuals.1 Surgic al management of Dupuytren contracture includes removal or release of the fascia via open fasciectomy, open fasciotomy, closed fasciotomy, and most recently, injectable collagenase. A doubleblind placebo-controlled trial published in 2010 showed a significantly greater mean increase in range of motion in the group that received collagenase (35.4°) than in the group that received placebo (7.6°) (P < .001); in addition, 50.7% of all joints treated with collagenase achieved a range of motion 0° to 5° of normal.2 With the US Food and Drug Administration approval of collagenase from Clostridium histolyticum in 2010, it was predicted that there would be increased use of collagenase, with an associated decrease in palmar fasciectomy and fasciotomy within the Veterans Affairs (VA) system.

Predicting the Presence of Nonmelanoma Skin Cancers After Biopsy: A Method to Reduce Unnecessary Surgical Procedures

ASSOCIATION OF VA SURGEONS Predicting the Presence of Nonmelanoma Skin Cancers After Biopsy: A Method to Reduce Unnecessary Surgical Procedures Nonmelanoma skin cancer (NMSC) is the most common type of skin cancer in the United States.1 The incidence of NMSC has nearly doubled in the past 20 years, creating a significant financial burden on health care systems.1 The current recommended surgical treatment of NMSC is complete reexcision of the biopsy scar with a several-millimeter margin. Studies2-4 have shown spontaneous clearance rates of 24% to 72% after biopsy and have tried to identify associated characteristics. Previous data from our institution suggest that the clinical appearance of a scar was associated with no cancer after surgical excision.5 The purpose of this study was to determine whether clearance of NMSC in excisional specimens can be predicted based on the appearance of a lesion after biopsy and on the demographic characteristics of the patient.