Primary Grafting Research Articles

Glaucoma in penetrating keratoplasty: risk factors, management and outcome

Glaucoma is a leading cause for graft failure. This retrospective study analyzes the risk factors, graft status, and treatment modalities in patients with post-penetrating keratoplasty glaucoma. A retrospective analysis of case records of 1,848 penetrating keratoplasties carried out between 2000 and 2005 was performed. A total of 160 patients (160 eyes) with post-penetrating keratoplasty glaucoma were included; 112 cases were primary grafts, 48 repeated grafts. The assessment included the pre-operative history of corneal disease and glaucoma, the lens status, and the anesthesiological techniques. Furthermore, the response to anti-glaucoma treatment, graft failure, and endothelial cell loss was evaluated. The incidence of post-penetrating keratoplasty glaucoma was 8.7 % (160/1,848). Preoperative glaucoma was the most important risk factor (62/160). Half of the patients (81 patients) responded to medical therapy (51 %) and the other half of patients (79 patients) to surgical therapy (49 %); of the latter, filtering surgery were performed in 16 %, cyclodestructive procedures in 66 % and both in 16 %. One patient received a glaucoma implant and cyclodestructive procedures (1 %). After 24 months, clear grafts were achieved in 94 eyes (59 %). Visual acuity after 24 months of 20/200 (logMAR 1.0) or better was achieved in 77 eyes (46 %) and of 20/50 (logMAR 0.4) in 33 eyes (21 %). Careful and ongoing observation of IOP, especially in the first year after PK, is recommended for patients after penetrating keratoplasty and prompt treatment of IOP elevation when indicated. Early filtering surgery with a better outcome than other surgery procedures should be preferred if medical treatment is not sufficient. Despite anti-glaucoma therapy, good visual outcome can remain beyond expectations despite a clear graft. While there is a potential option for graft exchange, damage to the optic nerve from end-stage glaucoma leads immutably to visual loss.

The usefulness of the bilobed flap for lateral cheek defects

The cheek and nose are common areas for skin cancers. There are multiple approaches to surgical excision and reconstruction, depending on the size of defect, tissue quality, adjacent cosmetic units and hairline. An effective solution to skin defects of the lateral cheek is the bilobed flap. This flap tends to be underused in the lateral cheek area because primary closure and skin grafts are perceived to be easier methods of reconstruction. However, the use of the bilobed flap for lateral cheek and other defect closures is encouraged. There are several basic principles that are key when performing this flap. These components of the procedure are highlighted.

Association between body mass index and outcome of coronary artery bypass

Studies have shown disparate findings regarding body mass index and outcomes after coronary artery bypass. We analyzed body mass index and other clinical variables that might predict morbidity and mortality after primary isolated coronary artery bypass. Data on 4,425 patients (79% men) were reviewed retrospectively. They were classified as underweight (1.6%), normal weight (65%), obese (32%), and morbidly obese (1.4%) according to body mass index <20, 20-29, 30-39, and >40 kg·m(-2), respectively. Multiple logistic regression was used for correlates of 30-day outcome. Cox regression was used for predictors of late outcome in underweight and morbidly obese patients. There were 45 (1%) deaths and 234 (5%) cases of morbidity within 30 days. Independent correlates of 30-day morbidity were smoking, logistic EuroSCORE, blood and blood product transfusions. Correlates of 30-day mortality were logistic EuroSCORE and blood transfusion. The only independent predictor of late death in underweight and morbidly obese patients was preoperative arrhythmia. Body mass index was not a predictor of 30-day morbidity or mortality. The 1-, 3-, and 7-year survival rates were not significantly different between underweight and morbidly obese patients. Body mass index did not affect short-term outcomes after primary coronary artery bypass grafting.

An unusual case of congenital melanocytic nevus presenting as neurocutaneous melanoma coexisting with Tuberous Sclerosis complex: A case report

IntroductionCongenital melanocytic nevi are among the several known risk factors for the development of melanoma. Neurocutaneous melanosis is a rare, congenital, non-hereditary disorder characterized by the presence of multiple and/or giant congenital melanocytic nevi. It is a rare condition, with fewer than 200 cases reported in the literature. Its association with tuberous sclerosis complex, a form of the neurocutaneous syndrome, is an unusual finding which, to the best of our knowledge, has not been documented in the English literature so far. Herein we present the first case documenting such an association in a 16-year-old post-pubertal Indian girl.Case presentationIn this report, we describe the case of a 16-year-old Indian girl who presented to our hospital with swelling on the scalp which had progressed from the hairline to just above the left brow, causing mechanical ptosis. She was born with a black-pigmented triangular patch covered with hair over the scalp which had increased in size over a period of eight years after birth. An X-ray of her skull and ultrasonography revealed soft tissue swelling in the left temporofrontoparietal region. Magnetic resonance imaging of her brain showed the presence of 8.99 cm × 2.26 cm abnormal signal intensity involving the scalp, a few small tubers with cortical dysplasia in the left frontoparietal region with asymmetric dilatation, and the presence of calcified subependymal nodules within the left lateral ventricle. These findings were suggestive of tuberous sclerosis. A histopathological examination of the swelling was suggestive of congenital melanocytic nevi. The patient underwent surgery. Excision of the tumor with primary skin grafting was done, with the graft being taken from the medial aspect of the right thigh.ConclusionThis case warrants further research to provide concrete evidence of an association of neurocutaneous melanoma with tuberous sclerosis complex. Research should be conducted to prove whether this is an unusual association or a new syndrome. Also, similar cases in other parts of the globe should be documented, as they would provide substantial support for such an association.

Median Nerve Repair with Autologous Sciatic Nerve Graft: A Case Report

Background. Peripheral nerve injury treatment options are limited to primary nerve repair, nerve grafting, and tendon transfers. In this case, a large suitable donor site was easily accessible and delayed grafting was indicative of poor prognosis. Case Description. A 25-year-old soldier presented to a military hospital in Afghanistan following a roadside bomb attack. The patient had a medial shrapnel wound in the bicipital groove with a cool pulseless hand and catastrophic lower extremity injuries. Bilateral above-the-knee amputations (AKAs) and exploration of the medial shrapnel wound were undertaken. A 7 cm traumatic defect in the median nerve was repaired with interpositional sciatic nerve graft harvested from the AKA. Conclusion. Recovery of motor function after nerve grafting is dependent on motor axons reinnervating target muscles, making proximal nerve injuries problematic. We identify a potential nerve harvest site in patients with lower extremity amputations in need of long segment nerve repairs.

FIXATION OF COMMINUTED DISTAL RADIUS FRACTURES WITH A MIXTURE OF CALCIUM PHOSPHATE AND CALCIUM SULFATE CEMENT

Distal radius fracture alignment and stabilization can be a surgical challenge in the face of severe comminution and bone loss. We describe a technique using a calcium phosphate/sulfate bone cement, as an adjunct to internal fixation. This bone cement is biocompatible, osteoconductive, and sets quickly with an isothermic reaction. The use of bone cement eliminates the need for primary autologous bone grafting and allows for easier reduction and retention of reduction at the time of surgery. Bone cement is employed for the following purposes in comminuted fractures: (1) to fill a void due to lost or crushed cancellous bone, (2) to hold larger unstable fragments while hardware is placed, and (3) to retain fragments too small to take hardware. Available bone cements, studies involving the use of bone cement for distal radius fractures, indications, and surgical technique will be reviewed.

Relation of Race, Ethnicity and Cardiac Surgeons to Operative Mortality Rates in Primary Coronary Artery Bypass Grafting in California

Relation of Race, Ethnicity and Cardiac Surgeons to Operative Mortality Rates in Primary Coronary Artery Bypass Grafting in California

Relation of Race, Ethnicity and Cardiac Surgeons to Operative Mortality Rates in Primary Coronary Artery Bypass Grafting in California

The aim of this study was to evaluate whether African American, Hispanic, and Asian patients in California were more likely to undergo coronary artery bypass grafting (CABG) by cardiac surgeons with higher risk-adjusted mortality rates (RAMRs). Clinical data from the California CABG Outcomes Reporting Program were analyzed for all patients who underwent isolated CABG from 2003 to 2006 by surgeons who performed ≥ 10 operations. Surgeons were divided into quintiles on the basis of their RAMRs, with the top-performing surgeons in the first quintile and the lowest performing surgeons in the fifth quintile. There were 72,845 isolated CABG procedures performed by 303 surgeons, including 49,886 in white, 9,380 in Hispanic, 6,867 in Asian, and 2,750 in African American patients. African American and Asian patients underwent CABG by surgeons with higher mean RAMRs (2.90% and 2.99%, respectively) compared with the state average of 2.65% (p <0.001). Compared to white patients, Asian and Hispanic patients were more likely to be treated by surgeons in the lowest quintile (odds ratio [OR] 1.2, 95% confidence interval [CI] 1.11 to 1.3, and OR 1.38, 95% CI 1.30 to 1.48, respectively). African Americans and Hispanics were less likely to be operated on by surgeons in the top quintile compared to white patients (OR 0.80, 95% CI 0.71 to 0.90, and OR 0.81, 95% CI 0.76 to 0.87, respectively). Hispanics were less likely to be treated by surgeons in the top quintile than by surgeons in the lowest quintile (OR 0.65, 95% CI 0.60 to 0.75). In conclusion, racial and ethnic minority patients who undergo isolated CABG in California may be more likely to be operated on by cardiac surgeons with higher RAMRs.

Interleukin-2 receptor antibody does not reduce rejection risk in low immunological risk or tacrolimus-treated intermediate immunological risk renal transplant recipients

The use of interleukin-2 receptor antibody (IL-2Ra) induction has been associated with reduced rejection rates in renal transplant recipients. However, the effect of IL-2Ra induction on graft and patient outcomes in renal transplant recipients with differing immunological risk remains unclear. Using Australia and New Zealand Dialysis and Transplant Registry, renal transplant recipients in Australia between 1995 and 2005 were included. Recipients were stratified into low immunological risk (primary grafts with < or = 2 human leucocyte antigen (HLA)-mismatches and panel-reactive antibody (PRA) < 10%) or intermediate immunological risk (subsequent grafts or >2 HLA-mismatches or PRA > 25%) recipients. Recipients receiving T-cell depletive induction therapy or steroid and/or calcineurin-free inhibitor regimens were excluded. Outcomes analysed included the presence of rejection at 6 months, estimated glomerular filtration rate at 1 and 5 years, graft and patient survival. 218 of 1220 (18%) low-risk and 883 of 3204 (28%) intermediate-risk recipients received IL-2Ra. In intermediate-risk recipients, IL-2Ra induction was associated with a 26% reduction in the incidence of acute rejection; but this benefit was restricted only to recipients initiated on cyclosporine-based immunosuppressive regimens. In contrast, the use of IL-2Ra in low-risk recipients was not associated with reduced rejection risk. There was no association between IL-2Ra induction and other graft or patient outcomes in both low- and intermediate-risk recipients. This registry analysis suggests that IL-2Ra induction may be associated with a reduction in rejection risk in cyclosporine-treated intermediate immunological risk recipients, but not in low-risk renal transplant recipients.

Induction With Basiliximab in Renal Transplantation

Introduction The use of monoclonal antibodies in renal transplantation for induction therapy has been associated with a marked reduction in acute rejection rates with an impact on graft and patient survivals. Objective We sought to evaluate the efficacy of renal transplant induction protocols using Basiliximab based on the rates of acute rejection episodes (ARE) and delayed graft function (DGF) of infectious complications in the first 6 months posttransplant, as well as patient and graft survivals. Methods We retrospectively evaluated all renal transplants performed between 2000 and 2008 that were primary grafts from cadaveric heart-beating donors, into recipients with a panel reactive antibody titer <5% and who were treated with an immunosuppression scheme based on cyclosporine, mycophenolate mofetil/mycophenolic acid plus corticosteroids, with (group 1) or without basiliximab (group 2). Results We enrolled 52 recipients in group 1 (induction with basiliximab) and 189 in group 2 (without basiliximab). The baseline characteristics were similar among the groups, except for time on dialysis which was longer in group 1 and the number of HLA matches, which was lower in group 1. The ARE rate was lower among group 1 (7.8% vs 27.8%; P = .001); rates of DGF and infectious complications were similar. There was no significant difference in graft and patient survivals. Conclusion In this study, induction with basiliximab was associated with a reduced rate rate of ARE, despite a lower number of HLA matches and a longer previous time on dialysis. The use of this induction modality was not associated with a greater rate of infectious complications.

Functional limb salvage in severe war injuries to limbs

High-velocity weapons usually result in a great amount of tissue damage and represent a surgical challenge. We analyzed the results of the treatment of patients after severe war injuries to the limbs (limbs at risk), in whom functional restoration of the limbs was performed. Eighteen patients with severe high-energy limb fractures after blast injuries and high-velocity gunshots were treated from 1993 to 2006. Soft-tissue debridement followed by axial realigning and fracture stabilization using tubular external fixators was performed on admission day in most of the patients. The primary tubular fixators were exchanged 5–7 days later for minimally invasive methods of definitive skeletal fixation (mostly Ilizarov frames), and soft-tissue coverage using delayed primary sutures, skin grafts or flaps was accomplished. Post-traumatic bone defects in three patients were treated by gradual bone transport in the Ilizarov frames. The injured limbs were preserved in all the treated patients and most returned to active lives. Staged treatment including primary temporary unilateral tubular stabilization performed in damage control procedures followed by definitive minimally invasive fracture fixation methods was found to be an effective tool in the management of patients suffering from severe tissue damage due to high-energy war injuries, including limbs at risk.

Primary Pediatric Keratoplasty: Indications and Outcomes

To evaluate patient characteristics, indications, and outcomes of pediatric keratoplasty, and to identify variables that may help predict poor surgical outcomes. The authors performed a retrospective chart review of penetrating keratoplasty performed in children 14 years and younger between 1991 and 2006. Primary keratoplasty data were used in the statistical analysis for graft survival. A total of 106 penetrating keratoplasties were performed in 47 patients during the study interval. Sixty procedures were primary grafts, and the remaining were regrafts. Median follow-up was 4.4 years. The surgical indications included congenital opacities in 37 eyes (61.6%), acquired nontraumatic opacities in 13 eyes (21.7%), and acquired traumatic opacities in 10 eyes (16.7%). Overall graft survival at 1 year was 54%. There was no statistically significant difference in 1 year graft survival among the surgical indication categories (congenital opacities 54%, acquired nontraumatic 53%, acquired traumatic 48%, P = 0.8). Graft survival at 1 year was similar among the different age groups (48% for patients younger than 6 months, 67% for patients 6 months to 5 years, 51% for patients older than 5 years, P = 0.78). Patients with Peters' anomaly had similar graft survival rates to patients with other congenital opacities (67% vs 48% survival at 1 year, P = 0.78) Patients with pretransplant and/or posttransplant glaucoma had worse 1-year graft survival compared with patients without preoperative glaucoma (glaucoma 32% vs no glaucoma 70%, P = 0.02) Pretransplant and/or posttransplant glaucoma was the only independent predictor of worse graft survival in a multivariate analysis (P = 0.02). Pediatric penetrating keratoplasty has a fair overall prognosis for graft survival of approximately 50% at 1 year. Prekeratoplasty and/or postkeratoplasty glaucoma is associated with poorer long-term graft survival.

Management of Extensive and Complex Scalp Defects in Patients of Neoplasm

Background: Reconstruction of extensive and complex scalp defects in patients of neoplasm remains a significant challenge because of cerebrospinal fluid leak, bacterial contamination from sinus exposure, effect of radiation therapy, neoadjuvant or postoperative chemotherapy, and functional and cosmetic deformity from the size and location of the defect. In this series, we present our experience in the management of extensive defects Materials and Methods: Between 1993 and 2008, ten patients with scalp defects received reconstruction with a variety of free flaps: four free vastus lateralis muscle flaps, three anterolateral thigh flaps, three latissimus dorsi flaps with fasciocutaneous extension and one radial forearm flap. These defects had a wide spectrum of complexities including extensive multilaminar defects with exposed brain and dura, irradiation damage, infection of the wounds and central nervous systems. The flaps were used to cover the defects resulting from the radical debridement or tumor ablation with or without radiation in patients ranging from 35 to 61 years of age. Follow-up ranged from one to ten years. The patients' demographics, surgical indications, type of flaps and exposed structures, comorbidity, complications and outcomes were assessed. Fisher's exact test was used to evaluate the correlation between CSF leakage and postoperative complications and mortality. Results: All patients were referred from our neurologic surgeons after ablative surgery with or without adjuvant radiotherapy. Among the ten patients, six had a cerebrospinal fluid leak at the time of the reconstruction. Of the six patients, one had total flap loss requiring another free flap reconstruction and two had partial flap necrosis, demanding debridement and split-thickness skin grafting. Four flaps totally survived and the cerebrospinal fluid leak all resolved in the six patients. In comparison, of the four patients without a cerebrospinal fluid leak, all flaps survived. The perioperative mortality is 10% and the overall mortality is 20%. One patient died of sepsis 1.5 months later and the other one died of primary cancer 1.5 years after reconstruction. Conclusion: Although our case number is very small, our results support that free flap reconstruction is a life-saving procedure in this high-risk population and that success is possible. Comparing to fasciocutaneous flaps, muscle flaps with primary or secondary split-thickness skin grafting can provide better cosmetic result. Difficult problems, such as severe central nervous system infection, recurrent cerebrospinal fluid leaks and large irradiated wounds including osteoradionecrosis, can be managed and resolved successfully using this technique.

Particulate Inlay Nasal Graft With Immediate Dental Implant Placement in a Patient With Repaired Alveolar Cleft: Case Report

Primary bone grafts in congenital cleft alveolus do not always provide sufficient bulk or height of bone for ideal placement of endosseous implants. Thus, maxillary sinus or nasal floor elevation and inlay bone grafts in previously grafted areas are not exceptions in the daily routine. This case report stresses the need of a detailed treatment plan and careful surgical management of nasal floor elevation with particulate autogenous bone graft to successfully provide the patient with osseointegrated prostheses.

Outcomes in right liver lobe transplantation: a matched pair analysis

Split liver transplantation (SLT) has proven to be an effective technique of increasing the donor pool and thereby reducing adult and paediatric waiting list mortality. There remains concern regarding complications in adult recipients. Here, we compare SLT with matched whole liver grafts. Adult recipients of primary extended right lobe grafts (ERL) were matched to recipients of whole liver transplantations (WLTs) according to the following criteria: model of end-stage liver disease (MELD) score, recipient age, indication for liver transplantation and year of transplantation. Twenty-seven pairs of recipients were transplanted for chronic liver disease. The overall 30-day patient survival rates after ERL and WLT were 88.9% and 92.5% and 3-year survival rates after SLT and WLT were 77.8% and 85.2% respectively (log-rank = 0.38). Two patients with SLTs had hepatic artery thromboses and were retransplanted with none from the WLT group. The prevalence of a biliary leak was higher among the SLT group (n = 4) compared with none in the WLT group (P = 0.05). Patients with preoperative hyponatraemia showed a trend towards poorer survival after SLT compared with WLT. Our data suggest that SLT with extended right liver lobes, although not significantly different, shows a trend towards a poorer outcome.

Porous Polyethylene (Medpor) Orbital Implants with Primary Acellular Dermis Patch Grafts

Purpose: To evaluate the results of the porous polyethylene (Medpor) orbital implantation technique combined with the use of a primary patch graft of acellular dermis. Methods: The study design was a retrospective, non-comparative single surgeon case series of 27 patients. The Medpor orbital implant was placed with a primary anterior sub-Tenon's acellular dermis patch after evisceration (23/27), enucleation (2/27) or implant exchange/secondary implant procedure (2/27) over a period of 3 years. Risk factors for dehiscence/complications were defined as trauma, infection, inflammation, previous ocular surgery, radiotherapy, secondary orbital implantation, and removal of extruding implants. The primary outcome measure was the development of implant exposure. Other complications were also recorded, including postoperative conjunctival wound dehiscence. Results: Twenty-five patients (93%) had more than 2 risk factors. Mean follow-up time was 22 months (median 24 months, range 4–34 months). Three (11%) patients needed further intervention, which included pyogenic granuloma excision (1) and fornix formation (1). Conjunctival wound dehiscence followed by implant exposure occurred in 1 of 27 eyes (3.7%). The cosmetic appearance was satisfactory in 26/27 patients. Conclusions: Our results with primary acellular dermis grafts when coupled with Medpor orbital implantation are encouraging.

SAME DAY DISCHARGE CAN BE ACHIEVED SAFELY IN THE MAJORITY OF ELDERLY PATIENTS UNDERGOING ELECTIVE PERCUTANEOUS CORONARY INTERVENTION

Conclusion: In patients with STEMI, a selective strategy of abciximab use can be safely employed. Dual oral antiplatelet therapy alone is adequate for patients without high-risk clinical and angiographic features. Avoiding routine abciximab use may reduce major bleeding and thrombocytopaenia. doi:10.1016/j.hlc.2008.05.399 399 SameDayDischarge can beAchieved Safely in theMajority of Elderly Patients Undergoing Elective Percutaneous Coronary Intervention Anil Ranchord ∗, Sandir Prasad, Sujith Seneviratne, Russell Anscombe, Mark Simmonds, Phillip Matsis, Andrew Aitken, Scott Harding Wellington Hospital, Wellington, New Zealand Introduction: We investigated whether day-case percutaneous coronary intervention (PCI) could safely be expanded to include the elderly. Methods: The study included 1385 consecutive patients undergoing elective PCI. The elderly group included 186 patients aged 75 and older (median age 77, range 75–92). The remaining 1199 patients formed the control group (median age 62, range 29–74). Results: The elderly were more likely to be female, hyper400 Comparison of the Clinical Characteristics and Mortality of Patientswith Cardiogenic ShockUndergoingCoronary Artery Bypass Grafting Compared with Percutaneous Coronary Intervention—Insights from Two Multi-centre Registries Michael Wong1,∗, Christopher Reid2, Nick Adrianopoulos 2, Siven Seevanayagam1, Omar Farouque1, Gishel New3, Gil Shardey4, Martin Sebastian5, Han Lim1, Julian Smith6, Angela Brennan2, Diem Dinh2, Andrew Ajani 7, Stephen Duffy4, David Clark1 1 Austin Hospital, Melbourne, Australia; 2 Monash University, Melbourne, Australia; 3 Box Hill Hospital, Melbourne, Australia; 4 Alfred Hospital, Melbourne, Australia; 5 Geelong Hospital, Melbourne, Australia; 6 Monash Medical Centre, Melbourne,Australia; 7 RoyalMelbourneHospital,Melbourne, Australia Background: The optimal revascularization strategy for patients with cardiogenic shock (CS) and multivessel disease is uncertain. The aim of this studywas to compare the clinical characteristics and early mortality of patients with CS undergoing primary coronary artery bypass grafting (CABG) compared with percutaneous coronary intervention (PCI). Methods: Comparison of two large parallel multi-centre tensive and to have had previous coronary artery bypass grafting and less likely to be current smokers or to have hyperlipidemia (allP 0.05). There were no deaths within 24 h of discharge. Readmission within 24h of discharge was very infrequent (elderly 0.54%, control 0.58%, P= 1.0) in both groups. In the elderly this was due to 1 access site complication. In the control group this was due to 2 stent thromboses, 4 access site complications and 1 episode of chest pain. The 30-day MACE rate was similar in both the elderly (3.25%) and control groups (3.1%, P= 1.0). Conclusions: Same day discharge is safe and can be achieved in themajority of elderly patients following elective PCI. Suitability for same day discharge should be determinedby theoccurrenceof in-hospital complications rather than age. doi:10.1016/j.hlc.2008.05.400 Australian registries consisting of PCI (Melbourne InterventionalGroup,MIG) andCABG (AustralasianSociety of Cardiac and Thoracic Surgeons, ASCTS) was performed with recruitment between April 2004 to June 2006. CS was present in 2.1% of both registries, PCI n= 97 and CABG n= 86, respectively. Results: PCI, n= 97 CABG, n= 86 p-Value Age (mean±S.D.) 67.4± 12.0 68.3± 9.8 0.58 Male, n (%) 66 (68) 58 (67) 1.00 DM, n (%) 24 (25) 33 (38) 0.2mmol/L), n (%) 18 (19) 2 (2) <0.01 Myocardial infarction <24h, n (%) 78 (80) 33 (38) <0.01 1–7 days, n (%) 15 (16) 27 (31) <0.01 Intra-aortic balloon pump, n (%) 58 (60) 56 (65) 0.54 The CABG group had at least one internal mammary artery used in 77.9% and there were 3.4± 1.2 (mean±S.D.) grafts. The PCI group used stents in 92.3% of which 69.9% were ACC/AHA type B2/C lesions. Thirty days mortality was higher in the PCI group compared to CABG registry (40.2% vs. 22.1%, respectively) (p< 0.01). Conclusion: In contemporary practice, patients with CS with acute (<24 h) myocardial infarction and renal failure aremuchmore likely to undergo PCI, while diabetics, and those with multivessel coronary and peripheral vascular

Primary Dermis-Fat Grafting in Children

Purpose: To report our experience with the use of primary dermis-fat grafts in the pediatric population. Methods: The charts of 12 young patients under the age of 16 years who underwent dermis-fat graft implantation from 1992 to 2004 were reviewed and the functional and cosmetic outcome was assessed. Results: Ten patients had enucleation combined with primary dermis-fat grafting. Age at the time of surgery ranged from 4.7 to 16 years. One patient was lost to follow-up after 1 year; the remaining 9 had follow-up between 3 to 10.2 years. In 8 of them, appropriate orbital soft tissue volume and good orbital symmetry, with a good prosthetic fit and good motility, were observed. In one patient there was hair growth on the graft, managed by laser coagulation. One child developed central graft ulcer that was repaired. Two children experienced abundant growth of their implants, managed by surgical debulking. Two patients had undergone dermis-fat grafting of congenital anophthalmic sockets, age 13.6 years and 10 months, respectively, at time of surgery. The 10-month-old showed adequate orbital soft tissue volume along with deep fornices (follow-up 6.5 years); the second was lost for follow-up. Conclusions: Some minor complications with the use of dermis-fat graft in children occur, but they are easily managed. The dermis-fat graft in young children's orbits appears to grow after implantation. Due to its high degree of safety concurrent with excellent functional and cosmetic results, the dermis-fat transplant appears particularly advantageous for young patients.

Primary Grafting with Autologous Cranial Particulate Bone Prevents Osseous Defects following Fronto-Orbital Advancement

Approximately 20 percent of patients require cranioplasty for defects after fronto-orbital advancement. The authors hypothesized that corticocancellous cranial particulate bone placed over exposed dura at the time of fronto-orbital advancement would decrease the frequency of incomplete ossification. The authors retrospectively analyzed consecutive children who underwent fronto-orbital advancement for craniosynostosis between 1988 and 2006. In group I, cranial gaps resulting from frontal advancement were left open and allowed to heal spontaneously. In group II, corticocancellous particulate bone was used to fill the calvarial defects. Bone was harvested from the endocortex of the frontal segments or parietal calvaria using a hand-driven brace and bit. Outcome variables were persistent osseous defects and need for corrective cranioplasty. The study included 213 children. There were 50 patients in group I: mean age at fronto-orbital advancement was 7.0 months (range, 2 to 15 months); 12 patients (24 percent) had residual defects and 10 (20 percent) required cranioplasty. Group II contained 163 patients: mean age at fronto-orbital advancement was 14.1 months (range, 6 to 72 months); nine children (5.5 percent) had a cranial defect and five (3.1 percent) required cranioplasty. Infants in group II were less likely to have bony defects (p = 0.0005) or require cranioplasty (p = 0.0002) compared with children in group I, despite being older at the time of fronto-orbital advancement (p = 0.001). Corticocancellous cranial particulate bone grafting during fronto-orbital advancement reduces the prevalence of osseous defects and the need for secondary cranioplasty, independent of patient age.

New Flap for Restoration of the Temporal Hair Line

The authors have devised a novel method of designing a flap for coverage of posttraumatic temporal hairline alopecia. They have successfully performed restoration of temporal hairline alopecia as large as 18 x 4 cm resulting from a previous trauma treated with a primary grafting. The new method uses a simple flap designed preoperatively by Doppler based on the supraorbital vessels up to the flap's anastomosis with the occipital vessels. This flap is easy to design and elevate with sufficient blood flow. Alopecia resulting from scar formation at the suture line is not conspicuous. The donor site can be closed primarily, and no dog ear has resulted from its application.