Multiple Reconstructive Procedures Research Articles

Endoscopic endonasal obliteration of the frontal recess and anterior skull base.

Although endoscopic techniques have become more widespread in repair of frontal sinus (FS) defects, certain pathologies still require open approach (extensive trauma or tumors). Under certain circumstances even multiple complex open reconstructive procedures might fail to resolve persistent pneumocephalus or CSF leak and subsequently surgeons tend to escalate the invasiveness and employ even more complex and aggressive approaches. We present our experience treating persistent pneumocephalus or CSF leak after previously failed transcranial reconstruction utilizing an endoscopic endonasal approach (EEA). We retrospectively reviewed a prospectively maintained database of all patients undergoing an EEA for repair of persistent pneumocephalus or CSF leak following FS cranialization between 2016 and 2020. Six patients who underwent cranialization of the FS with subsequent persistent pneumocephalus or CSF leak were identified; two patients suffered a traumatic fracture of the FS, remaining four patients had undergone previous cranial surgery. Clear violation of the FS was not recognized in one patient. All patients underwent cranialization of the FS either directly following initial craniotomy or during open repair of a FS fracture. Two patients underwent multiple transcranial surgeries including using vascularized free tissue transfer. Complete cessation of pneumocephalus/CSF leak was achieved in 83.3% (5/6) after the first and 100% (6/6) after two endoscopic procedures. No morbidity or mortality resulted from the endoscopic procedure. Skull base defects following a failed cranialization of FS are usually located in or in close proximity to the frontal recess. These defects can be safely and effectively repaired via an EEA.

Redo surgery to improve urinary function, sexual function and cosmesis in male patients with exstrophy–epispadias complex complications. Technical principles and pearls based on case scenarios

The bladder exstrophy-epispadias complex includes some of the most challenging conditions treated by pediatric urologists. They are associated with the need for multiple intricate reconstructive procedures, aimed at restoring the anatomy and function of the bladder, urethra and external genitalia. These patients often endure multiple redo reconstructive procedures to improve urinary function, sexual function and cosmesis throughout the first two decades of life. In this article, we present the 30-year experience of a single surgeon performing redo surgery for males born with epispadias and bladder exstrophy. Through detailed documentation of 6 clinical cases, we highlight technical aspects that may contribute to a successful surgical reconstruction in these patients. The article is focused specifically on patients undergoing redo epispadias repair with or without concomitant continence procedures. We make the case for complete penile disassembly with external rotation of the corpora to correct recurrent dorsal curvature; this approach also allows the surgeon to have access to the proximal urethra and bladder neck after opening the intersymphiseal scar/band. This is useful when additional procedures on the bladder, such as bladder neck tailoring, are necessary. We also highlight the importance of avoiding reverse Byars' flaps when performing skin closure, due to the resulting midline scar. Besides being associated with a poor cosmetic outcome, it can also contribute to recurrent dorsal curvature. The authors advocate for rotational skin flaps to cover the penile shaft. Correction of dorsal curvature and improved cosmesis obtained with complete penile disassembly sometimes comes at the expense of the urethra being left as a hypospadias (figure). This will require further surgeries (usually a 2-stage buccal mucosa graft), much like the treatment of proximal hypospadias. Redo epispadias surgery in males remains a challenge. The systematic approach offered by the case scenarios may help guide surgeons dealing with this difficult condition. Patient with complications after repair of classic bladder exstrophy. A) Stone retrieved from posterior urethra after complete penile disassembly. B) After opening the inter-symphiseal scar, the bladder has been opened and the bladder neck tailored. C) Complete penile disassembly has been completed with corporal bodies and urethra individualized. D,E,F) Final appearance of the repair; abdominal wall was closed with anterior rectus sheath flaps, penile skin was closed with rotational flaps and urethra ended up as a hypospadias.

Orbital Extenteration Defects: Ablative and Reconstructive Flowchart Proposal.

Orbital exenteration is a radical and disfiguring operation. It is still under debate the absence of correlation between the term describing the resulting orbital defect and the type of reconstruction. Authors' goal was to propose a consistent and uniform terminology for Orbital Exenteration surgery in anticipation of patients' tailored management. Twenty-five patients who underwent orbital exenteration between 2014 and 2020 were reviewed. A parallel comprehensive literature review was carried on. Five different types of orbital exenteration where outlined. Multiple reconstructive procedures were enclosed. An algorithm for orbital reconstruction was proposed based on anatomic boundaries restoration. Eyelid removal was first considered as an independent reconstructive factor, and both orbital roof and floor were indicated as independent reconstructive goals, which deserve different defect classification. In our opinion, this algorithm could be a useful tool for patient counseling and treatment selection, which might allow a more tailored patient care protocol. Level III.

Salvaging lives in carbapenem-resistant Gram-negative osteoarticular and soft tissue infections: early compromises save lives.

Incidence of carbapenem-resistant Gram-negative infections has risen alarmingly all across the globe, both in developed and developing countries alike. The purpose of this study was to assess whether challenges of life-threatening infections with very high resistance pattern can be successfully addressed by a modified approach. This is a retrospective study of 26 patients with osteoarticular and soft tissue infections with carbapenem-resistant Gram-negative bacilli treated between 2001 and 2017 with at least twoyear follow-up after stopping antibiotics. All were treated by a multispecialty team approach with primary aim of "source control at the earliest and avoiding recurrence at all cost". The protocol involved opting for early compromises especially in at "risk individuals", such as resorting to early amputations, especially if salvage meant multiple bony and soft tissue reconstructive procedures, explanation of prosthesis than staged revision, avoiding internal fixations, opting for shortest possible time in external fixators with reshaping and telescoping bone ends to get bony stability and increase surface area even if it meant compromising length. There were five amputations, two excision arthroplasty of hip, many minor but acceptable malunions and shortening. However, lives of 24/26 patients could be salvaged, much better than most of the published data. The two patients who died had peri-prosthetic joint infection after total hip arthroplasty and presented very late in sepsis and died within days of explantation. Infection remission could be achieved in remaining patients. These "risk to life" cases can be successfully treated by lowering the aims and expectations from "excellent function to salvage of life and infection remission". Therein lies the "success" in these complex high-risk cases.

Workhorse flaps for thumb reconstruction

Posttraumatic thumb defects result in significant functional impairment. Multiple reconstructive procedures have been described for the management and improvement of function. Compared with no treatment, all reconstructive methods are beneficial. Each of the available procedures may be more applicable under certain conditions, can offer great benefits, and have its own downsides as well. With a thorough assessment and meticulous technique, the results of thumb reconstruction can be excellent. We present a review of the current reconstructive procedures for traumatic thumb amputation.

Nephron Sparing Management of Complex Emphysematous Urinary Tract Infection of the Whole Urinary System: A Case Report

Emphysematous urinary tract infections (EUI) are rare life-threatening infections that are often found in diabetic patients with a predilection for females. Emphysematous pyelonephritis (EPN) is more frequently reported than emphysematous cystitis (EC). However, concurrent occurrence has been reported as well. On the other hand, ureteric involvement in cases of EUI has not been described well in the literature. Treatment should be aggressive as the rate of death can be as high as 15.4%. Early surgical intervention has been described for severe infections. However, conservative approach has also been adopted especially in cases where preserving kidney function is of utmost importance. We present a 22-year-old lady who is known to have chronic kidney disease, bladder dysfunction and multiple reconstructive urological procedures, presented with emphysematous urinary tract infection affecting the whole urinary system (both kidneys, ureters and urinary bladder), which was successfully treated in a nephron sparing approach.

A Quantitative Assessment of Wound Healing With Oxygenated Micro/Nanobubbles in a Preclinical Burn Model.

Burns are devastating injuries, carry significant morbidity, and require long-term treatment or multiple reconstructive procedures. Wound healing and secondary insults caused by burn wound conversion are amendable to therapeutic intervention, where ischemia has been cited as one of the major factors (Dermatol Surg. 2008;34:1159-1169). Halting injury progression in the zone of stasis is crucial as conversion creates increased burn surface area and depth, leading to local and systemic consequences (J Burns Wounds. 2006;5:e2). Oxygen-carrying micro/nanobubbles, MNB(O2), offer a novel technology that can be used to effectively deliver oxygen to burn wounds and potentially counteract burn wound ischemia. Topical irrigation with MNB(O2) of full-thickness burn wounds on a rodent model (n = 3) was compared against saline-treated controls (n = 3). Tissue structure (reduced scattering coefficient, μs'), oxyhemoglobin concentration (cHbO2), and tissue perfusion were quantified over the course of 28 days through spatial frequency domain imaging and laser speckle imaging. Histological samples taken at the end of the experiment were examined for evidence of wound healing. Findings in this preliminary study showed hastened healing with significant differences in spatial frequency domain imaging-measured μs' during wound healing (days 11-28) in MNB(O2) group. The healing "tipping point" seemed to occur at days 9 to 11 with increased collagen organization and increased cHbO2 occurring around that period confirming the gross healing improvements observed. In addition, histological evidence indicated that only the MNB(O2) burns had reached the remodeling phase by the end of 28-day study period. These preliminary findings propose the potential of MNB(O2) as a topical method for improving burn wound healing.

Multiple Sequential Free Flap Reconstructions of the Head and Neck: A Single-Center Experience.

Free flap reconstruction is the standard of care in extensive defects of the head and neck area, and although most patients may be treated sufficiently with one flap, recurrence of a malignant tumor or failure of a previous reconstruction may make the use of a second (or more) flap necessary. The aim of this study was to evaluate the indications and success rates of multiple consecutive reconstructive procedures in a large cohort of patients. Nine hundred ninety-six free flap reconstructions were retrospectively analyzed and cases of sequential reconstructions in the same patient were identified. Indications, success rates, perioperative procedures, and frequently used flaps were evaluated. Two hundred twenty cases of sequential microvascular reconstructions were identified, ranging from two to six flaps per patient. The overall flap success rate was 89.1 percent. A history of diabetes was identified as a risk factor for flap failure (p = 0.029). There was no association of flap loss with the number of reconstructive procedures per patient. The use of several free flaps in the same patient is a feasible option for patients suffering from recurrent tumors or to improve quality of life by a secondary reconstruction. A salvage free flap transfer to replace a lost transplant exhibits good success rates. Therapeutic, IV.

Surgical Management of FGFR2 Mutation-Related Syndromic Craniosynostosis: Retrospective Review of a 45-Year Experience By a Single Surgeon

PURPOSE: Mutations in the fibroblast growth receptor 2 (FGFR2) gene have been identified in syndromic craniosynostosis syndromes such as Apert, Crouzon, and Pfeiffer syndrome. Patients have severe malformations of the skull and face requiring multiple complex reconstructive procedures. As described by Paul Tessier, surgical correction of such patients is performed for 3 main reasons: functional, morphologic, and psychological. The surgical treatment algorithm has evolved over time. Despite numerous articles describing treatment of syndromic craniosynostosis, there are few reports of long-term results. Long-term follow up of patients after midface surgeries is important for evaluating which techniques result in consistent favorable outcomes, and which should be improved. We present a retrospective review reporting surgical procedures performed by a single surgeon in patients with Apert, Crouzon, and Pfeiffer Syndrome over a period of 45 years, with the intent to delineate procedures that have been effective over time. We also present our surgical treatment algorithm for pediatric patients with FGFR2 mutation–related syndromic craniosynostosis based on the senior author’s experience. METHODS: A retrospective review was performed of all patients with FGFR2 mutation–related syndromic craniosynostosis that underwent reconstruction for craniofacial defects, as performed by the senior author between 1975 and 2020. Patients without syndromic craniosynostosis were excluded. Inclusion criteria was limited to Apert, Crouzon, and Pfeiffer syndromes. Surgical procedures and complications were recorded for patients at all stages of the reconstructive process. RESULTS: A total of 68 patients were identified who had complete records for evaluation, including 30 patients with Apert syndrome, 27 patients with Crouzon syndrome and 11 patients with Pfeiffer syndrome. The average patient age was 30±15.8 years, with a range of 3–77 years of age. Mean long-term follow-up after initial surgery was 10.5 ± 10.1 years. Primary procedures performed for correction of craniofacial deformities included posterior distraction or expansion (10.3%), frontal expansion (14.7%), fronto-orbital advancement (39.7%), facial bipartition (11.8%), Le Fort III (19.1%), and Le Fort I (23.5%). Mean ages at which procedures were performed were 1.5 ± 1.6 years for posterior distraction or expansion, 1.1 ± 1.2 years for fronto-orbital advancement, 6.2 ± 3.8 years for monobloc frontoacial advancement, 4.6 ± 1.8 years for monobloc frontofacial advancement with facial bipartition, 13.2 ± 8.2 years for Le Fort III, and 17.0 ± 3.8 years for Le Fort I. Additional procedures commonly used included nasal bone grafts (25.0%) and lateral canthopexies (19.1%). CONCLUSIONS: This study, with an extensive long-term follow-up period, presents a pediatric surgical treatment algorithm for patients with FGFR2 mutation–related syndromic craniosynostosis. Our treatment algorithm entails a posterior distraction or expansion and fronto-orbital advancement at 6 months, monobloc frontofacial advancement ± facial bipartition at age 6 or 7, or a Le Fort III if morphologically indicated, and in most cases, a Le Fort I at age 17 or 18. Although multiple reconstructive procedures are necessary, complications are rare. This treatment algorithm results in good results in adolescence, allowing patients to integrate into mainstream life. However, patients tend to prematurely age, a problem that is not addressed by the current pediatric surgical treatment algorithm. Future directions include defining aesthetic surgical management of adults.

Reconstructive and prosthodontic outcomes after multiple palatomaxillary reconstructions.

A subset of patients who undergo major palatomaxillary reconstruction do not initially achieve their intended oncologic and/or reconstructive goals and require additional surgery. We aim to detail the unique management considerations in this patient population. We performed a retrospective review of patients who underwent palatomaxillary reconstruction by the senior author (m.l.u.) between 1998 and 2016. Twenty-one patients required multiple reconstructions. The median time to second reconstruction was 17 months. The most common reason for a second reconstruction was for recurrent disease (10 of 21), followed by functional/aesthetic reasons (7 of 21) and osteoradionecrosis (4 of 21). Four patients went on to have a third reconstruction, and two underwent a fourth. A total of 27 reconstructions were performed, consisting of 20 soft tissue free flaps, four vascularized bone free flaps, and three locoregional flaps. This patient cohort represents unique oncologic and reconstructive challenges. With long-term follow-up, multiple reconstructions may be required to optimize oncologic and functional/aesthetic outcomes. This is the first series of its kind that details the reasons for, as well as the outcomes of, patients who required multiple reconstructive procedures following initial palatomaxillary reconstruction. 2B Laryngoscope, 130:2349-2353, 2020.

Autologous breast reconstruction in older women: A retrospective single-centre analysis of complications and uptake of secondary reconstructive procedures

Women aged ≥65 years have the highest age-specific rates of breast cancer incidence in the UK. However, national audit results demonstrate that the rates of post-mastectomy breast reconstruction offered to and performed on this age group are considerably lower than in younger women (Jeevan, 2009). This discrepancy may arise from unsubstantiated concerns over greater medical and surgical risk in older patients (James, 2015). In the present study, the first of its kind in the UK, we sought to evaluate potential differences in postoperative complications following autologous breast reconstruction between young and older patient populations. We conducted a retrospective review of 59 patients (31 'younger' <65 years; 28 'older' ≥65 years) who underwent autologous breast reconstruction at Oxford University Hospitals, between 2008 and 2017. Clinical, operative, and outcome variables were compared across the two age groups. To examine the complete multi-stage process of breast reconstruction as a whole, we also compared rates of uptake of multiple secondary reconstructive and revisional procedures across age groups. Major surgical, minor surgical, and medical complication rates, as well as length of stay, did not differ significantly by age group. The scar revision rate (at the flap donor site) was higher in the <65 group (19.4% vs. 0.0%; p = 0.025). Otherwise, rates of secondary reconstructive and revisional procedures were comparable across both groups. Patients aged ≥65 years were not at a significantly greater risk of complications following autologous breast reconstruction compared to younger patients. Chronological age, in itself, should not influence treatment decisions surrounding breast reconstruction.

A European perspective of the cost effectiveness of facial composite tissue allotransplantation

BackgroundFacial composite tissue allotransplantation (CTA) may be considered in cases of severe facial injury. To date, no reports have analysed the cost of potential facial CTA in the UK. The aims of this study were to establish (1) the cost implications without facial CTA, necessitating multiple reconstructive procedures in cases with severe facial deformities, and (2) if facial CTA would be cost-effective in the UK given recent European and North American published cost analyses.MethodsHospital episodes’ data from two potential candidates for facial CTA were used to calculate cost of treatment. In these cases, severe facial trauma was managed by multiple disciplinary teams performing numerous conventional reconstructive procedures. One case served as an indicator of the cost of primary reconstruction during the immediate post-traumatic episode, from admission until first discharge. The other served as an indicator of the accumulative cost of care following primary reconstruction from first discharge to six years later. Costs incurred served as a guide for the cost of standard reconstruction in the UK. These were compared with the costs of similar reconstructive procedures performed in the USA. This was used with data reporting the cost of facial CTA in the USA and France to predict the cost of facial CTA in the UK.ResultsAnalysis revealed a cost benefit for facial CTA in a UK context that would become apparent from the third year post-transplant onwards.ConclusionFacial CTA may therefore be a more cost-effective long-term reconstructive option for patients with severe facial defects.Level of evidence: Level V, risk/prognostic study.

Pelvic pain in patients with complex mullerian anomalies including Mayer–Rokitansky–Kuster–Hauser syndrome (MRKH), obstructed hemi-vagina ipsilateral renal anomaly (OHVIRA), and complex cloaca

Caring for patients with congenital pelvic anomalies can be challenging in many ways but one crucial aspect is providing longitudinal into adulthood. Newborns with urinary, intestinal or vaginal obstruction require urgent operations to relieve obstruction followed by multiple reconstructive procedures involving the perineum. Openings are created in the pelvic floor musculature that did not exist in development. Adolescence presents further challenges for these postoperative patients while other diagnoses present for the first time in the peri-pubertal teenage years. Young adults can have new symptoms when they become sexually active and are faced with reproductive decisions. During all of these time periods, optimization of function is of paramount importance and patients who are suffering are not able to participate in school, sports or work. This study evaluates the prevalence of pelvic pain in newborns and adolescents with complex congenital pelvic anomalies, associated factors and possible treatment options.

Urinary Continence Outcomes in Classic Bladder Exstrophy: A Long-Term Perspective.

We investigated surgical approaches to urinary incontinence and long-term continence outcomes after successful bladder reconstruction in a heterogeneous patient population with classic bladder exstrophy. We hypothesized that while most patients will achieve urinary continence after surgery, only a select group will void volitionally per urethra. An institutional database of 1,323 patients with exstrophy-epispadias complex was reviewed for patients with classic bladder exstrophy who underwent successful bladder closure and a subsequent continence procedure between 1975 and 2017. Procedures included bladder neck reconstruction, bladder neck reconstruction with augmentation cystoplasty or continent catheterizable stoma, and bladder neck closure with continent catheterizable stoma. Cloacal exstrophy, epispadias and variant exstrophy cases were excluded from analysis. Continence at last followup was defined as a dry interval of 3 or more hours without nighttime leakage. Those patients with more than 3 months of followup were assessed. Overall 432 patients underwent successful bladder closure (primary 71.5%, repeat 28.5%) and a urinary continence procedure. At last followup 162 (37%) underwent bladder neck reconstruction, 76 (18%) underwent bladder neck reconstruction with augmentation cystoplasty or continent catheterizable stoma, 173 (40%) underwent bladder neck closure with continent catheterizable stoma and 18 underwent other procedures. Median followup from the first continence procedure was 7.2 years (IQR 2.3-13.7). Continence was assessed in 350 patients. After isolated bladder neck reconstruction 91 of 142 patients were continent (64%, 95% CI 56-72). After bladder neck closure with continent catheterizable stoma 124 of 133 patients evaluated were continent (93%, 95% CI 87-97). Most patients with classic bladder exstrophy require multiple reconstructive procedures to achieve continence. Only about 25% of patients are expected to void normally per urethra without reliance on catheterization or urinary diversion.

Mayo Clinic's First Face Transplant

In June 2016, we performed the first face transplant at Mayo Clinic. Mayo Clinic established a reconstructive transplant program as an extension of clinical practice in 2010. A 31-year-old Caucasian male had significant functional limitations and disfigurement despite multiple conventional reconstructive procedures following a self-inflicted gunshot to the face. These limited his social interactions and potential for career advancement. He was referred for transplant 7 years after his injury. He was listed for transplant after 2 1/2 years of evaluation, education, psychosocial assessment and follow-up. The surgical team rehearsed the planned surgery over 50 Saturdays in the cadaver lab. Guides developed by Medical Modeling using 3D CT reconstruction aided bone cuts. He received a blood group compatible, negative flow cross match, no DSA transplant. Donor and recipient were EBV negative. Donor was CMV positive and the recipient negative. The graft consisted of all facial tissues from below the eyelids including maxilla, mandible and teeth. Immunosuppression consisted of anti-thymocyte globulin (ATG) induction and a triple immunosuppressive regimen consisting of tacrolimus, mycophenolate mofetil, and corticosteroids. The patient recovered well from surgery. The aesthetic result was deemed excellent by the patient “better than I expected”. He regained his sense of smell, the ability to chew food (prior to the transplant he had only two molar teeth with significant microstomia. Gradually nerve regeneration progressed with the ability to smile and coapt his lips. Nasal breathing was also possible. One VCA Banff grade two rejection occurred on day 57-post transplant. This was successfully treated with a course of pulse corticosteroids. Seven months after transplant valganciclovir prophylaxis was discontinued due to leucopenia. Asymptomatic primary CMV infection was detected on surveillance. A combination of viral markers and virus specific immune monitoring was used to tailor therapy. A short course of valganciclovir controlled the infection and the patient developed humoral and cellular virus specific monitoring. One year after transplant two-point discrimination was 5 mm. Renal function was preserved and functional recovery continues.

Management of a Complex Lower Limb Open Fracture in a Teenage Patient: A Case Report

The challenges of managing Gustilo IIIB tibial fractures (ie, high energy trauma with a contaminated wound >10 cm in length, severe comminution ["crumbling"] or segmental fractures, and periosteal stripping) in children are unique in part because no clear guidelines exist and the injuries may cause short-term and long-term complications. Repeated wound debridement and secondary reconstruction are required in approximately 20% of these cases in both adults and children. A 13-year-old girl presented with severe polytrauma including an open Gustilo type IIIB fracture of the left lower leg. The patient declined limb amputation; a multidisciplinary team (plastic, pediatric, orthopedic-trauma surgeons, pediatrician, psychiatrist, clinical pharmacologist, anesthesiologist, physiotherapist, nurses) was assembled in order to give the patient the best chance of a successful outcome. Multiple limb salvage and reconstructive procedures including wound debridements, necrectomies, long-term negative pressure wound therapy, soft tissue reconstructions, external bone fixation, bone osteosynthesis, multiple skin grafts, and free-flap reconstruction were provided over a period of 6 months with great success. The patient is doing well 3 years after initial injury and is walking without complications. A multidisciplinary approach and structured treatment plan are important to minimize complications, avoid unnecessary delays in treatment, decrease morbidity, and provide the patient with the best result possible. Studies examining optimal treatment strategies for children and adolescents with these complicated fractures are needed.

Upper Extremity Patterns of Injury and Management at a Plastic and Reconstructive Surgery Referral Center in Mexico City.

Acute upper extremity injuries remain one of the most common consultations in the emergency departments for plastic surgery services. These injuries can affect a person's quality of life and negatively affect work-related or social interactions if not properly managed. We aim to evaluate our experience and management in a specialized referral center in Mexico City. A retrospective review was performed. All patients with hand trauma managed by our service from July 2010 to June 2015 were included; their demographic characteristics were described as well as the most common patterns of injury, management, and outcome. A total of 4751 patients with injuries in the upper extremities were included, 77% were males with a mean age of presentation of 26.9 ± 17.9 years; the age group most commonly affected was between 16 to 30 years (39%); 54% of the cases affected the right hand. Lacerative wounds were the most common mechanism of injury (60.7%), followed by blunt trauma (28.7%). Management was surgical in 87% of the cases. Upper extremity trauma encompasses a wide range of clinical presentations, from simple lacerations to catastrophic injuries that require extensive or multiple reconstructive procedures. The clear understanding of the trauma mechanisms and how they are related with certain patterns of injury might maximize awareness and guide a surgeon's management effectively.

Reevaluation of the arterial blood supply of the auricle.

The anatomical basis for auricular flaps used in multiple aesthetic and reconstructive procedures is currently based on a random distribution of the underlying arterial network. However, recent findings reveal a systematic pattern as opposed to the present concepts. Therefore, we designed this study to assess the arterial vascular pattern of the auricle in order to provide reliable data about the vascular map required for surgical interventions. Sixteen human auricles from eight body donors (five females/three males, 84.33±9.0years) were investigated using the unique 'Spalteholz' method. After arterial injection of silicone, a complete transparency of the tissue was achieved and the auricular arteries and branches were visible. Qualitative and quantitative evaluation of the arterial vascular pattern was performed. The superior and the inferior anterior auricular artery provided the vascular supply to the helical rim, forming an arcade, i.e. helical rim arcade. On the superior third of the helical rim another arcade was confirmed between the superior anterior auricular artery and the posterior auricular artery (PAA), i.e. the helical arcade. The perforators of the PAA were identified lying in a vertical line 1cm posterior to the tragus, supplying the concha, inferior crus, triangular fossa, antihelix and the earlobe. The results of this study confirmed the constant presence of the helical rim arcade (Zilinsky-Cotofana), consistent perforating branches of the PAA, and the helical arcade (Erdman), and will help and guide physicians performing auricular surgeries toward fast and simple procedures with optimal patient satisfaction.

Health-Related Quality of Life and the Desire for Revision Surgery Among Children With Cleft Lip and Palate.

Children with cleft lip with or without palate (CLCP) require multiple reconstructive procedures, however, little is known about their desire for surgical revision. The purpose of this study was to examine the relationship between health-related quality of life (HRQOL) and the desire for revision. The authors surveyed children with CLCP (n = 71) and their caregivers regarding general and cleft-specific HRQOL and the desire for revision surgery. The authors used logistic regression models to evaluate the relationship between HRQOL and the desire for revision stratified by age, and determined the level of agreement between caregivers and children. In this cohort, 54.9% of children desired revision, primarily of the nose (n = 23), lip (n = 20), and dentoalveolar structures (n = 19). Children 11 years or older were more likely to desire revision than younger children (OR 3.39, 95% CI [1.19, 9.67], P <0.05). Children who reported poorer HRQOL with respect to appearance (OR 2.31, 95% CI [1.25-4.29], P = 0.008), social development (OR 0.91, 95% CI [0.84-0.99], P = 0.02), and communication (OR 0.94, 95% CI [0.89-0.99], P = 0.02) were significantly more likely to desire revision than children who reported more positive HRQOL. Caregivers' and children's desires for revision were only modestly correlated (r = 0.41). Children with CLCP who report poorer HRQOL are more likely to desire revision than children with higher HRQOL; these differences are further magnified among older children. Given the modest correlation between patient and caregiver goals for revision, it is important to evaluate both perspectives when considering revision surgery.

Superior Limbic Keratoconjunctivitis-like Inflammation in Patients with Chronic Graft-Versus-Host Disease

PurposeDescribe the presentation and management of superior limbic keratoconjunctivitis (SLK)-like inflammation and secondary limbal stem cell dysfunction in the setting of ocular chronic graft-versus-host disease (cGVHD). MethodsRetrospective observational case series in a multicenter clinical practice. Participants were 13 patients (26 eyes) with ocular cGVHD and SLK-like inflammation presenting to the University of Illinois at Chicago and BostonSight® between January 1, 2009 and July 1, 2013. Main outcome measures1) Reversal or worsening of SLK, and 2) development of limbal stem cell dysfunction. ResultsAll eyes showed evidence of SLK-like inflammation and superior limbal stem cell dysfunction manifested by conjunctival injection and superior conjunctival and corneal staining. In addition to aggressive lubrication, management strategies for SLK included topical steroids (20/26), punctal occlusion (18/26), topical cyclosporine (24/26), autologous serum tears (12/26), therapeutic soft contact lens (13/26 eyes) and scleral lenses (4/26 eyes). SLK and limbal stem cell dysfunction were reversed in 23/26 eyes. Three eyes of two patients with long-standing disease demonstrated frank limbal stem cell deficiency (LSCD) and corneal pannus, with one patient requiring multiple reconstructive surgical procedures. ConclusionsSLK-like inflammation is an under-recognized condition in patients with severe dry eyes secondary to ocular cGVHD. Untreated SLK can potentially lead to permanent LSCD over time. Early recognition and management of SLK in ocular cGVHD can improve vision, reverse signs, and may prevent these long-term consequences.