Mardini, Samir

Background: Cleft lip and cleft palate (CLP) are among the world’s most common congenital malformation and has a higher prevalence in developing nations due to environmental and genetic factors. Global efforts have been developed in order to prevent and treat the malformation. Telemedicine has been implemented in various humanitarian global missions with success and is currently the primary means of care due to COVID-19. Objective: To assess the benefits and barriers of telehealth in the care of patients with CLP through a global approach. Methods: Systematic review of the PubMed and Cochrane Review databases with relevant terms related to telemedicine in cleft lip and palate surgery. Results: Eight articles fit the inclusion criteria and suggested benefits with the use of telemedicine in regard to education, preoperative, and postoperative care as well as increased access to underserved populations. Barriers included connectivity and accessibility concerns. Conclusion: Telehealth is a beneficial way to evaluate patients with CLP in developing countries with proper care and follow-up to reduce complications and to improve health outcomes.

Summary: Social interactions are largely dependent on the interpretation of information conveyed through facial expressions. Although facial reanimation seeks restoration of the facial expression of emotion, outcome measures have not addressed this directly. This study evaluates the use of a machine learning technology to directly measure facial expression before and after facial reanimation surgery. Fifteen study subjects with facial palsy were evaluated both before and after undergoing cross-facial nerve grafting and free gracilis muscle transfer. Eight healthy volunteers were assessed for control comparison. Video footage of subjects with their face in repose and with a posed, closed-lip smile was obtained. The video data were then analyzed using the Noldus FaceReader software application to measure the relative proportions of seven cardinal facial expressions detected within each clip. The facial expression recognition application detected a far greater happy signal in postoperative (42 percent) versus preoperative (13 percent) smile videos (p < 0.0001), compared to 53 percent in videos of control faces smiling. This increase in postoperative happy signal was achieved in exchange for a reduction in the sad signal (15 percent to 9 percent; p = 0.092) and the neutral signal (57 percent to 37 percent; p = 0.0012). For video clips of patients in repose, no significant difference in happy emotion was detected between preoperative (3.1 percent) and postoperative (1.4 percent) states (p = 0.5). This study provides the first proof of concept for the use of a machine learning software application to objectively quantify facial expression before and after surgical reanimation. CLINICAL QUESTION/LEVEL OF EVIDENCE: Diagnostic, IV.

Background: Several materials are available for cranioplasty reconstruction and consensus regarding the ideal material is lacking. The goal of this study is to present surgical and patient-reported outcomes with PEEK versus Titanium alloplastic cranioplasty. Methods: A retrospective review of all patients who underwent alloplastic cranioplasty with PEEK or Titanium from 2010 to 2017 was conducted. Patient demographics and complications were abstracted and analyzed. Information regarding patient-reported outcomes was collected through a telephone survey. Results: A total of 72 patients (median age 55 years) who underwent 77 cranioplasties were identified (38% PEEK, n = 29; 62% Titanium, n = 48). Overall complication rates were similar between the PEEK (24%, n = 7) and Titanium groups (23%, n = 11), P = 0.902. Similarly, implant failure was similar between the 2 groups (7% in PEEK (n = 2), 13% in Titanium (n = 6), P = 0.703). History of radiation was associated with increased rate of infection in patients with Titanium mesh cranioplasty (38% in radiated patients (n = 3), 3% in nonradiated patients (n = 1), P = 0.012) but not PEEK implants (0% infection rate in radiated patients (n = 0), 15% in nonradiated patients (n = 4), P = 1.000). A total of 24 patients (33% response rate) participated in the telephone survey. All PEEK cranioplasty patients who responded to our survey (n = 13) reported good to excellent satisfaction, while 72% of our titanium mesh cohort (n = 8) described good or excellent satisfaction and 27% (n = 3) reported acceptable result. Conclusion: Cranial reconstruction is associated with high satisfaction among cranioplasty patients with PEEK or Titanium showing comparable complications, failure, and patient-reported satisfaction rates. Patients with history of radiotherapy demonstrated a higher infection rate when titanium mesh was used.

Abstract Background Autologous breast reconstruction (ABR) has grown in popularity due to improved aesthetic and long-term patient reported outcomes, but data regarding sensory reinnervation of autologous flaps remain limited. Traditionally, the lateral cutaneous branch of the fourth intercostal nerve has been used for flap neurotization, but the use of the anterior cutaneous branch of the intercostal nerves (ACB) offer a more optimal location to the microsurgical field when using internal mammary vessels for the microanastomosis. This study aimed to evaluate the optimum ACB recipient site level for sensory nerve coaptation in ABR. Methods Twelve hemi-chests were dissected from six fresh cadaveric females. Costal cartilages were removed and the anterior cutaneous intercostal nerve (ACB) and the lateral (subcutaneous) division of the anterior cutaneous branch (LACB) of the intercostal nerve were exposed. Anatomical measurements were recorded, and nerve samples were evaluated histologically with carbonic anhydrase staining to differentiate sensory fascicles. Assessment of fascicular diameter, axonal counts, and fascicular area were compared. Results A total of 75 nerve specimens were assessed. The ACB was identified at all levels (100%) and the subcutaneous LACB was noted consistently in the second to fourth rib space (96% cadavers), with a median length of 43, 37.5, and 37 mm, respectively. Across all rib spaces, the fascicular and axonal counts were comparable between the LACB and ACB. Nerves in the second intercostal space had a significantly larger mean fascicular area mean (112,816 ± 157,120 µm2) compared with that in the fourth (mean 26,474 ± 38,626 µm2), p = 0.03. Axonal count of sensory fascicles was the highest in the second intercostal nerves (p < 0.05). Conclusion This study provides anatomical and histological basis to determine the optimum recipient site choice for sensory coaptation in microsurgical breast reconstruction. This would aid in operative decision-making regarding the ideal recipient anterior cutaneous intercostal nerve branches for recipient site coaptation in ABR.

Repair of ventral hernias constitutes one of the most common surgical procedures. Although an abundance of data exists on objective outcome measures, very little information exists on subjective measures of surgeon preference and patient satisfaction in surgical management of ventral hernias. Moreover, there are minimal data on indications for elective repair of ventral hernias. Two questionnaires were sent to a population of general and plastic surgeons active in hernia surgery. The first of these aimed at gathering information from surgeons about their indications and contraindications for repair of ventral hernias. The second survey was aimed at determining surgeons’ perception of patient satisfaction with repair of large ventral hernias (greater than 15 cm width). Five hundred sixty-eight surgeons responded to the first survey and 336 responded to the second survey. The most common indications for elective repair of abdominal wall hernias were generalized pain (68.7%) and cosmesis (54.6%), whereas the most common contraindications were morbid obesity (43.3%), American Society of Anesthesiologists Class III or IV (35.4%), and enterocutaneous fistula (33.1%). The majority of surgeons do not routinely repair large abdominal wall hernias in asymptomatic patients, but 31.6 per cent do repair asymptomatic large hernias. Most surgeons reported that the majority of patients had resolution of pain and subjective impression of improved cosmesis after surgery. This study demonstrates uniform indications and contraindications for surgical repair of ventral hernias among surgeons as well as surgeons’ perception of improvements in satisfaction of most patients after surgery. Future studies will focus on comparing surgeon and patient satisfaction.

Background: Autologous fat grafting is a dynamic modality used in plastic surgery as an adjunct to improve functional and aesthetic form. However, current practices in fat grafting for soft-tissue augmentation are plagued by tremendous variability in long-term graft retention, resulting in suboptimal outcomes and repetitive procedures. This systematic review identifies and critically appraises the evidence for various enrichment strategies that can be used to augment and improve the viability of fat grafts. Methods: A comprehensive literature search of the Medline and PubMed databases was conducted for animal and human studies published through October of 2017 with multiple search terms related to adipose graft enrichment agents encompassing growth factors, platelet-rich plasma, adipose-derived and bone marrow stem cells, gene therapy, tissue engineering, and other strategies. Data on level of evidence, techniques, complications, and outcomes were collected. Results: A total of 1382 articles were identified, of which 147 met inclusion criteria. The majority of enrichment strategies demonstrated positive benefit for fat graft survival, particularly with growth factors and adipose-derived stem cell enrichment. Platelet-rich plasma and adipose-derived stem cells had the strongest evidence to support efficacy in human studies and may demonstrate a dose-dependent effect. Conclusions: Improved understanding of enrichment strategies contributing to fat graft survival can help to optimize safety and outcomes. Controlled clinical studies are lacking, and future studies should examine factors influencing graft survival through controlled clinical trials in order to establish safety and to obtain consistent outcomes.

Abstract Background and Objectives The purpose of this study is to present our experience using free fillet flaps to reconstruct massive oncologic defects of the upper and lower extremity. Methods A retrospective chart review was performed to include patients who underwent oncologic resection followed by reconstruction using free fillet flaps from July 2001 to October 2018. Patient demographics, clinical and surgical characteristics, and postoperative complications were reviewed. Results In total, 12 patients were identified and included in this study. Mean age was 48.9 years old. Five patients had extended forequarter amputations and seven patients had external hemipelvectomies, all for locally advanced tumors. Mean tumor size was 15 ± SD 6.4 cm, and negative tumor margins were achieved in all the patients. Mean flap size was 1028 ± SD 869 cm 2 . The mean follow‐up was 13 months. There were no partial or total flap losses in the postoperative period. Two patients had flap‐related postoperative complications, including flap bleeding and wound dehiscence. Median survival was 18 months. Conclusion The free fillet flap is a safe, reliable, and valuable approach for reconstructing oncological defects. It offers the advantage of avoiding donor site morbidity, while providing extensive soft‐tissue coverage as a one‐step solution for massive oncologic defects.