Wang, Leda

ABSTRACT Background Abdominal‐based free flaps are the mainstay in autologous breast reconstruction. Their safety and consistency in outcomes are well‐documented. When flap compromise occurs, operative salvage is the gold standard. However, when—and if—to place these patients on heparin infusions is unclear. The goal of this study was to investigate abdominal‐based free flap compromise and compare outcomes with and without heparin infusion. Materials and Methods This was a single‐institution, multiple‐surgeon, retrospective chart review of patients undergoing autologous, abdominal‐based free flap breast reconstruction who experienced anastomotic compromise within a 6‐year period. Treatment and outcomes data collected include flap salvage, hematoma, seroma, surgical site infection (SSI), transfusion requirement, and length of hospital stay. Results Fifty‐one flaps had evidence of compromise. A total of 31 (60.8%) patients were placed on heparin infusions after experiencing anastomotic compromise, compared to 20 who did not receive heparin infusion. Thirty‐five patients (68.6%) underwent deep inferior epigastric perforator flaps. Twenty‐six patients (51%) experienced venous congestion, 22 patients (43.1%) experienced arterial compromise, and three (5.9%) experienced both. Twenty‐eight patients (54.9%) received tissue plasminogen activator; in the heparin infusion group, 21 patients (67.7%) received tissue plasminogen activator. The total salvage rate of compromised flaps was 94.1% (48/51). There was no significant difference between heparin infusion and standard cares in length of hospital stay, length of drains in‐place, successful salvage (93.5% vs. 95%), hematoma (19.4% vs. 15%), fat necrosis, SSI, hospital readmission (19.4% vs. 15%), and return rates to the operating room (48.4% vs. 50%). However, there was a significantly higher transfusion rate in patients receiving heparin infusion (38.7% vs. 10%). Of the 25 flaps with evidence of thrombosis, 72% were placed on heparin infusions while 28% were not; there was no significant difference in salvage rate in this sub‐group. Conclusions This review of autologous breast reconstruction free flap compromise provides evidence of similar safety profiles, with similar salvage rates, when comparing salvage with and without heparin infusion; there is a higher transfusion requirement when treating with heparin infusion.

Background: Reporting the 50 most cited manuscripts on virtual surgical planning (VSP) for craniofacial surgery, thereby providing a comprehensive review of landmark papers. Methods: The Web of Science Citation Index was used to identify the 50 most cited manuscripts on VSP in craniofacial surgery. These were classified by level of evidence, type of study, topic of interest, and anatomic site. Results: The mean number of citations was 126.3 ± SD 51.7. Twenty were clinical papers: 9 reviews, and 21 workflow or technology. The most common level of evidence (LoE) was 4 ( n = 12), followed by 3 ( n = 6), 2 ( n = 1), and 5 ( n = 1). Thirty-nine of 50 articles focused on the maxillomandibular area of the face, 5 zygomatic, 5 orbit, 2 cranial vault, and 1 nasal ethmoid bone. The majority of articles (37 of 50) were on orthognathic surgery, 11 facial reconstruction, 2 calvarium reconstruction or craniosynostosis, and 2 free flap procedures. Year of publication ranged from 2000 to 2019; 34 articles were published in craniomaxillofacial journals. Conclusion: VSP is a relatively new technology and most highly cited articles on this topic pertain to workflow, technology, and protocols, as these are necessary for its integration into clinical practice. In our list, VSP was most used in orthognathic surgery; however, due to the potential increased efficiency and accuracy, it is being explored in other areas of craniofacial surgery such as facial reconstruction and craniosynostosis. Accordingly, we expect to see increasingly widespread usage of VSP in other areas of surgery, which could potentially lead to highly cited papers.

Purpose: To review cases of lateral brow dermoid cysts and gain insight into the utility of preoperative imaging, incidence of intraorbital extension, and recurrence rate. Methods: This is a retrospective study of all patients who underwent excision of lateral brow dermoid cysts at the authors' academic center over a 37-year period. Results: A total of 136 patients were included. The median age at presentation was 5.6 months [interquartile range (IQR) 3–16.5], and the median age at removal was 1.5 years (IQR 0.9–3.4). Preoperative imaging was performed in 44 patients. Intraorbital communication was predicted in 4 patients who underwent imaging and confirmed in 6 patients (4.4%) intraoperatively. Superficial dermoids were the most common depth (n=79, 58.1%), followed by periosteal (n=37, 27.2%) and intraosseous (n=14, 10.3%). Two patients (1.4%) presented with postoperative hematoma that required surgical evacuation. Recurrence was seen in 2 patients (1.4%). Among those who completed a follow-up, the median follow-up time was 1 month (IQR 0.44–5.8 months). Conclusion: The authors' study revealed that the majority of lateral brow dermoid cysts are either superficial or involve the periosteum, with orbital involvement being rare. None of our patients demonstrated intracranial communication. Imaging did not seem to add clinical value in patients for whom there was no clinical suspicion for the involvement of the deeper tissues, so careful consideration of ordering preoperative imaging would help decrease health care costs and avoid radiation exposure, which is particularly concerning for pediatric patients. The recurrence rate of lateral brow dermoid cyst seems to be low but studies with longer follow-ups are needed.

Objective Dermoid cyst (DC) is a congenital cyst with the potential to have intracranial extension (ICE). This study aims to evaluate the imaging yield and surgical outcomes of nasal, medial brow, forehead, and scalp DCs. Design Retrospective review of craniofacial DCs treated at our institution between 1992 and 2024. Results A total of 117 patients (57 females) were included. The median age at cyst detection and removal were 4.8 months (IQR 3.6-9.6) and 1.8 years (IQR 0.9-5.3), respectively. In 42 patients, parents have noticed the presence of the cyst immediately after birth. Cyst wall rupture during surgical removal was reported in 15.4%. The median follow-up time was 1.3 months (IQR 0.5-12.2). Three patients experienced recurrence. No postoperative complication was reported. The regions with the highest prevalence of ICE were the forehead, frontotemporal scalp, and nasal region. The lateral frontal/temporal scalp had a 33.3% rate of ICE. Midline forehead/scalp lesions demonstrated a higher risk of ICE compared to their lateral equivalents (54.5% vs 17.5%, P = .03). The sensitivity and specificity of magnetic resonance imaging (MRI) were 100% and 95.7%, while for computed tomography (CT scans) were 72.7% and 96.5%. The Area Under the Curve for MRI was 0.978, and for CT was 0.846. The sensitivity and specificity of ultrasound were 50% and 100%. Conclusions Midline forehead/scalp DCs are more prone to extend intracranially than lateral DCs. MRI had a higher sensitivity and specificity than CT scans in detecting ICE. Routine screening imaging should be considered in midline forehead/scalp, lateral frontal/temporal, and nasal DCs.