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5% CL -6.0, 11.5) and between VLPS and pinning by -0.14(-9.2,8.9). However, at 6 weeks, mean MHQ Summary score for VLPS was greater than EFP by 19(p less then 0.001), pinning by 11(p less then 0.001) and casting by 7(p=0.03). VLPS participants demonstrated significantly better radiologic alignment throughout the follow-up period, though there was no relationship between any outcome and radiographic alignment. Malunion was experienced by 48% of casting participants. CONCLUSIONS Recovery was fastest for VLPS participants and slowest for EFP participants according to most measures, but by 12 months there were no meaningful differences in outcomes. Casting participants experienced satisfactory results despite loss of radiologic alignment.BACKGROUND We describe the technique of robotic vaginectomy, anterior vaginal flap urethroplasty, and use of a longitudinally split pedicled gracilis muscle flap to recreate the bulbar urethra and help fill the vaginal defect in female-to-male gender affirming phalloplasty. METHODS Vaginectomy is performed via robotic assisted laparoscopic transabdominal approach. Concurrently, gracilis muscle is harvested and passed through a tunnel between the groin and vaginal cavity. It is then split longitudinally and the inferior half is passed into the vaginal cavity, where it is inset into the vaginal cavity. Following urethroplasty, the superior half of the gracilis flap is placed around the vaginal flap to buttress this suture line with well-vascularized tissue. RESULTS From May 2016 to March 2018, 16 patients underwent this procedure, of average age 35.1 ± 8.8 years, BMI 31.4 ± 5.5, and ASA class 1.8 ± 0.6. The average length of operation was 423.6 ± 84.6 minutes, with an estimated blood loss of 246.9 ± 84.9 mL. Patients were generally out of bed on post-operative day 1, ambulating on post-operative day 2, and discharged home on post-operative day 3 (average day of discharge 3.4 ± 1.4 days). At mean follow-up time of 361.1 ± 175.5 days, no patients developed urinary fistula at the urethroplasty site. click here CONCLUSIONS Our use of the longitudinally split gracilis muscle in first stage phalloplasty represents a novel approach to providing well-vascularized tissue to achieve both urethral support and closure of intra-pelvic dead space, with a single flap, in a safe, efficient, and reproducible manner.BACKGROUND Large decompressive craniectomies may be life-saving; however, they may result in 'Syndrome of the Trephined' (SofT). This post-recovery sequela is characterized by dizziness, fatigue, depression, weakness, speech slowing, gait disturbance, and impaired mentation. Since this entity is poorly understood, we attempted to quantify the functional improvement in patients with SofT after cranial vault reconstruction. METHODS Patients with cranial vault defects (>50cm) from trauma, meningioma, and hemorrhage were studied preoperatively and postoperatively (6 months) after cranial vault reconstruction using 1) Cognistat Active Form and 2) The FIM instrument (n=40). Cranial vault reconstructive techniques varied from split cranial bone to alloplastic implants (PEEK or titanium mesh). RESULTS Of the 143 patients treated with decompressive craniectomies, 28% (n=40) developed symptoms of SofT. A larger craniectomy defect size correlated with development of SofT. Time from craniectomy to presentation of symptoms was 4.5 months. Time from craniectomy to cranial vault reconstruction was 6.1 months. Time from cranial vault reconstruction to symptom improvement was 4.3 days. Complete functional recovery of SofT was seen in 70%. Type of cranial vault reconstruction PEEK implant (57.5%), Split calvarial graft (22.5%), Titanium mesh (20%), was not a determinant for functional improvement. Cognistat assessment score noted improvement (from 38 to 69); likewise, the FIM measurement tool showed improvement (from 38 to 98). CONCLUSIONS Syndrome of the Trephined occurs more frequently then previously described in post-traumatic patients with large cranial vault defects. Cranial vault reconstruction leads to significant, quantifiable functional improvement in a large number of patients.BACKGROUND Repair of unilateral incomplete cleft lip is the surgeon's opportunity to achieve a superior result with few revisions. METHODS This study is a retrospective review of consecutive patients with unilateral incomplete cleft lip, defined as a defect extending 30-90% of cutaneous labial height, treated between 1985-2013 by one surgeon. Rates and types of revisions were collected, and photographs of patients who did not have a revision were reviewed to determine if a revision was needed. RESULTS One hundred and thirty-six patients met inclusion criteria. Fifty-seven percent needed revision of the mucosal free margin; less than ten percent needed other minor labial revisions. Fifteen percent required a nasal revision, most commonly reelevation of the lower lateral cartilage. Over time, the only statistically significant change in frequency was increased revisions of the free border. CONCLUSIONS Nasal revision rates are low in unilateral incomplete cleft lip compared to complete forms in previously published data by the senior author. In contrast, labial revisions of the free margin are more common. The reason is the surgeon became more cognizant of vermilion-mucosal deficiency on the non-cleft side and more likely to offer a submucosal flap or dermis-fat graft to level the lip for normal upper incisor show.BACKGROUND/OBJECTIVE Autoimmune diseases such as rheumatoid arthritis (RA) and systemic lupus erythematosus (SLE) have been associated with an impaired function of the autonomic nervous system and reduced vagus nerve (VN) tone measured through lower heart rate variability (HRV). Targeting the VN through electrical stimulation has been proposed as a treatment strategy with promising results in patients with RA. Moreover, it has been suggested that the VN can be stimulated physiologically through deep breathing. In this study, the aim was to investigate if the VN can be stimulated through deep breathing in patients with RA and SLE, as measured by HRV. METHODS Fifty-seven patients with RA and SLE performed deep breathing exercises for 30 minutes in this explorative study. Before the breathing exercise, 2 electrocardiogram recordings were obtained to determine the patient's baseline HRV during rest. After the 30-minute breathing exercise, 5 minutes of electrocardiogram recordings were obtained to determine postintervention HRV and used as a measure of vagal activity.
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