Oliver, Jeremie D

Background: Pediatric calvarial reconstruction is challenging because of the unique anatomical and growth considerations in this population. Comparative studies evaluating current cranioplasty materials are lacking. This review addresses the knowledge gap in pediatric cranioplasty outcomes with emphasis on current materials used. Methods: A systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Outcome data comparing fresh bone, banked bone, titanium, poly(methyl methacrylate), and polyetheretherketone were abstracted. Results: Twenty studies met the authors’ selection criteria. The mean patient age ranged from 4 to 17.4 years. Autologous cranioplasty was performed in 439 patients, and 201 patients underwent alloplastic reconstruction. Fresh bone grafts and titanium mesh were associated with the lowest infection rates (0.4 percent and 3.3 percent, respectively; p < 0.001), graft failures (2.9 percent and 3.3 percent, respectively; p < 0.001), and surgical-site occurrence rates (8.8 percent and 6.7 percent, respectively; p < 0.001). Banked bone flaps had the highest overall complication rates (51 percent; p < 0.001), bone resorption (39.7 percent; p < 0.001), and failure rates (40.2 percent; p < 0.001), whereas polyetherether ketone had the highest rates of infection (16.1 percent; p < 0.001). Conclusions: Based on the available evidence to date, fresh bone grafts and titanium mesh demonstrated the lowest surgical-site infection, surgical-site occurrence, and graft failure rates. Banked bone flaps had the highest overall surgical-site complications and graft failures. Pediatric cranioplasty outcomes studies are needed to evaluate current and novel cranioplasty materials.

Background: External ear melanoma (EEM) is a rare condition with controversies in the literature. We analyzed patients with EEM in the United States compared to other head and neck melanomas (OHNMs). Methods: The National Cancer Database (NCDB) was used to select patients with head and neck melanoma from January 1, 2004 to December 31, 2015. Mann–Whitney and χ 2 tests were used to estimate statistical significance, and multivariate logistic regression to identify independent associations adjusted for confounders. Results: A total of 137,233 patients met the study criteria. Among them, 16,991 (12.4%) had EEM and 120,242 (87.6%) had OHNM. For patients with EEM, the mean (standard deviation) age was 66.26 (15.798) years. Most of the patients with EEM were men (85.5%), insured by Medicare (52.4%), and treated in Academic/Research Programs (47.7%) or Comprehensive Community Cancer Programs (32.3%). Most of the EEM tumors had invasive behavior (68.0%) were Stages 0 (30.3%) or I (40.3%), and were without ulceration (76.9%). Mean time to receive any treatment was 14.1 days for EEM compared with 14.6 days for OHNM (P < 0.001). We noticed a greater proportion of EEM in men (14.8%; adjusted odds ratio [aOR] 2.72 [2.605–2.852]; P < 0.001) compared to women (6.22%; reference). EEM was an independent factor for tumor Stage I (14.47%; aOR 1.61 [1.101–1.224], P < 0.001) and invasive behavior (13.86%; aOR 1.268 [1.15–1.389]; P < 0.001) compared to OHNM. Conclusion: EEM was associated with higher odds of invasive behavior compared to OHNM. Furthermore, men were found to have a higher likelihood to develop EEM compared to women.

AbstractBackgroundIn microvascular free‐tissue harvest and transfer, the need for repositioning from lateral decubitus position and the inability to use a two‐team approach are major drawbacks of the subscapular system. We present our experience with the subscapular system for upper and lower extremity reconstruction using a two‐team approach without need for repositioning.MethodsWe conducted a retrospective chart review for all patients undergoing free flap transplant based on the subscapular system to the upper or lower extremity at our microsurgical facility from January 1, 2007 to December 31, 2011. Only cases not requiring intraoperative repositioning were included. Sixty‐four patients underwent the two‐team approach (37 upper extremity and 27 lower extremity transplants). Flap types included latissimus dorsi musculocutaneous, partial superior latissimus, dorsal thoracic fascia, serratus, scapular bone, and thoracodorsal artery perforator, either alone or as chimeric flaps. All patients were placed in the lateral decubitus position for the duration of the surgery.ResultsThe ipsilateral subscapular system was used in 16% of cases for lower extremity defects, where the anterior tibial vessels served as recipient vessels. The contralateral subscapular system was used in all remaining cases for upper extremity or the vast majority for lower extremity (84%) defects, where either the superficial femoral, genicular, popliteal, sural, or posterior tibial vessels served as recipient vessels. With the exception of one partial flap loss secondary to infection, all flaps survived.ConclusionsProper lateral decubitus positioning allows for a two‐team approach without compromising safety or outcomes.

Background: Eyelid melanoma (EM) is a rare condition that accounts for <1% of all cutaneous melanomas. In this analysis, patients diagnosed with EM in the United States were compared to those with other melanomas in the head and neck. Methods: The National Cancer Database was used to select patients with head and neck melanoma from 2004 to 2015. Results: A total of 137,233 patients met the criteria of the study. Among them, 2694 were diagnosed with EM (2%) and 134,539 in other head and neck locations (98%). Regarding the patients with EM, the mean age was 68.56 years (standard deviation 14.04). A greater number of them were treated in Academic/Research Programs (53.6%), insured by Medicare (55.7%), tumor in situ (52.2%), stage 0 (49%), and without ulceration (75.9%). The mean time to treatment commencement was 18.96 days for EM compared to 14.4 days for other melanoma in the head and neck regions (P < 0.001). There was a greater proportion of EM in female patients (odds ratio [OR] 2.371 [2.191–2.566], P < 0.001), compared to male; age greater than 80 years (OR 1.622 [1.360–1.934], P < 0.001) compared to 0 to 49 years. Moreover, EM was an independent predictor for treatment in Academic/Research Programs (OR 1.258 [1.160–1.365], P < 0.001) and diagnosis at autopsy (OR 1.414 [1.083–1.847], P = 0.011) compared to other melanoma in the head and neck region. Conclusion: These novel findings have the potential to guide clinical decision making in head and neck melanoma management.

Background: While trauma to the upper extremity is known to cause acute compartment syndrome (ACS), nontraumatic causes of ACS of the upper extremity are rare. Nontraumatic ACS of the upper extremity can lead to adverse outcomes if not recognized early. There are limited reports of spontaneous ACS published in the literature. The aim of this comprehensive systematic review is to increase awareness among plastic surgeons and hand surgeons of this acute event and provide an algorithmic approach to management in the acute setting through an illustrative case example. Methods: A comprehensive systematic review of published literature was conducted in the Medline/PubMed database with the search terms, “compartment syndrome,” “extremity,” “spontaneous,” “nontraumatic,” and “atraumatic” without timeframe limitations. Articles were identified and included in this review based on ACS localization in the upper extremity and etiology of nontraumatic, spontaneous origin. Results: Sixteen publications and 19 total cases of nontraumatic ACS of the upper extremity from 1993 to 2016 met our search criteria. A bleeding disorder was the etiology in three cases, systemic anticoagulation in three cases, infection in six cases, and unknown in three cases. The remaining four cases included systemic sclerosis, Ehlers-Danlos syndrome, rhabdomyolysis, and McArdle disease. Conclusions: Nontraumatic causes of ACS of the upper extremity include infection, anticoagulation therapy, and bleeding disorders. Even though trauma is the most common cause of ACS, clinicians should be aware of these other potential causes of ACS in the nontraumatic setting. Appropriate medical and surgical intervention should be done to avoid potential adverse outcomes.

Background: In those undergoing treatment for breast cancer, evidence has demonstrated a significant improvement in survival, and a reduction in the risk of local recurrence in patients who undergo postmastectomy radiation therapy (PMRT). There is uncertainty about the optimal timing of PMRT, whether it should be before or after tissue expander or permanent implant placement. This study aimed to summarize the data reported in the literature on the effect of the timing of PMRT, both preceding and following 2-stage expander-implant breast reconstruction (IBR), and to statistically analyze the impact of timing on infection rates and the need for explantation. Methods: A comprehensive systematic review of the literature was conducted using the PubMed/Medline, Ovid, and Cochrane databases without timeframe limitations. Articles included in the analysis were those reporting outcomes data of PMRT in IBR published from 2009 to 2017. Chi-square statistical analysis was performed to compare infection and explantation rates between the two subgroups at p < 0.05. Results: A total of 11 studies met the inclusion criteria for this study. These studies reported outcomes data for 1565 total 2-stage expander-IBR procedures, where PMRT was used (1145 before, and 420 after, implant placement). There was a statistically significant higher likelihood of infection following pre-implant placement PMRT (21.03%, p = 0.000079), compared to PMRT after implant placement (9.69%). There was no difference in the rate of explantation between pre-implant placement PMRT (12.93%) and postimplant placement PMRT (11.43%). Conclusion: This study suggests that patients receiving PMRT before implant placement in 2-stage expander–implant based reconstruction may have a higher risk of developing an infection.

The risks of systemic anti-coagulation or its reversal are well known but accepted as necessary under certain circumstances. However, particularly in the plastic surgical patient, systemic alteration to hemostasis is often unnecessary when local therapy could provide the needed adjustments. The aim of this review was to provide a summarized overview of the clinical applications of topical anti- and pro-coagulant therapy in plastic and reconstructive surgery. While not a robust field as of yet, local tranexamic acid (TXA) has shown promise in achieving hemostasis under various circumstances, hemostats are widely used to halt bleeding, and local anticoagulants such as heparin can improve flap survival. The main challenge to the advancement of local therapy is drug delivery. However, with increasingly promising innovations underway, the field will hopefully expand to the betterment of patient care.