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INTRODUCTION Surgical procedures with loupe magnification, headlights, and microscopes expose craniofacial surgeons to mechanical stress that can increase risk of long-term musculoskeletal pain and injury. Identifying the prevalence and cause of work-related musculoskeletal discomfort may guide preventative strategies to prolong well-being, job satisfaction, and greater duration of surgical careers. METHODS A 29-question online survey was distributed to the surgeon members of the American Cleft Palate-Craniofacial Association. Eight hundred seventy-three surveys were distributed, and the anonymous responses were recorded using Google forms. RESULTS One hundred ninety-six unique responses were recorded (22.5% response rate). A total of 64.2% reported experiencing musculoskeletal symptoms during their career, with neck, lower back, and shoulders being the most common problem areas. Multivariate analysis demonstrated surgical loupes (odds ratio 2.36, P = 0.03) and length of surgical practice >15 years (odds ratio 1.95, P = 0.04) were independently associated with greater odds of developing symptoms. Headlights (median pain = 3, P

Background Complications from medical tourism can be significant, requiring aggressive treatment at initial presentation. This study evaluates the effect of early surgical versus conservative management on readmission rates and costs. Methods A single-center retrospective review was conducted from May of 2013 to May of 2017 of patients presenting with soft-tissue infections after cosmetic surgery performed abroad. Patients were categorized into two groups based on their management at initial presentation as either conservative or surgical. Demographic information, the procedures performed abroad, and the severity of infection were included. The authors' primary outcome was the incidence of readmission in the two groups. International Classification of Diseases, Ninth Revision; International Classification of Diseases, Tenth Revision; and CPT codes were used for direct-billed cost analysis. Results Fifty-three patients (one man and 52 women) presented with complications after procedures performed abroad, of which 37 were soft-tissue infections. Twenty-four patients with soft-tissue infections at initial presentation were managed conservatively, and 13 patients were treated surgically. The two groups were similar in patient demographics and type of procedure performed abroad. Patients who were managed conservatively at initial presentation had a higher rate of readmission despite having lower severity of infections (OR, 4.7; p = 0.037). A significantly lower total cost of treatment was shown with early surgical management of these complications (p = 0.003). Conclusions Conservative management of complications from medical tourism has resulted in a high incidence of failure, leading to readmission and increased costs. This can contribute to poor outcomes in patients that are already having complications from cosmetic surgery. Clinical question/level of evidence Therapeutic, III.

PURPOSE: Open cranial vault remodeling (CVR) with autologous split calvarial bone grafts redistributes and recontours an abnormal calvarium to create an expanded cranial vault in patients with craniosynostosis. We report a 12-year retrospective review of 162 nonsyndromic patients who underwent operative repair using our previously-described technique which portends excellent surgical outcomes and can be applied to patients of any age group and with any variety of suture fusion. METHODS: Data was gathered on patients who underwent CVR from 2005 to 2016. Surgical records for each patient were analyzed and included operative time, estimated blood loss, and intraoperative transfusion volumes. Intraoperative and postoperative complications, the need for revision surgery, postoperative length of stay, and follow-up records were also reviewed. Syndromic patients were excluded, as well as patients with incomplete data sets. Patients who underwent either anterior or posterior vault remodeling were compared. RESULTS: A total of 162 patients were included in this case series. Patients undergoing anterior CVR were significantly older than those undergoing posterior CVR (13.3 versus 11.0 months, P < 0.015) and also had significantly greater intraoperative red blood transfusion volumes (20.3 versus 15.3cc/kg, P < 0.0207) and longer operative time than posterior CVR patients (274.9 versus 216.7 minutes, P < 0.0001). No patients required reoperation for resorption or recurrence or persistent contour irregularities. There were no visual or neurological complications. Calvarial bone was successfully split in 100% of cases. CONCLUSIONS: This surgical approach to CVR results in good surgical outcomes with a low recurrence rate, while also maximizing operative efficiency, and minimizing total blood loss and transfusion volume. This technique can be applied to any affected suture in a patient with craniosynostosis and in patients of any age group.

Autologous fat grafting is an important tool for plastic surgeons treating the aging face. Malar augmentation with fat is often targeted to restore the youthful facial contour and provides support to the lower eyelid. The existence of distinct facial fat compartments suggests that a stepwise approach may be appropriate in this regard. The authors describe a three-step approach to malar augmentation using targeted deep malar fat compartmental augmentation, termed the "boomerang lift." Clinical patients undergoing autologous fat grafting for malar augmentation were injected in three distinct deep malar fat compartments: the lateral sub-orbicularis oculi fat, the medial sub-orbicularis oculi fat, and the deep medial cheek (n = 9). Intraoperative three-dimensional images were taken at baseline and following compartmental injections (Canfield VECTRA H1). Images were overlaid between the augmented and baseline captures, and the three-dimensional surface changes were analyzed, which represented the resulting "augmentation zone." Three-dimensional analysis demonstrated a unique pattern for the augmentation zone consistent across patients. The augmentation zone resembled a boomerang, with the short tail supporting the medial lower lid and the long tail extending laterally along the zygomatic arch. The upper border was restricted by the level of the nasojugal interface, and the lower border was defined medially by the nasolabial fold and laterally by the level of the zygomaticocutaneous ligament. Lateral and medial sub-orbicularis oculi fat injections defined the boundaries of the boomerang shape, and injection to the deep medial cheek provided maximum projection. This is the first description of deep malar augmentation zones in clinical patients. Three-dimensional surface imaging was ideal for analyzing the surface change in response to targeted facial fat grafting. The authors' technique resulted in a reproducible surface shape, which they term the boomerang lift.

Background The American Society for Aesthetic Plastic Surgery (ASAPS) sponsors an annual conference that promotes education, advocacy, and care. There, researchers deliver abstracts as podium and poster presentations. Subsequently, ASAPS encourages submitting these research findings for publication. Yet, many never become published manuscripts. Objectives To quantify the conversion rates of oral abstract presentations to publication from 1995 to 2010. Secondary objectives included evaluating trends in presentations, publications, time to publication, and published journal distribution. Methods Comprehensive literature search in PubMed cross-referencing oral abstract presentations and determining peer-reviewed publication status. The conversion rate and time to publication was calculated. Results A total of 569 oral presentations met the inclusion criteria. The mean annual presentations was 35.6. A total of 360 presentations became journal publications. The mean annual publications was 22.5. The mean conversion rate was 63.3% (R2, 0.1271; P -value of .23). The mean time to publication was 19.8 months. Most publications occurred within two years of presentation (87.5%). Publications appeared in Plastic and Reconstructive Surgery ( PRS , 48.6%), Aesthetic Surgery Journal ( ASJ , 27.8%), Aesthetic Plastic Surgery ( APS , 5.6%), Annals of Plastic Surgery ( AnnPS , 4.2%), Clinics in Plastic Surgery ( CPS , 3.9%), and other journals (10%). Trending ASJ publications vs other journals in five year intervals demonstrated an increase from 18.7% to 58.8%. Conclusions While the number of presentations and publications declined, the time to publication, and conversion rate remained largely the same. Despite its short existence, ASJ became the predominant journal publishing ASAPS abstracts by the end of the study period.

Background Sarcoma is the most common midface malignancy in children. While first-line treatment in adults is resection, the challenges associated with resection and reconstruction of these tumors in children often lead to radiation therapy as primary treatment. This report highlights the feasibility and efficacy of midface reconstruction in the pediatric population after resection. In most cases, the same principles utilized in reconstructing midface defects in adults hold for the pediatric population. Patients and Methods From 2008 to 2013 seven pediatric patients underwent resection and reconstruction for maxillary sarcomas. These patients ranged in age from 18 months to 20 years. Five patients were reconstructed with six microvascular free flaps. Two patients received pedicled flaps. Follow-up ranged from 15 months to 4.5 years. Reconstructive, oncological, and functional outcomes were analyzed. Results Seven patients underwent eight reconstructions for sarcomas of the maxilla. Flaps utilized included vertical rectus abdominis, anterolateral thigh, fibula, and temporoparietal fascia. One flap was complicated by venous thrombosis but was successfully salvaged after thrombectomy and revision using vein graft. One patient developed recurrence after initial flap placement and required salvage resection and a second free flap. Six patients were judged to have good facial symmetry and tolerated a regular oral diet with normal or near-normal dental occlusion. Conclusions Standard primary therapy for sarcomas of the maxilla in the pediatric population consists of nonsurgical management. However, a radiation-first approach is associated with significant morbidity and makes surgical salvage more difficult. Based on our experience, microsurgical reconstruction of the pediatric midface is safe and effective, and should be considered a first-line treatment option for midface sarcomas in children. In general, there is no significant area of departure between the principles that govern midface reconstruction in adults and children.

BACKGROUND The choice of the recipient vessels for microsurgical reconstruction is based on proximity to the defect, vessel caliber, anatomic reliability, and ease of dissection. Traditionally in head and neck reconstruction, the superficial temporal artery and vein (STA/V) have been reserved as secondary recipient vessels. Others, including the facial artery (FA) and vein have been the preferred choice for facial reconstruction. METHODS A retrospective analysis of all consecutive head and neck reconstructions using the STA/V by the senior author (E.S.G.) over a 5-year period was performed. Perioperative data were reviewed for all the patients. In a subset of patients, radiographic analysis was used to delineate STA and FA anatomy including vessel diameter and distances to standard anatomic landmarks. RESULTS A total of 31 patients had 32 microsurgical reconstructions using the STA/V as recipient vessels. Radiographic analysis revealed no significant difference between the STA and FA diameters. The distances from the STA to the upper and middle face were significantly shorter relative to the FA, 64 versus 102 mm (p

Mandibular distraction osteogenesis (DO) has become an accepted method to manage severe cases of micrognathia-induced airway obstruction in neonates. Current imaging used to plan these procedures aids in surgical planning, but offers only a rough guide for the operating room. To our knowledge the following report offers the first description of virtual surgery used to guide DO in the mandible of a neonate. The plan provided a valuable link between the simulated procedure and the actual operative steps. Such technology can serve an important role in DO and offers objective guidance in device selection, vector planning and operative guide positioning.

Over the last 40 years, craniofacial surgery, in general, and surgery for craniosynostosis, in particular, has witnessed the introduction of a number of new materials for use in operations involving the cranial vault. Some of these materials have proven quite useful over time, while others have failed to meet their stated objectives. In this review, the more popular implant materials are analyzed, and their relative merits and drawbacks are discussed. Craniofacial surgery in the pediatric population has its own unique limitations, quite different from the adult population and those issues are reviewed as well.

Abstract —Preclinical studies in animal models and early results of clinical trials in patients suggest that intramuscular injection of naked plasmid DNA encoding vascular endothelial growth factor (VEGF) can promote neovascularization of ischemic tissues. Such neovascularization has been attributed exclusively to sprout formation of endothelial cells derived from preexisting vessels. We investigated the hypothesis that VEGF gene transfer may also augment the population of circulating endothelial progenitor cells (EPCs). In patients with critical limb ischemia receiving VEGF gene transfer, gene expression was documented by a transient increase in plasma levels of VEGF. A culture assay documented a significant increase in EPCs (219%, P P P v β 3 , and E-selectin after VEGF gene transfer. Constitutive overexpression of VEGF in patients with limb ischemia augments the population of circulating EPCs. These findings support the notion that neovascularization of human ischemic tissues after angiogenic growth factor therapy is not limited to angiogenesis but involves circulating endothelial precursors that may home to ischemic foci and differentiate in situ through a process of vasculogenesis.

We appreciate the opportunity to respond to the letter from Dr Rodriguez Muniz. I suspect that Dr Daher et al, who Dr Muniz credit with being …