Epidemiologic Trends of Cleft Lip and Palate in a Southern State: A 30-Year Follow-Up.

OBJECTIVES: Children's of Mississippi at the University of Mississippi Medical Center serves as the state's only American Cleft Palate-Craniofacial Association-approved cleft team at the only pediatric hospital in the state. The goal of this study is to report geographic and demographic patterns of patients with orofacial cleft (OFC) treated at Children's of Mississippi, which are lacking. METHODS: Patients with OFC treated at Children's of Mississippi from 2015 to 2020 were included. Demographic data were collected, including birth county and total live births from state data. Significant differences between incidence of OFC among public health regions of Mississippi were examined using analysis of variance (P < 0.05). Cases were compared with historical data from 1980 to 1989. RESULTS: There were 184 patients who presented with OFC, with a statewide incidence of 0.83 per 1000 live births among 222,819 live births in the state across 6 years. The incidence of OFC was 0.83/1000 for Whites and 0.82/1000 for non-Whites versus a historical rate of 1.36 and 0.54, respectively. Significantly fewer children in the northern region (0.25/1000) were born with OFC than in central (1.21; P < 0.001) and southern (0.86; P < 0.001) regions. CONCLUSIONS: Results from this study suggest changing regional patterns of OFC in Mississippi. Although rates increased among non-White infants, the overall incidence of OFC has decreased compared with historical data. The findings may reflect actual incidence patterns in the state or the proximity of certain regions to Children's of Mississippi. Further study may reveal regional differences in risk factors underlying OFC incidence, and/or issues with access to cleft care for different regions in the state.

Posterior Vault Distraction in the Acute Setting.

ABSTRACT: Posterior vault distraction osteogenesis (PVDO) has been shown to resolve acute intracranial hypertension (AIH) while carrying an acceptable perioperative morbidity profile. PVDO has been associated with symptomatic improvement and fewer surgeries in those requiring ventriculoperitoneal shunts. The authors' experience using PVDO as an acute intervention is presented, demonstrating its safety and efficacy for management of AIH. Four cases of children with craniosynostosis that underwent PVDO in the acute setting are outlined. All patients presented with papilledema and symptoms of AIH. One patient with slit ventricle syndrome (SVS) presented with a nonfunctioning shunt following multiple shunt revisions. No intraoperative complications during distractor placement or removal were reported. Distraction protocol for all patients began on postoperative day 1 at 1-2 mm per day, resulting in an average total distraction of 30.25 mm. For the 3 cases with no shunt, the average length of stay was 7 days. As part of the planned treatment course, the patient with SVS required externalization of the shunt during distraction followed by early distractor removal and planned shunt replacement. One case of surgical site infection (in an immunocompromised patient) required premature distractor removal during the consolidation period. Computed tomography (CT) in all patients indicated increased intracranial volume following distraction, and symptomatic improvement was reported. Six-month follow-up showed resolution of papilledema in all patients. The authors' experience using PVDO in the acute setting is reported, alongside a review of current literature, in order to provide supporting evidence for the efficacy of PVDO as a tool for resolving AIH.

"Travel Burden to ACPA Approved Cleft and Craniofacial Teams: A Geospatial Analysis".

BACKGROUND: Despite the existence of American Cleft Palate and Craniofacial Association (ACPA)-approved Cleft and Craniofacial Teams, access to multidisciplinary team-based care remains challenging for patients from rural areas, leading to disparities in care. We investigated the geospatial relationship between U.S. counties and ACPA-approved centers. METHODS: The geographic location of all ACPA-approved cleft and craniofacial centers in the U.S. was identified. Distance between individual U.S. counties (n=3,142) and their closest ACPA-approved team was determined. Counties were mapped based on distance to nearest cleft or craniofacial team. Distance calculations were combined with U.S Census data to model the number of children served by each team and economic characteristics of families served. These relationships were analyzed using independent t-tests and ANOVA. RESULTS: Over 40% of U.S. counties did not have access to an ACPA-approved craniofacial team within a 100-mile radius (n=1,267) versus 29% for cleft teams (n=909). Over 90% of counties greater than 100 miles to a craniofacial team had a population <7,500 (n=1,150). Of the counties >100 miles from a cleft team, 64% had a child poverty rate greater than national average (n=579). Counties with the highest birth rate and >100 miles to travel to an ACPA team are in the Mountain West. CONCLUSIONS: Given the time-sensitive nature of operative intervention and access to multidisciplinary care, the lack of equitable distribution in certified cleft and craniofacial teams is concerning. Centers may better serve families from distant areas by establishing satellite clinics, telehealth visits, and training local primary care providers in referral practices.

Allograft as an Adjunct for Free Omental Flaps for Lower Extremity Coverage of a Mangled Lower Extremity.

The utility of allograft for temporary coverage of soft tissue defects is well-established, most notably in the burn literature. Its utility as an adjunct to free tissue transfer for soft tissue defects has been described, but literature on the effectiveness of this hybrid approach for lower extremity salvage is limited. We present a series of two patients who underwent lower extremity salvage using an omental free flap and allograft followed by staged split-thickness skin grafting at our institution. Patient characteristics analyzed included age, smoking status, comorbidities, mechanism of injury, wound class, and wound surface area. Endpoints included partial or complete flap loss, number of days from allograft to autograft, postoperative infection, unplanned reoperation, and successful, functional extremity salvage.  Both patients were male, ages 50 and 35, with a BMI of 31 and 19.2 kg/m2, respectively. Both were active smokers and had contaminated Gustilo IIIB wounds with areas of over 300 cm2. Both flaps had partial necrosis, averaging 6cm2, that was debrided at the planned second stage. Neither had an unplanned return to surgery, and both patients returned to ambulation.  Allograft skin as a practical and effective adjunct to omental free flap for post-traumatic lower extremity reconstruction. It can facilitate the resolution of edema and prevent flap desiccation, allowing time demarcation of partial flap necrosis and confirmation of flap viability prior to definitive skin autograft. This is particularly useful for large surface area contaminated highly irregular traumatic lower extremity wounds.

The Simultaneous Use of Spring-Mediated Cranioplasty and Distraction Osteogenesis as a Safe Modality for Multi-Suture Craniosynostosis.

ABSTRACT: Craniosynostosis caused by premature fusion of the cranial sutures most commonly involves a single suture. Less commonly, multiple sutures may fuse prematurely resulting in complex craniosynostosis. The authors present 1 case of a patient with unilateral sagittal and unilateral lambdoid craniosynostosis treated safely simultaneous with spring-mediated cranioplasty and distraction osteogenesis.

Surgical management of giant acne keloidalis nuchae lesions.

Acne keloidalis nuchae (AKN) is a progressive inflammatory condition that affects posterior neck and occiput. Treatment options include antibiotics, steroids, lasers, radiotherapy and surgery. We present three patients with advanced 'tumor-stage' AKN that underwent radical local excision followed by either immediate or delayed skin resurfacing, and briefly review existing literature.