Introduction: Mandibular distraction osteogenesis (MDO) is becoming the procedure of choice for patients with Robin Sequence (RS) as it offers superior long-term respiratory outcomes in avoidance of tracheostomy. Lacking, is an analysis of the short- and long-term complications. To that end, we have conducted a comprehensive review focusing on complications of MDO. Materials and Methods: A systematic review of primary clinical studies reporting outcomes and complications of MDO in RS patients. Outcomes included tracheostomy avoidance and decannulation rate. Complications included dental trauma, nerve injury, surgical site infection and hardware failure. Complications were stratified according to distractor type (internal versus external) and age (>2 months versus <2months). Results: A total of 49 studies yielded 1209 patients with a mean follow-up of 43.78 months. The tracheostomy avoidance rate was 94% (n = 817/870) and the mortality rate was 0.99% (n = 12/1209). The complication rate was 28.9% (n = 349/1209) with surgical site infections (10.5%) being most common. Dental and nerve injuries occurred in 7.9% and 3.2% of patients, respectively. Hardware replacement occurred in 1.2% of patients. internal distractors had higher rates of dental injury whereas external distractors had higher technical failure rates. There were no differences in complication rates (P = 0.200), mortality (P = 0.94) or tracheostomy avoidance (P = 0.058) between patients >2months or <2months of age. Conclusion: Mandibular distraction osteogenesis is highly reliable and effective with a low mortality and high tracheostomy avoidance rate. There are important complications including nerve and dental injuries which require long-term follow-up. Neonatal patients do not appear to be at higher risk of complications reinforcing the safety of MDO in this population.
Background: In light of the recent surge of media coverage and social media influence regarding breast implants, it is essential to understand patients’ concerns and misconceptions so that we can better serve them. Methods: The authors designed a survey study for assessing the awareness and perception of patients toward breast implant–associated anaplastic large cell lymphoma (BIA-ALCL) and breast implant illness (BII). In total, 130 patients presenting to the senior author’s breast reconstruction clinic completed the survey. The survey assessed patients’ knowledge on and their perception of BIA-ALCL and BII. Results: “News article” and “Television” were most often selected as sources of information for BIA-ALCL (21% and 20%, respectively) and BII (20% and 25%, respectively). A total of 100 patients (77%) had previous knowledge of BIA-ALCL. Forty-seven percent (n = 47/100) responded that they were unsure of the fate of a person diagnosed with BIA-ALCL, and 25% (n = 25/100) were unaware of the association between BIA-ALCL and specific implant type. Patients who were unaware of BIA-ALCL prognosis reported being less likely to receive breast implants in the future (P = 0.012, χ2 = 19.48). Eighty-nine patients (68%) had previous knowledge of BII. A total of 60 symptoms were mentioned by patients, with “Fatigue” (12%, n = 26) being cited the most often. Conclusions: The present survey highlights the importance for plastic surgeons to frequently discuss these entities with their patients. This should be done despite the obscurity of BII, in an effort to offer the best available evidence to our patients.
Introduction: Despite there being several clinical studies reporting promising outcomes of resorbable plates for fixation of pediatric mandible fractures, the literature is devoid of large studies or comprehensive reviews assessing safety rates, complications and long-term outcomes. The purpose of the current review is to obtain a global consensus, shed light on efficacy and complications, and provide the reader with evidence-based data to help guide clinical management. Methods: A systematic review of clinical studies assessing outcomes for resorbable plates in pediatric mandibular fractures was carried out. The main outcomes included infection, hardware failure, hardware exposure, malocclusion, reoperation and nonunion. Overall rates were pooled and stratified by fracture and implant type. Results: Ten studies were included yielding 232 patients with 269 fractures. The mean age at surgery was 8.24 years with a mean follow up of 1.03 years. The overall complication rate was 5.2% (n = 12). Complications included infection (n = 4, 1.7%), hardware exposure (n = 3, 1.29%), wound dehiscence (n = 2, .86%) and intra-oral fistula formation (n = 2, .86%). One patient (0.43%) had malocclusion and none (0%) had hardware failure, nonunion or revision surgery. Patients with multiple fractures (≥ 2) had higher complication rates compared to isolated fractures (12.5% versus 1.7%). Conclusion: The use of resorbable plates for pediatric mandibular fractures is a viable option with similar rates of post-operative complications and outcomes compared to standard metallic counterparts. In the absence of large studies or systematic reviews, this study provides craniofacial surgeons with an evidence-based reference to guide decision making and improve informed consent.
Background: Despite recent advances in surgical, anesthetic, and safety protocols in the management of nonsyndromic craniosynostosis (NSC), significant rates of intraoperative blood loss continue to be reported by multiple centers. The purpose of the current study was to examine our center’s experience with the surgical correction of NSC in an effort to determine independent risk factors of transfusion requirements. Methods: A retrospective cohort study of patients with NSC undergoing surgical correction at the Montreal Children’s Hospital was carried out. Baseline characteristics and perioperative complications were compared between patients receiving and not receiving transfusions and between those receiving a transfusion in excess or <25 cc/kg. Logistic regression analysis was carried out to determine independent predictors of transfusion requirements. Results: A total of 100 patients met our inclusion criteria with a mean transfusion requirement of 29.6 cc/kg. Eighty-seven patients (87%) required a transfusion, and 45 patients (45%) required a significant (>25 cc/kg) intraoperative transfusion. Regression analysis revealed that increasing length of surgery was the main determinant for intraoperative (P = 0.008; odds ratio, 18.48; 95% CI, 2.14–159.36) and significant (>25 cc/kg) intraoperative (P = 0.004; odds ratio, 1.95; 95% CI, 1.23–3.07) transfusions. Conclusions: Our findings suggest increasing operative time as the predominant risk factor for intraoperative transfusion requirements. We encourage craniofacial surgeons to consider techniques to streamline the delivery of their selected procedure, in an effort to reduce operative time while minimizing the need for transfusion.
Background: Cranial vault surgery for craniosynostosis is generally managed postoperatively in the intensive care unit (ICU). The purpose of the present study was to examine our center's experience with the postoperative management of otherwise healthy patients with nonsyndromic craniosynostosis (NSC) without routine ICU admission. Methods: A retrospective cohort study of patients with NSC operated using a variety of vault reshaping techniques in our pediatric center between 2009 and 2017 was carried out. Patients with documented preexisting comorbidities that would have required admission to the ICU regardless of the surgical intervention were excluded. Results: A total of 102 patients were included in the study. Postoperatively, 100 patients (98%) were admitted as planned to a general surgical ward following observation in the recovery room. Two patients (2%) required ICU admission due to adverse intraoperative events. There were no patients who required transfer to the ICU from the recovery area or surgical ward. Within the surgical ward cohort, 6 patients (6%) had minor postoperative complications that were readily managed on the surgical floor. Postoperative anemia requiring transfusion was the most common complication. Conclusion: The results from this study suggest that otherwise healthy patients with NSC undergoing cranial vault surgery can potentially be safely managed without routine admission to the ICU postoperatively. Key elements are proper preoperative screening, access to ICU should an adverse intraoperative event occur and necessary postoperative surgical care. The authors hope that this experience will encourage other craniofacial surgeons to reconsider the dogma of routine ICU admission for this patient population.
Background:Mandibular fractures in adults commonly require rigid fixation to ensure proper occlusion while minimizing infection risks. Numerous centers have assessed the efficacy of resorbable materials as a potential alternative to metallic plates. The purpose of the current systematic review and meta-analysis is to shed light on overall outcomes for resorbable implants and to compare these results to those for metallic counterparts.Methods:A systematic review of clinical studies reporting outcomes for resorbable plates for mandible fractures was carried out. The reported outcomes were hardware failure/exposure, infection, wound dehiscence, reoperation, malocclusion, and nonunion. The results were pooled descriptively and stratified according to fracture and implant type. A subset meta-analysis of prospective studies comparing metallic and resorbable implants was also carried out.Results:Eighteen studies were included for a total of 455 patients managed with resorbable implants (mean follow-up, 8.95 months) with an overall complication rate of 19.8 % (n = 90/455). Infection (n = 31/455, 6.8%) and wound dehiscence (n = 28/455, 6.2%) were the most common complications. Nonunion occurred in 1.1% (n = 5/455) of patients. Seven studies were included in a meta-analysis, and the rates of adverse events in the resorbable and metallic groups were 18.0% (n = 32/178) and 18.3% (n = 33/180), respectively, with no statistically significant difference between both cohorts (95% CI 0.58, 1.82, P = 0.93).Conclusions:This study suggests that there are no statistical differences in outcomes for patients with mandible fractures managed with resorbable or metallic implants. In the absence of meta-analyses or large randomized controlled trials, the current study provides surgeons with an evidence-based reference to guide decision-making.
Background Vascularized lymph node transfers (VLNT) are being used with increasing frequency for the treatment of breast cancer-related lymphedema (BCRL). However, there is a lack of consensus in the surgical field as to which recipient site should be utilized. We, therefore, aim to assess the evidence comparing the wrist and axilla as recipient sites for VLNT in BCRL. Methods We conducted a systematic literature review to compare the wrist and axilla as recipient sites for VLNT in BCRL. Demographic data, as well as circumference reduction rate (CRR), excess volume reduction (EVR), postoperative decrease in infections per year, postoperative discontinuation of compression garments, and overall pooled complication rate were extracted from included studies. These were compared through a meta-analysis. Results A total of 37 studies met the inclusion criteria for a total of 689 patients. VLNTs to the wrist and axilla resulted in a decrease in CRR of 42.1 and 51.5%, and a decrease in EVR of 35.6 and 48.8%, respectively. However, our meta-analysis showed no significant differences between CRR or EVR and between wrist and axilla as recipient sites. Similarly, we found no differences in postoperative decrease in infections per year, postoperative discontinuation of compression garments, and overall pooled complication rate. Conclusion These data suggest noninferiority between the wrist and axilla as recipient sites for VLNT in the context of BCRL. In the absence of randomized, prospective data, we hope these results can be used as an evidence-based reference and facilitate future studies.
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