Surgeon In Surgical Planning Research Articles

Evaluation of pneumatized structures and osteoma frequency in the paranasal region

Aims: The aim of our study was to evaluate the incidence of pneumatized structures in the paranasal region and the presence of osteomas. Methods: Paranasal CT images obtained with Multislice (Philips) 64-slice computed tomography (CT) at Kırıkkale University Hospital in 2023 were retrospectively analyzed. Pneumatized variations and the presence of osteoma were evaluated. Results: The images of 186 patients (93 female and 93 male) with paranasal CT were analyzed. The most common pneumatized variation was middle turbinate bullosa with 40.3%, and the least common was pneumatization of the nasal septum with 2.1%. Anterior clinoid pneumatization was observed in 23.1%, posterior clinoid pneumatization in 2.2%, pneumatization of the uncinate process in 4.9%, and crista galli pneumatization in 4.3%. The frequency of osteomas in the paranasal region was 3.2% (n=6). Conclusion: Our study will provide a better understanding of paranasal anatomy by providing information about the frequency of pneumatized paranasal variations and the presence of osteomas. This will guide the surgeon in surgical planning and at the time of surgery.

Effect of Preoperative Trabecular Meshwork Pigmentation and Other Eye Characteristics on Outcomes of Combined Phacoemulsification/Minimally Invasive Glaucoma Surgery

PurposeTo investigate associations between pigmentation of the trabecular meshwork (PTM) and other preoperative eye characteristics and outcomes of minimally invasive glaucoma surgery combined with phacoemulsification (Phaco/MIGS). DesignRetrospective interventional case series. ParticipantsAcademic glaucoma clinic patients with symptomatic cataract and glaucoma treated with combined Phaco/MIGS. MethodsAnalyzing preoperative PTM, intraocular pressure (IOP), IOP-lowering medications and visual acuity (VA) data in relation to Phaco/MIGS outcomes. Main Outcome MeasuresPTM and other preoperative eye characteristics in relation to Phaco/MIGS success defined as postoperative IOP between 5-21 mmHg and IOP reduction of ≥20% and/or a reduction of ≥1 IOP-medications compared to baseline, and final IOP, IOP-lowering medications and VA. Results265 eyes (172 patients, mean age, 73.5 [SD, 10.0], range 35-95 years, male 40.0%) were identified and categorized with high PTM (108 eyes, 40.8%) or low PTM (157 eyes, 59.2%). The high PTM group, compared with the low PTM group, demonstrated higher preoperative IOP (16.7 [SE 0.4] vs. 15.2 [0.4] mmHg, p=0.009), included more eyes with primary open-angle glaucoma (POAG, p=0.03), fewer eyes with normal-tension glaucoma (NTG, p=0.01), and fewer eyes with mild stage glaucoma (p=0.001). Compared to baseline, final IOP decreased by 6.5 [2.4]% and 13.4 [3.0]% (p=0.075) to 13.5 [0.3] mmHg and 13.6 [0.4] mmHg (p=0.77) in the low and high PTM groups, respectively, and IOP-lowering medications decreased by 34.6 [4.9]% (n=116) and 18.1 [7.3]% (n=85), respectively (p=0.062). Surgical success was 59.9% and 58.3%, respectively (p=0.87). It was positively associated with higher preoperative IOP (Hazard Ratio 1.08 [95% CI 1.04-1.12] p<0.0001) and higher number of preoperative IOP-medications (1.20 [1.05-1.37] p=0.007), negatively associated with history of Selective Laser Trabeculoplasty (SLT, 0.40 [0.23-0.68] p=0.0009) and longer axial length (0.87 [0.80-0.94], p=0.0006), but was not associated with PTM. ConclusionsHigher PTM was associated with POAG rather than NTG, with more severe glaucoma and higher preoperative IOP, but not with Phaco/MIGS success. Surgical success was positively associated with higher preoperative IOP and number of IOP-medications and negatively associated with history of SLT and longer axial length. These findings may help guide glaucoma surgeons in surgical planning and patient counselling.

INCLUSION OF OPEN INJURIES IN AN UPDATED SCHENCK CLASSIFICATION OF KNEE DISLOCATIONS BASED ON A GLOBAL DELPHI CONSENSUS STUDY

AbstractIntroductionKnee dislocations (KDs) are complex injuries which are often associated with damage to surrounding soft tissues or neurovascular structures. A classification system for these injuries should be simple and reproducible and allow communication among surgeons for surgical planning and outcome prediction. The aim of this study was to formulate a list of factors, prioritised by high-volume knee surgeons, that should be included in a KD classification system.MethodsA global panel of orthopaedic knee surgery specialists participated in a Delphi process. A list of factors to be included in a KD classification system was formulated by 91 orthopaedic surgeons, which was subsequently prioritised by 27 experts from 6 countries. The items were analysed to find factors that had at least 70% consensus for inclusion in a classification system.ResultsThe four factors that reached consensus agreement and thus deemed critical for inclusion in a classification system were vascular injuries (89%), common peroneal nerve injuries (78%), number of torn ligaments (78%), and open injuries (70%).ConclusionThe wide geographic distribution of participants provides diverse insight and makes the results of the study globally applicable. The most important factors to include in a classification system as determined by the Delphi technique were vascular injuries, common peroneal nerve injuries, number of torn ligaments, and open injuries. The Schenck anatomic classification system most accurately identifies these patient variables with the addition of open injuries. The authors propose to update the Schenck classification system with the inclusion of open injuries as an additional modifier.

Use of individualized 3D-printed models of pancreatic cancer to improve surgeons' anatomic understanding and surgical planning.

Three-dimensional (3D) printing has been increasingly used to create accurate patient-specific 3D-printed models from medical imaging data. We aimed to evaluate the utility of 3D-printed models in the localization and understanding of pancreatic cancer for surgeons before pancreatic surgery. Between March and September 2021, we prospectively enrolled 10 patients with suspected pancreatic cancer who were scheduled for surgery. We created an individualized 3D-printed model from preoperative CT images. Six surgeons (three staff and three residents) evaluated the CT images before and after the presentation of the 3D-printed model using a 7-item questionnaire (understanding of anatomy and pancreatic cancer [Q1-4], preoperative planning [Q5], and education for trainees or patients [Q6-7]) on a 5-point scale. Survey scores on Q1-5 before and after the presentation of the 3D-printed model were compared. Q6-7 assessed the 3D-printed model's effects on education compared to CT. Subgroup analysis was performed between staff and residents. After the 3D-printed model presentation, survey scores improved in all five questions (before 3.90 vs. after 4.56, p < 0.001), with a mean improvement of 0.57‒0.93. Staff and resident scores improved after a 3D-printed model presentation (p < 0.05), except for Q4 in the resident group. The mean difference was higher among the staff than among the residents (staff: 0.50‒0.97 vs. residents: 0.27‒0.90). The scores of the 3D-printed model for education were high (trainees: 4.47 vs. patients: 4.60) compared to CT. The 3D-printed model of pancreatic cancer improved surgeons' understanding of individual patients' pancreatic cancer and surgical planning. The 3D-printed model of pancreatic cancer can be created using a preoperative CT image, which not only assists surgeons in surgical planning but also serves as a valuable educational resource for patients and students. • A personalized 3D-printed pancreatic cancer model provides more intuitive information than CT, allowing surgeons to better visualize the tumor's location and relationship to neighboring organs. • In particular, the survey score was higher among staff who performed the surgery than among residents. • Individual patient pancreatic cancer models have the potential to be used for personalized patient education as well as resident education.

Ultrasound Calculation of Fat Volume for Liposuction: A Clinical Software Validation.

Fat manipulation procedures such as liposuction contain a degree of subjectivity primarily guided by the surgeon's visual or tactile perception of the underlying fat. Currently, there is no cost-effective, direct method to objectively measure fat depth and volume in real time. Utilizing innovative ultrasound-based software, the authors aimed to validate fat tissue volume and distribution measurements in the preoperative setting. Eighteen participants were recruited to evaluate the accuracy of the new software. Recruited participants underwent ultrasound scans within the preoperative markings of the study area before surgery. Ultrasound-estimated fat profiles were generated with the in-house software and compared directly with the intraoperative aspirated fat recorded after gravity separation. Participants' mean age and BMI were 47.6 (11.3) years and 25.6 (2.3) kg/m2, respectively. Evaluation of trial data showed promising results following the use of a Bland Altman agreement analysis. For the 18 patients and 44 volumes estimated, 43 of 44 measurements fell within a confidence interval of 95% when compared with the clinical lipoaspirate (dry) volumes collected postsurgery. The bias was estimated at 9.15 mL with a standard deviation of 17.08 mL and 95% confidence interval between -24.34 mL and 42.63 mL. Preoperative fat assessment measurements agreed significantly with intraoperative lipoaspirate volumes. The pilot study demonstrates, for the first time, a novel companion tool with the prospect of supporting surgeons in surgical planning, measuring, and executing the transfer of adipose tissues.

A deep learning-based precision and automatic kidney segmentation system using efficient feature pyramid networks in computed tomography images

This paper proposes an encoder-decoder architecture for kidney segmentation. A hyperparameter optimization process is implemented, including the development of a model architecture, selecting a windowing method and a loss function, and data augmentation. The model consists of EfficientNet-B5 as the encoder and a feature pyramid network as the decoder that yields the best performance with a Dice score of 0.969 on the 2019 Kidney and Kidney Tumor Segmentation Challenge dataset. The proposed model is tested with different voxel spacing, anatomical planes, and kidney and tumor volumes. Moreover, case studies are conducted to analyze segmentation outliers. Finally, five-fold cross-validation and the 3D-IRCAD-01 dataset are used to evaluate the developed model in terms of the following evaluation metrics: the Dice score, recall, precision, and the Intersection over Union score. A new development and application of artificial intelligence algorithms to solve image analysis and interpretation will be demonstrated in this paper. Overall, our experiment results show that the proposed kidney segmentation solutions in CT images can be significantly applied to clinical needs to assist surgeons in surgical planning. It enables the calculation of the total kidney volume for kidney function estimation in ADPKD and supports radiologists or doctors in disease diagnoses and disease progression.

Inclusion of open injuries in an updated Schenck classification of knee dislocations based on a global Delphi consensus study

ObjectivesKnee dislocations (KDs) are complex injuries defined as incongruity of the tibiofemoral joint, which leads to tears of two or more of the main stabilising knee ligaments, and they are often associated with damage to surrounding soft tissue or neurovascular structures. A classification system for these injuries should be simple and reproducible and allow communication among surgeons for surgical planning and outcome prediction. The aim of this study was to formulate a list of factors, prioritised by high-volume knee surgeons, that should be included in a KD classification system. MethodsA global panel of orthopaedic knee surgery specialists participated in a Delphi process. The first survey employed 91 orthopaedic surgeons to generate a list of patient- and system-specific factors that should be included in a KD classification system that may affect surgical planning and outcomes. This list was subsequently prioritised by 27 identified experts (mean 15.3 years of experience) from Brazil (n = 9), USA (n = 6), South Africa (n = 4), India (n = 4), China (n = 2), and the United Kingdom (n = 2). The items were analysed to find factors that had at least 70% consensus for inclusion in a classification system. ResultsOf the 12 factors identified, four (33%) achieved at least 70% consensus for inclusion in a classification system. The factors deemed critical for inclusion in a classification system included vascular injuries (89%), common peroneal nerve injuries (78%), number of torn ligaments (78%), and open injuries (70%). ConclusionConsensus for inclusion of various factors in a KD classification system was not easily achieved. The wide geographic distribution of participants provides diverse insight and makes the results of the study globally applicable. The most important factors to include in a classification system as determined by the Delphi technique were vascular injuries, common peroneal nerve injuries, number of torn ligaments, and open injuries. To date, the Schenck anatomic classification system most accurately identifies these patient variables with the addition of open injury classification. The authors propose to update the Schenck classification system with the inclusion of open injuries as an additional modifier, although this is only a small step in updating the classification, and further studies should evaluate the inclusion of more advanced imaging modalities. Future research should focus on integrating these factors into useful existing classification systems that are predictive of surgical treatment and patient outcomes.

Sphenoid sinus pneumatization in a sample of Nepalese population: A multidetector computed tomography study.

&#x0D; Introduction: The purpose of study was to assess the prevalence of different types of pneumatization of sphenoid sinus in the Nepalese population as detected in CT scan of paranasal sinus. Materials and Methods: This study included patients attending radiology department for CT scan of paranasal sinus. The CT images of paranasal sinus were assessed for the type of pneumatization of the sphenoid sinus and type of clival, lateral recess and lesser wing extensions. Results: Most common type of pneumatization found in our study was complete sellar type (61.7%) and partial sellar type was second common type (27.4%). Pre-sellar type of pneumatization was seen in 10.9%. There were no patients with conchal type of pneumatization in our study. The clival extension of pneumatization was seen in 64%, lateral extension was found in 35.4%. and lesser wing type of pneumatization was found in 9.7%. Conclusion: Pre-surgical assessment of types and extension of sphenoid sinus pneumatization helps surgeons in surgical planning and to reduce complications during surgery. The variation in prevalence of sphenoid sinus pneumatization was found between our study population and other different population. This confirms that ethnicity influences types and extension of sphenoid sinus pneumatization.

Feasibility and adaptation of three-dimensional model for surgical planning and training: A pilot study

Background: Three dimensional (3D) printing can produce accurate anatomical model of any part of the body. This study is based on reconstruction of models of the affected body part for preoperative planning and to see its usefulness in training of resident doctors and for patient education. Methodology: Thirty-five surgically operated patients were retrospectively reviewed and were divided into the conventional planning group (n = 14) and planning with 3D printing group (n = 16). Pathological structures from clinical cases were identified on multidetector computed tomography images and were then transferred to Dicom to print software and saved in a standard format digital imaging and communication in medicine. Segmented regions were combined to create 3D models. Printout of models was taken after being edited by Geomagic free form plus software. Models prepared using 3D printing technology were used to simulate the real surgical operation. The models were used by surgeons for surgical planning and to train their resident doctors. Surgical duration and blood loss were recorded during operation. A questionnaire was provided to the surgeons and residents to assess the utility of 3D models in pre-surgical planning. Results: The mean surgical time in planning with the 3D printing group and conventional planning group was 129.090 ± 36.79 min and 218 ± 94.932 min (P < 0.05). The intraoperative blood loss in planning with 3D printing group and conventional planning group was 130 ± 69.019 ml and (455 ± 44.122 ml) (P < 0.05). Forty subjects completed the survey. Twenty-nine (96.66%) surgeons gave favorable responses (80% found it to be very helpful and 16% helpful) when asked about the utility of these models in the visualization of abnormal pathological anatomy and preoperative planning. Conclusion: Our study suggests that 3D printing technology is useful to aid to surgical planning and provides teaching materials for residents in learning surgery.

Radiographic Features Associated With Increased Surgical Invasiveness in Pyogenic Vertebral Column Osteomyelitis.

Study Design:Single center retrospective cohort study.Objectives:Assess the association between well-known radiographic features for spinal instability from the Spinal Instability in Neoplasia Score (SINS) and surgical invasiveness in treating vertebral column osteomyelitis (VCO). This will potentially help surgeons in surgical planning and aid in developing a pathology specific score.Methods:Patients with VCO were identified from hospital coding. On preoperative computed tomography radiographic features, including spinal alignment, vertebral body collapse, location, type of bone lesion, and posterolateral involvement were assessed and scored 0 (stable) to 15 (highly unstable). Surgical invasiveness was graded as 0 = no surgery, 1 = decompression alone, 2 = shortening or posterior stabilization, or 3 = anterior column reconstruction.Results:A total of 41 patients were included. The mean age of the cohort was 63.3 years (SD 12.0) with male comprising 78%. The mean total radiographic score for the nonsurgical group was 6.39 (3.14) and for the surgical group 10.38 (3.06), P < .001. Spinal alignment, vertebral body collapse, type of bone lesion, and posterolateral involvement correlated with surgical invasiveness (all Ps < .05). Subgroup comparison following analysis of variance showed that only spinal alignment was significantly different between groups 2 and 3.Conclusions:Our findings show correlation of the radiographic components of the SINS with surgical invasiveness in management of pyogenic VCO—these findings should aid development of an “instability score” in pyogenic VCO. While most radiographic features assessed correlated with surgical invasiveness spinal alignment appears to be the key feature in determining the need for more invasive surgery.

Towards a new 3D classification for adolescent idiopathic scoliosis.

Retrospective analysis of consecutive cases. To identify clinically relevant three-dimensional (3D) sub-groups for adolescent idiopathic scoliosis (AIS). Classifications for AIS are developed to assist surgeons in surgical planning and therapeutic management. However, current systems are based on two-dimensional (2D) parameters that do not completely describe the 3D deformity. Hence, variations in surgical results based on pre-operative 2D classifications may be attributed to the lack of 3D description. Subjects from a multicenter database of AIS patients were included in this study. All patients had bi-planar radiographs and 3D reconstruction of the entire spine. A clustering algorithm based on fuzzy c-means was utilized to identify sub-groups based on the following ten parameters measured on 3D reconstructions of the spine: Cobb angle, orientation of the plane of maximum curvature of the proximal thoracic, mid-thoracic (MT) and thoracolumbar (TLL) levels, axial rotation of the apical vertebra of the MT and TLL segments, T4-T12 thoracic kyphosis, and L1-S1 lumbar lordosis. Da Vinci views were also generated and analyzed for each patient in the study. A panel of four experienced spine surgeons from the SRS 3D Scoliosis Committee reviewed and evaluated each group to determine if cluster groups were clinically distinct from each other. The clustering algorithm was able to detect 11 sub-groups. The population size for each cluster varied from 11 to 290. Statistically significant differences were seen between the parameters for each group. Four spine surgeons reviewed the three most representative cases of each group and unanimously agreed that each cluster group represents a sub-group that was not defined in current classifications. This study presents a new method of classifying AIS based on a fuzzy clustering algorithm using parameters describing the 3D characteristics of the deformity. Further clinical validation is needed to confirm the usefulness of this classification system. IV.

3D imaging applications for robotic urologic surgery: an ESUT YAUWP review.

Despite the current era of precision surgery in robotics, an unmet need still remains for optimal surgical planning and navigation for most genitourinary diseases. 3D virtual reconstruction of 2D cross-sectional imaging has been increasingly adopted to help surgeons better understand the surgical anatomy. To provide a short overview of the most recent evidence on current applications of 3D imaging in robotic urologic surgery. A non-systematic review of the literature was performed. Medline, PubMed, the Cochrane Database and Embase were screened for studies regarding the use of 3D models in robotic urology. 3D reconstruction technology creates 3D virtual and printed models that first appeared in urology to aid surgical planning and intraoperative navigation, especially in the treatment of oncological diseases of the prostate and kidneys. The latest revolution in the field involves models overlapping onto the real anatomy and performing augmented reality procedures. 3D virtual/printing technology has entered daily practice in some tertiary centres, especially for the management of urological tumours. The 3D models can be virtual or printed, and can help the surgeon in surgical planning, physician education and training, and patient counselling. Moreover, integration of robotic platforms with the 3D models and the possibility of performing augmented reality surgeries increase the surgeon's confidence with the pathology, with potential benefits in precision and tailoring of the procedures.

Intramedullary Screw Fixation and Relevant Diameter of the Proximal Phalanges of the Foot

Category: Midfoot/Forefoot Introduction/Purpose: The average intramedullary diameter of the proximal phalanges of the foot has not been well documented in the literature. This dimension has important implications for surgical fixation devices, such as intramedullary screws. By design, intramedullary fixation devices rely on endosteal fit to provide stability. The precise intramedullary diameter is not readily identifiable on plain radiographs. A better understanding of the average diameter of the proximal phalanges of the foot can assist surgeons in surgical planning and appropriate screw diameter selection to provide more satisfactory patient outcomes. Methods: Twenty below-knee cadaveric specimens were dissected to expose each proximal phalanx. A sagittal saw was used to transect the diaphysis at its narrowest portion. The dorsal to plantar and medial to lateral diameters were measured using a digital manometer. Results: The average diameter dorsal to plantar for each digit was 6.25 ± 2.24 mm, 3.61 ± 1.25 mm, 2.94 ± 0.70 mm, 2.72 ± 0.77 mm, and 2.48 ± 0.80 mm, respectively. The average diameter medial to lateral for each digit was 7.83 ± 2.13 mm, 3.08 ± 0.93 mm, 2.47 ± 0.74 mm, 2.33 ± 0.73 mm, and 2.62 ± 0.69 mm, respectively. The overall average diameter for toes one through five was 7.04 ± 1.95 mm, 3.35 ± 1.04 mm, 2.71 ± 0.66 mm, 2.52 ± 0.71 mm, and 2.55 ± 0.63 mm, respectively. Conclusion: Understanding the intramedullary diameters of the proximal phalanges of the foot is a valuable tool when utilizing intramedullary surgical stabilization. The hallux proximal phalanx demonstrated the largest, and most variable, diameter, which could make selection intramedullary fixation difficult. In addition, the hallux proximal phalanx may lend itself better to 2 smaller fixation devices rather than one larger one. The lesser phalanges demonstrated smaller diameters more consistently, which is more amenable to a single smaller (2.5 mm) intramedullary device. This data can provide surgeons with an expected intramedullary diameter during surgical planning.

Classification of Diffusion Tensor Metrics for the Diagnosis of a Myelopathic Cord Using Machine Learning.

In this study, we propose an automated framework that combines diffusion tensor imaging (DTI) metrics with machine learning algorithms to accurately classify control groups and groups with cervical spondylotic myelopathy (CSM) in the spinal cord. The comparison between selected voxel-based classification and mean value-based classification were performed. A support vector machine (SVM) classifier using a selected voxel-based dataset produced an accuracy of 95.73%, sensitivity of 93.41% and specificity of 98.64%. The efficacy of each index of diffusion for classification was also evaluated. Using the proposed approach, myelopathic areas in CSM are detected to provide an accurate reference to assist spine surgeons in surgical planning in complicated cases.

Joint segmentation of bones and muscles using an intensity and histogram-based energy minimization approach

Background and objectivesThe segmentation of muscle and bone structures in CT is of interest to physicians and surgeons for surgical planning, disease diagnosis and/or the analysis of fractures or bone/muscle densities. Recently, the issue has been addressed in many research works. However, most studies have focused on only one of the two tissues and on the segmentation of one particular bone or muscle. This work addresses the segmentation of muscle and bone structures in 3D CT volumes. MethodsThe proposed bone and muscle segmentation algorithm is based on a three-label convex relaxation approach. The main novelty is that the proposed energy function to be minimized includes distance to histogram models of bone and muscle structures combined with gray-level information. Results27 CT volumes corresponding to different sections from 20 different patients were manually segmented and used as ground-truth for training and evaluation purposes. Different metrics (Dice index, Jaccard index, Sensitivity, Specificity, Positive Predictive Value, accuracy and computational cost) were computed and compared with those used in some state-of-the art algorithms. The proposed algorithm outperformed the other methods, obtaining a Dice coefficient of 0.88 ± 0.14, a Jaccard index of 0.80 ± 0.19, a Sensitivity of 0.94 ± 0.15 and a Specificity of 0.95 ± 0.04 for bone segmentation, and 0.78 ± 0.12, 0.65 ± 0.16, 0.94 ± 0.04 and 0.95 ± 0.04 for muscle tissue. ConclusionsA fast, generalized method has been presented for segmenting muscle and bone structures in 3D CT volumes using a multilabel continuous convex relaxation approach. The results obtained show that the proposed algorithm outperforms some state-of-the art methods. The algorithm will help physicians and surgeons in surgical planning, disease diagnosis and/or the analysis of fractures or bone/muscle densities.

Minimally invasive laser vibrometry (MIVIB) with a floating mass transducer – A new method for objective evaluation of the middle ear demonstrated on stapes fixation

Ossicular fixation through otosclerosis, chronic otitis media and other pathologies, especially tympanosclerosis, are treated by surgery if hearing aids fail as an alternative. However, the best hearing outcome is often based on knowledge of the degree and location of the fixation. Objective methods to quantify the degree and position of the fixation are largely lacking. Laser vibrometry is a known method to detect ossicular fixation but clinical applicability remains limited. A new method, minimally invasive laser vibrometry (MIVIB), is presented to quantify ossicle mobility using laser vibrometry measurement through the ear canal after elevating the tympanic membrane, thus making the method feasible in minimally invasive explorative surgery. A floating mass transducer provides a clinically relevant transducer to drive ossicular vibration. This device was attached to the manubrium and drove vibrations at the same angle as the longitudinal axis of the stapes and was therefore used to assess ossicular chain mobility in a fresh-frozen temporal bone model with and without stapes fixation. The ratio between the umbo and incus long process was shown to be useful in assessing stapes fixation. The incus-to-umbo velocity ratio decreased by 15 dB when comparing the unfixated situation to stapes fixation up to 2.5 kHz. Such quantification of ossicular fixation using the incus-to-umbo velocity ratio would allow quick and objective analysis of ossicular chain fixations which will assist the surgeon in surgical planning and optimize hearing outcomes.

Quantifying Craniometric Change Early After Fronto-Orbital Advancement in Metopic Synostosis.

Frontal orbital advancement (FOA) for metopic synostosis results in cranial vault expansion, supporting underlying growth of the developing brain and improving head shape. Previous studies have shown that FOA in younger infants leads to a greater incidence of long-term growth restriction of intracranial volume; however, it is still unknown as to whether this is due to undercorrection at the time of surgery versus primary suture pathology. The purpose of our study is to provide a method for objective analyses of intracranial volumes in the early post-FOA period. A retrospective chart review was conducted on patients who underwent FOA over a 10-year period by a single surgeon. Data collected included patient characteristics and clinical outcomes. Radiological analysis of intracranial volumes pre- and post-FOA was determined using Amira volume-rendering software. Average increase in intracranial volume at 6 weeks post-FOA was 139.27 mL (80.01-225.25 mL) with average relative cranial vault expansion of 18.1% (3.3-48%). Patients who underwent FOA older than 12 months of age had an average increase in intracranial volume of 8.5% (3.3-13.1%). Patients younger than 12 months had a statistically higher average increase of 25% (12.8-48%). Frontal orbital advancement effectively increases intracranial volume in patients with metopic synostosis. When compared with older patients, patients younger than 1 year of age have a greater relative increase in intracranial volume in the immediate postoperative period. Quantifying cranial vault expansion after FOA can assist surgeons in surgical planning as well as in measuring and monitoring clinical outcomes within and across craniofacial centers regardless of technique.

Preoperative and intraoperative predictors of positive margins after breast-conserving surgery: a retrospective review

Breast-conserving therapy is an established treatment for early breast cancer. Current practice mandates reoperation for positive margins. Presently most patients are brought to the operating room with a diagnosis of breast cancer made on core biopsy. Preoperative and intraoperative predictors of margin status are needed. A retrospective review of patients with adenocarcinoma proven on core biopsy undergoing breast-conserving surgery between 2000 and 2007. Clinical, radiographic, pathological, and operative data were collected. These were correlated with margin status on excision. One hundred twenty-seven patients met the inclusion criteria. Predictors of positive margins at lumpectomy were younger age, larger size on imaging, calcifications on mammography, multifocality, ductal carcinoma insitu (DCIS) or necrosis on core biopsy, and close margins on specimen films. In the era of preoperative diagnosis of breast cancer with core biopsy, several pre- and intraoperative predictors of positive margins are identified that can aid the surgeon in surgical planning.

Anatomy and quantitation of the subscapular nerves

Information regarding branches of the brachial plexus can be of utility to the surgeon for neurotization procedures following injury. Sixty-two adult cadaveric upper extremities were dissected and the subscapular nerves identified and measured. The upper subscapular nerve originated from the posterior cord in 97% of the cases and in 3% of the cases directly from the axillary nerve. The upper subscapular nerve originated as a single nerve in 90.3% of the cases, as two independent nerve trunks in 8% of the cases and as three independent nerve trunks in 1.6% of the cases. The thoracodorsal nerve originated from the posterior cord in 98.5% of the cases and in 1.5% of the cases directly from the proximal segment of the radial nerve. The thoracodorsal nerve always originated as a single nerve from the brachial plexus. The lower subscapular nerve originated from the posterior cord in 79% of the cases and in 21% of the cases directly from the proximal segment of the axillary nerve. The lower subscapular nerve originated as a single nerve in 93.6% of the cases and as two independent nerve trunks in 6.4% of the cases. The mean length of the lower subscapular nerve from its origin until it provided its branch into the subscapularis muscle was 3.5 cm and the mean distance from this branch until its termination into the teres major muscle was 6 cm. The mean diameter of this nerve was 1.9 mm. The mean length of the upper subscapular nerve from its origin to its termination into the subscapularis muscle was 5 cm and the mean diameter of the nerve was 2.3 mm. The mean length of the thoracodorsal nerve from its origin to its termination into the latissimus dorsi muscle was 13.7 cm. The mean diameter of this nerve was 2.6 mm. Our hopes are that these data will prove useful to the surgeon in surgical planning for potential neurotization procedures of the brachial plexus.

Treatment of Congenital Facial Nevi

The treatment of congenital facial nevi is often difficult and challenging. Previous authors have reported their techniques, results, and complications when treating these lesions. Our objectives are to simplify the treatment planning by subdividing the lesions with a new classification and using this to formulate a surgical algorithm. One hundred and two patients with congenital facial nevi were reviewed. All of these patients have had surgical excision for the lesions. We have subgrouped the lesions into three groups, according to size, number of aesthetic units involved, and number of reconstructive stages required. Group I included lesions 1 to 3 cm in maximal diameter, within one aesthetic unit, and requiring one or two reconstructive stages. This group included 29 patients. Group II included lesions 3 to 12 cm in maximal diameter, covering one or two aesthetic units, and requiring not more than two stages of reconstruction. This group had 41 patients. Group III consisted of extensive lesions, over 12 cm in maximal diameter, covering several aesthetic units, and requiring several stages of reconstruction. In this group, we had 32 patients. On the basis of our experience in treating congenital facial nevi in this series, we have developed a surgical algorithm for reconstruction. We are optimistic that this will assist the surgeon in surgical planning and treating this complex patient population. The algorithm is arranged according to the new classification of congenital facial nevi that is presented.