Abstract Metopic craniosynostosis is the second most frequent type of craniosynostosis. When the phenotypic presentation has been deemed severe the treatment is surgical in nature and is performed in infancy with fronto-orbital advancement and cranial vault remodeling. At the time of this writing, there is no consensus regarding an objective evaluation system for severity, diagnostic criteria, or indications for surgery. This study aims to review the anthropometric cranial measurements and the relative diagnostic criteria/classification of severity/surgical indications proposed so far for this skull malformation, and to investigate if there is any scientific support for their utility.
SummaryWide alveolar clefts impair secondary alveolar bone grafting due to deficient mucoperiosteal tissue for grafted bone coverage. Consequently, preparatory or alternative techniques are often required for closure of such defects. We conducted a PRISMA-adherent systematic literature review on wide alveolar cleft repair to compare treatment efficacies and patient populations. With this information, we provide guidance on the relative advantages and disadvantages of each examined method.Forty-two studies published 1987–2022 were included, containing 332 patients treated with distraction osteogenesis (52.1%), orthognathic surgery (33.1%), local flap (8.1%), or free flap (6.6%) repair. There were no significant differences among distraction osteogenesis device types in patient ages (p=0.401, Kruskal-Wallis) nor between treatment intervals, except that tooth-borne consolidation was significantly quicker than bone-borne consolidation (p<0.01 one-way ANOVA with Tukey HSD).Orthognathic surgery and free flap patients were more likely to have prior failed cleft reconstructions compared to distraction osteogenesis and local flaps (p<0.05 chi-square test of independence), suggesting a "second-line" designation to orthognathic surgery and free flap repair. Orthognathic surgery also had significantly higher osseous closure rates than other treatments (p<0.0125 chi-square test with Bonferroni correction). Younger patients more often received orthognathic surgery or distraction osteogenesis while older patients received free or local flaps (p<0.05 Welch's one-directional ANOVA with Games-Howell).The techniques evaluated each have unique features regarding patient age, recovery duration/complexity preferences, and treatment history. Although the ideal treatment may differ between patients, orthognathic surgery and free flaps appear to be the most effective techniques for wide alveolar cleft repair.
The surgical anatomy of the midface relevant to its subperiosteal elevation and repositioning is assessed.The aim of this study is to give more details on the anatomy relevant to the midface lift.Twenty hemifacial dissections were performed. The location of the zygomatic branches of the facial nerve (ZBFN) and the terminal branches of the infraorbital nerve (ION) were dissected. The location of the masseteric and zygomatic ligaments and the elevation of midface following their release were documented.On average, there were 3 branches of the facial nerve innervating the zygomatic major muscle and 1.8 branches entering the muscle superior to the caudal origin of the zygomaticomaxillary (ZM) suture. The most superior ZBFN was found to lie at an average of 6.2 ± 1.6 mm cranial to ZM suture and 1.4 ± 0.4 mm superficial to the bone. The most inferior branch was at a mean of 4.8 ± 3.3 mm inferior to ZM suture. On average the ION had 5.2 branches that traveled for 10.2 mm above the periosteum before they passed into a superficial plane. Division of the zygomatico-masseteric retaining ligaments allowed for elevation of the midface by 4.8 ± 1.0 mm medially and 5.5 ± .9 mm laterally.Branches of the ZBFN and ION lie in close proximity to the subperiosteal plane in the midface. These branches are at risk for damage during release of the upper zygomatic ligaments and placement of the periosteal suspension sutures during midface elevation procedures.
Abstract Introduction Above elbow transplants represent 19% of the upper extremity transplants. Previous large‐animal models have been too distal or heterotopic, did not use immunosuppression and had short survival. We hypothesize that an orthotopic forelimb transplant model, under standard immunosuppression, is feasible and can be used to address questions on peri‐transplant ischemia reperfusion injury, and post‐transplantation vascular, immunologic, infectious, and functional outcomes. Materials and methods Four forelimbs were used for anatomical studies. Four mock transplants were performed to establish technique/level of muscle/tendon repairs. Four donor and four recipient female Yucatan minipigs were utilized for in‐vivo transplants (endpoint 90‐days). Forelimbs were amputated at the midarm and preserved through ex vivo normothermic perfusion (EVNP) utilizing an RBC‐based perfusate. Hourly perfusate fluid‐dynamics, gases, electrolytes were recorded. Contractility during EVNLP was graded hourly using the Medical Research Council scale. EVNP termination criteria included systolic arterial pressure ≥115 mmHg, compartment pressure ≥30 mmHg (at EVNP endpoint), oxygen saturation reduction of 20%, and weight change ≥2%. Indocyanine green (ICG) angiography was performed after revascularization. Limb rejection was evaluated clinically (rash, edema, temperature), and histologically (BANFF classification) collecting per cause and protocol biopsies (POD 1, 7, 30, 60 and endpoint). Systemic infections were assessed by blood culture and tissue histology. CT scan was used to confirm bone bridging at endpoint. Results Animals 2, 4 reached endpoint with grade 0‐I rejection. Limbs 1, 3 presented grade III rejection on days 6, 61. CsA troughs averaged 461 ± 189 ng/mL. EVNLP averaged 4.3 ± 0.52 h. Perfusate lactate, PO 2 , and pH were 5.6 ± 0.9 mmol/L, 557 ± 72 mmHg and 7.5 ± 0.1, respectively. Muscle contractions were 4 [1] during EVNLP. Transplants 2, 3, 4 showed bone bridging on CT. Conclusion We present preliminary evidence supporting the feasibility of an orthotopic, mid‐humeral forelimb allotransplantation model under standard immunosuppression regimen. Further research should validate the immunological, infectious, and functional outcomes of this model.
PURPOSE: Vascularized lymph node (VLN) transfer is a promising treatment option for patients suffering from lymphedema.1 Despite positive preliminary outcomes, several questions remain unanswered, including mechanism of action and optimal flap design.2–4 The purpose of this study was to: 1) evaluate the mechanism of lymph drainage through the VLN flap, and 2) investigate if the number of VLNs impacts lymph transit time through the flap. MATERIALS AND METHODS: Twenty-seven axillary VLN flaps were elevated in 14 male Sprague-Dawley rats (450- 500g) and divided into 3 groups (n=9 each) based on the number of lymph nodes present: Group 1 (0 VLNs), Group 2 (2 VLNs), and Group 3 (4 VLNs). Indocyanine green (n=8/group) and Alexa680-albumin (n=1/group) were injected into the edge of flaps and latency period between injection and fluorescence in the axillary vein was recorded. Stereomicroscopic fluorescent lymphography was performed to directly visualize lymphatic transit through the VLNs (Figure 1).Figure 1: Stereomicroscopic lymphography displaying lymphatic fluid drainage through the rat axillary VLN flap. * – Alexa680-albumin injection site; Arrows: afferent lymphatics; Green dashed line – flap contour; Yellow dashed line – VLN contour.RESULTS: Fluorescence was detected in the axillary vein after 197±188, 109±97, and 73±57 seconds in Groups 1, 2, and 3, respectively. Increased lymph node number decreased lymph transit time as shown by the negative correlation between the number of VLNs in the flap and the latency period (r =-0.39; p=0.03). Mean flap weights were comparable in Group 1, 2, and 3 (275±54, 298±74, 309±60 mg; ANOVA p=0.54). Stereoscopic lymphography allowed direct visualization of lymphatic fluid transit first through afferent lymphatics into the lymph nodes, followed by movement through the hilum into vessels draining toward the flap pedicle vein (Figure 2).Figure 2: Stereomicroscopic lymphography showing high magnification view of lymph node.CONCLUSION: Our results suggest that lymphatic fluid in VLN flaps drains into the venous system mainly by passing through the afferent lymphatics and lymph nodes. A secondary mechanism is the diffusion of fluid directly into the venous system via flap capillary lymphatics. This is shown by the delayed presence of fluorescence in the pedicle vein in flaps without VLNs. Increasing the number of lymph nodes in the flap directly improves flap lymphatic drainage capacity.
Background: Feminizing genioplasty warrants chin modification to achieve feminine characteristics. This study compared female and male facial skeletal dimensions and shape to guide feminizing genioplasty. Methods: Skulls stored at the Cleveland Museum of Natural History were analyzed. Sex, age, and race were documented. Heights and widths of the face and chin were measured, normalized, and compared. Results: Forty-three male (43.58±12.52-y-old) and 43 female (40.48±12.04-y-old) skulls were included. Within each group, 25 skulls were of African American (AA) origin and 18 were of Caucasian (C) origin. Absolute chin heights were larger in AA and C males compared with females ( P <0.05). After normalization to lower facial height, there was a trend toward greater chin height in AA males compared with females ( P =0.07). Parasagittal chin width in AA males was significantly larger than AA females ( P =0.0006). Interforaminal chin width in C males trended toward being significantly larger than females ( P =0.08). Following normalization of chin widths, no significant sex-based differences were noted for AA skulls except for the interforaminal/intergonial ratio, which was smaller in AA males ( P =0.04). For C skulls, most normalized ratios were significantly smaller in males ( P <0.05). C females had wider angles at the point of maximum chin projection ( P =0.007) and wider symphyseal inclinations ( P <0.0001). These differences were not present in AA skulls ( P >0.05). Regardless of race, male chins appeared square, whereas female chins were round. Conclusions: While chin width reduction is not needed for most patients, height reduction could be considered. Chin contouring is the most central component of feminizing genioplasty.
Maintenance of the blood supply to the lymph nodes is necessary for survival and function. We report the outcome of vascularized lymph node transfer with hilar perforators compared with the conventional technique.A total of 21 patients affected by early stage II upper limb lymphedema were included in this study. Of them, 11 patients received a free groin flap containing lymph nodes, and 10 patients received vascularized inguinal lymph nodes with hilar perforators. Mean follow-up was 46 and 40 months, respectively. Complications, secondary procedures, circumference of the limb, and subjective symptomatology were registered. The differences were evaluated statistically.The limb circumferences decreased significantly in the new group. The number of secondary procedures was significantly higher in the standard group. There were 2 cases of partial flap loss and donor site lymphorrhea in the standard group. In both the groups, visual analog scale scores improved after the operation.Transfer of vascularized inguinal lymph nodes based on the hilar perforators improves the outcomes in the treatment of early lymphedema of the upper extremity.
