Anesthetic Exposure in Staged Versus Single-Stage Cleft Lip and Palate Repair: Can We Reduce Risk of Anesthesia-Induced Developmental Neurotoxicity?

ABSTRACT: Cleft lip and palate (CLP) repair is typically performed in a staged fashion, which requires multiple instances of anesthetic exposure during a critical period of infant neurodevelopment. One solution to this concern includes the implementation of a single-stage CLP repair performed between 6 and 12 months of age. This study aimed to compare total anesthetic exposure between single-stage and staged CLP repairs. A retrospective review of unilateral CLP repairs between 2013 and 2018 conducted at a single institution was performed. Patients underwent either traditional, staged lip and palate repair, or single-stage complete cleft repair, where palate, lip, alveolus, and nasal repair was performed simultaneously. Primary endpoints included: total surgical time and total anesthetic exposure. Secondary endpoints included: excess anesthesia time, recovery room time, length of stay, and type of anesthetic administered. Two hundred twenty-five (n = 225) unilateral CLP repairs were conducted at the Loma Linda University. Detailed anesthetic data for eighty-six (n = 86) single-stage and twenty-eight (n = 28) staged operations were available. There was a statistically significant decrease in anesthetic exposure in single-stage versus staged repairs (316 minutes versus 345 minutes, P = 0.017), despite similar procedure times (260 minutes versus 246 minutes, P = 0.224). This resulted in near double excess anesthetic exposure time in the staged group (98 minutes versus 56 minutes, P < 0.001), primarily occurring during induction. This analysis suggests that single-stage CLP repair can reduce wasted time under general anesthesia and potentially reduce harmful neuronal toxicity in the developmental period in this at-risk population.

Cost Utility Analysis of Staged Versus Single-Stage Cleft Lip and Palate Repair.

PURPOSE: As one of the most common congenital craniofacial deformities, cleft lip and palate repair is a complex and much published topic. Proper treatment can require a multitude of appointments and operations and can place a significant burden on both the patients' families and the health care system itself. One proposed solution has been to combine multiple cleft procedures. However, these more complex operations have drawn concerns from institutions and providers regarding increased cost. This study provides a cost utility analysis between single-stage and staged unilateral cleft lip and palate repairs. METHODS: A retrospective review was conducted via current procedural terminology code identification of all cleft-related operations performed between 2013 and 2018. Patients were screened according to diagnosis, and only analysis on unilateral cleft lip and palate patients was performed. Patients were split into 2 cohorts: those that underwent a single-stage complete cleft repair, which includes palate, lip, alveolus, and nasal repair-termed "PLAN" at our institution, and those that underwent more traditional staged lip and palate repairs. Demographic and billing data were collected for any procedure performed between patient ages 0 and 24 months. χ, t-tests, and parametric regression analyses were performed to compare the cohorts. RESULTS: Between 2013 and 2018, 968 (n = 968) cleft-related operations were conducted at Loma Linda University Children's Hospital. Seven hundred ninety-six (n = 796) noncleft lip/palate repairs and 38 (n = 38) bilateral cleft lip repairs were excluded. Of the remaining 135 (n = 135) patients with unilateral cleft lip and palate, detailed cost data were available for 86 single-stage and 28 staged repairs. The average combined total cost for single-stage repairs was US $80,405 compared with US $109,473 for staged repairs (P < 0.001). The average total intraoperative cost for single-stage repairs was US $60,683 versus US $79,739 for staged repairs (P < 0.001), and the average total postoperative cost for single-stage repairs versus staged repairs was US $19,776 and US $29,703, respectively (P < 0.001). CONCLUSIONS: This analysis suggests that single-stage PLAN repair, provides an effective, cost-efficient solution to unilateral cleft lip and palate care, reducing burden on patients' families and the health care system at large.

Reconstruction of Extended Orbitomaxillectomy and Hemimandibulectomy Defects With Fibula Flaps and Patient-Specific Implants.

An extended orbitomaxillectomy and hemimandibulectomy for polyostotic juvenile ossifying fibroma resection were performed with the assistance of patient-specific cutting guides. The resulting defects were reconstructed in stages. First, a patient-specific mandibular reconstruction plate was fixed to the hemimandibulectomy defect in the same operation as the resection. After margins were proven to be free of tumor on histologic analysis, a free fibula flap contoured to the reconstruction plate was used to reconstruct the mandible. Reconstruction of the maxilla, alveolus, and orbit were performed with a second free fibula flap and patient-specific implants. The lining of the total nasal vault cavity was reconstructed with septal flaps. At 7 months postoperatively, the patient had an excellent esthetic result and resolved diplopia.

Polyostotic Juvenile Ossifying Fibroma: An Exceptionally Rare Case.

Accurate and early diagnosis of benign fibroosseous lesions is important because the treatment and resulting outcomes of each differ. Juvenile ossifying fibromas typically occur in young patients and grow rapidly with a high recurrence rate. Their monostotic nature has previously differentiated these tumors from other fibroosseous lesions. We describe an interesting and extremely rare case of polyostotic juvenile ossifying fibromas in a 14-year-old boy with involvement of the maxilla and mandible. The available literature on juvenile ossifying fibromas is also briefly reviewed. When diagnosing a polyostotic fibroosseous lesion, it is important to not exclude the possibility of juvenile ossifying fibromas because this may warrant a different treatment.

Benefits of the Retrocaruncular Approach to the Medial Orbit: A Clinical And Anatomic Study.

BACKGROUND: Current trends in the management of medial orbital wall fractures are toward the development of transconjunctival incisions and the use of endoscopic-assisted methods. Different authors have suggested variations of the medial transconjunctival approach. METHODS: (1) In 30 fresh cadaver orbits, the classic transcaruncular approach was compared with the precaruncular and retrocaruncular approach under magnified dissection. (2) A retrospective analysis was conducted on a series of 20 consecutive patients that underwent primary repair of medial orbital wall fractures using a retrocaruncular approach without endoscopic assistance. Postoperative computed tomography scans were obtained for all patients and were evaluated by 3 experienced clinicians. RESULTS: (1) Anatomic dissections showed that all 3 approaches provided excellent exposure of the entire medial orbital wall. The transcaruncular and precaruncular approaches, however, (a) both resulted in exposure of the upper and lower tarsi when incisions greater than 10 mm were used; (b) both required a transition from the preseptal plane to the postseptal plane when combined with inferior fornix incisions. (2) A clinical study of 20 patients showed all reconstructions were possible without endoscopic assistance, resulting in no postoperative complications. Postoperative computed tomography scans showed anatomic orbital reconstruction in all patients judged as excellent by the clinicians. CONCLUSIONS: Medial orbital wall fractures can be successfully repaired using transconjunctival incisions without using endoscopes. The retrocaruncular approach surpasses the transcaruncular and precaruncular methods due to its decreased risk of postoperative lid complications and its ability to be directly carried to the inferior conjunctival fornix.

A True Single-Stage Reconstruction of a Projected Auricle for Concha-Type Microtia Incorporating Endoscopically Harvested Temporoparietal Fascia.

Reconstruction of microtia with autogenous costal cartilage that produces a well-projected ear in a single stage is a challenging endeavor. In this case report, we describe a single-stage, projected costal cartilage-based reconstruction of concha type mitoria. Due to the patient's low hairline, his hair-bearing scalp would encroach on the ear framework if placed subcutaneously in the standard fashion. Thus, a large TPF flap harvested with endoscopic assistance was planned to achieve both a color-matched hairless skin envelope and a well-projected ear in single stage.

The reconstructive challenges and approach to patients with excoriation disorder.

Many mental and emotional disorders have some variations of physical manifestations that are often the first definitive sign of disease. One such disorder is excoriation (skin-picking) disorder, also known as dermatillomania, acne excoriée, neurotic excoriation, or psychogenic excoriation. First identified in the dermatologic literature in 1920, excoriation disorder involves repetitive scratching behavior that sometimes accompanies pruritus and is often associated with depression, anxiety, and obsessive-compulsive disorder. In the latest edition of the Diagnostic and Statistical Manual of Mental Disorders, the Diagnostic and Statistical Manual of Mental Disorders fifth edition, excoriation or skin-picking disorder is listed as a stand-alone disorder associated with obsessive-compulsive disorder. In certain patients, the skin lesions are shallow and have adherent crusts that can be mistaken for acne. These lesions, once healed, may appear white and partially atrophic. Because these patients often initially present to dermatologists or plastic surgeons for their skin conditions rather than to psychiatric professionals, it is important to recognize the salient diagnostic features and to acknowledge the importance of a multidisciplinary approach to patient care and management. We present a case of a 51-year-old woman with excoriation disorder who required medical management by dermatology, neurosurgery, psychiatry, and plastic surgery for a definitive surgical treatment.

Use of two cleft lip and palate classification systems by nonsubspecialized health care providers.

Objective : The purpose of this experiment was to evaluate the use of RPL and LAHSHAL coding systems by individuals not specialized in craniofacial abnormalities to code cleft lip and palate (CLP). The effectiveness of system use by referring services and the electronic medical record (EMR) applicability of other CLP systems was evaluated by literature review and testing data. Design and Participants : The RPL and LAHSHAL systems were presented together to a sample of medical students (n = 28) and neonatal intensive care unit nurses (n = 24) from Loma Linda University. Following the presentation, a test assessing the application of each system was administered. A second assessment of the medical students (n = 23) 2 weeks after the initial presentation evaluated system retention. Scores were compared using t test (P ≤ .05). Results : Both the medical students and nurses used RPL more accurately than LAHSHAL in the first assessment (76.9% versus 45.2%, P < .001; 46.6% versus 22.5%, P < .001). Medical students again used RPL more accurately at the 2-week assessment (72.2% versus 43.7%, P < .001). Accuracy of use within each system was not significantly different between the two assessments. Conclusion : Our test results and literature review indicate that, when compared with LAHSHAL, RPL is more easily and accurately used by representatives not specialized in abnormalities in CLP; therefore, RPL may be a more effective system for nonspecialist health care providers to improve the accuracy of referrals and simple EMR documentation.

Indirect cerebral revascularization with a temporoparietal fascial flap in pediatric moyamoya patients: a novel technique and review of current surgical options.

Moyamoya syndrome is a progressive occlusive disease of the cerebral vessels. There are a variety of surgical treatments directed at revascularizing the ischemic brain in pediatric moyamoya disease. Many reports of varying success with both direct and indirect type of procedures can be found in medical literature. We present a novel technique, encephalo-TPF-synangiosis (ETS) with a pedicled bone flap, for indirect moyamoya revascularization in pediatric patients. A three-quarters osteoplastic temporal craniotomy was created. A pedicled temporoparietal fascial flap was passed intracranially through the temporalis muscle and placed into contact with the pial surface. The bone flap was the reaffixed to the skull. We performed 8 ETS in 6 patients. This is a well-vascularized, highly reliable method that offers broad-based surface area for revascularization. We also offer a composite overview of current surgical indirect revascularization techniques.

The angel flap for nipple reconstruction.

Creation of an aesthetically pleasing nipple plays a significant role in breast reconstruction as a determining factor in patient satisfaction. The goals for nipple reconstruction include minimal donor site morbidity and appropriate, long-lasting projection. Currently, the most popular techniques used are associated with a significant loss of projection postoperatively. Accordingly, the authors introduce the angel flap, which is designed to achieve nipple projection with lasting results. The lateral edges of the flap and the area surrounding the top of the nipple are de-epithelialized and the flaps are wrapped to create a nipple mound composed primarily of dermis. Decreasing the amount of fat within core of the nipple and enhancing dermal content promotes long-lasting projection. Furthermore, the incision pattern fits within a desired areolar size, preventing unnecessary superfluous extension of the incisions. Thus, the technique described herein achieves the goals of nipple reconstruction, including adequate and long-lasting projection, without extension of the lateral limb scars.

La création d'un mamelon agréable sur le plan esthétique est un facteur déterminant de la satisfaction de la patiente qui subit une reconstruction mammaire. La reconstruction du mamelon vise à susciter une morbidité minimale au foyer du prélèvement et une projection pertinente et durable. Les techniques actuelles les plus populaires s'associent à une importante perte de projection après l'opération. C'est pourquoi les auteurs présentent le lambeau de l'ange, conçu pour procurer une projection du mamelon aux résultats durables. Les bordures latérales du lambeau et de la région entourant le dessus du mamelon sont désépithélialisées et les lambeaux sont repliés pour former un monticule mamelonnaire composé surtout de derme. Le fait de réduire la quantité de matière grasse au cœur du mamelon et d'en accroître le contenu dermique favorise une projection durable. De plus, le mode d'incision s'associe à la dimension souhaitée de l'aréole et évite l'extension inutile des incisions. La technique décrite aux présentes permet donc la reconstruction du mamelon, y compris une projection convenable et durable, sans extension des cicatrices latérales sur les membres.

A unique case of tessier 30 and bilateral cleft lip and palate: a new clinical syndrome?

Background : Tessier 30 cleft is rare and sparsely reported in the literature. A unique case of an infant with a Tessier 30 cleft, bilateral cleft lip and palate, and other anomalies is presented. In addition to craniofacial anomalies, he had cardiac, gastrointestinal, and genitourinal defects. The constellation of these findings suggests the possibility of a new clinical syndrome. We present these findings and postoperative results following surgical treatment. Patient and Methods : A 37-week gestational male infant with multiple congenital anomalies is presented. Findings on clinical exam were notable for Tessier 30 median mandibular cleft, bilateral cleft of the lip and palate, and bifid tongue. Further workup revealed levocardia, perimembranous moderate-to-large ventricular septal defect, patent foramen ovale, double outlet right ventricle, intestinal malrotation, and bilateral undescended testicles. There were no extremity anomalies, and cytogenetic studies for 22q deletion were negative. Results : The preoperative, intraoperative, and postoperative findings and images are discussed. Conclusion : We present a unique case of a child with a Tessier 30 cleft associated with bilateral cleft lip and palate in the absence of intraoral masses or limb anomalies. Previous reports of median facial clefts have occurred either in the presence of intraoral hamartomas, suggesting the palatal defects are a result of sequence abnormalities, or in association with extremity findings consistent with the spectrum of orofaciodigital syndrome. The case we present is distinct and may represent a new clinical syndrome.

Demographics of cleft care providers in Africa and reported experience in training and practice: direct analysis of continent-based practitioners.

OBJECTIVE: To elucidate the impact of several geographic, cultural, and socioeconomic variables on cleft care delivery in Africa, and to investigate the current status of cleft care delivery in Africa. DESIGN: Survey of practitioners attending the second Pan-African Congress on Cleft Lip and Palate (PACCLIP). SETTING: The annual PACCLIP conference in Ibadan, Nigeria, West Africa, February 2007. MAIN OUTCOME MEASURE: To provide an analysis of the demographics and training experience of cleft care providers in Africa by collating information directly from the continent-based practitioners. RESULTS: Plastic surgeons and oral and maxillofacial surgeons provide the majority of cleft care. Most of the participants reported availability of formal training programs in their respective countries. The predominant practice settings were university and government-based. During training, half of the providers had encountered up to 30 cleft cases, and a quarter had managed more than 100 cases. Representation of visiting surgeons were equally distributed between African and non-African countries. CONCLUSIONS: This study provides initial and detailed analysis crucial to understanding the underlying framework of cleft care composition teams, demographics of providers, and training and practice experience. This awareness will further enable North American and other non-African plastic surgeons to effectively partner with African cleft care providers to have a further reaching impact in the region.

Massive congenital kaposiform hemangioendothelioma of the eyelid in a neonate.

BACKGROUND: Kaposiform hemangioendothelioma (KHE) is a rare and aggressive vascular tumor of infancy and childhood. It is associated with the development of Kasabach-Merritt syndrome, a life-threatening consumptive thrombocytopenia. We report an interesting case of a massive periorbital congenital KHE in a neonate to raise awareness of this aggressive diagnosis. METHODS: A male neonate presented with a large congenital mass of the lower eyelid. To prevent development of amblyopia, this mass was surgically excised on the sixth day of life. RESULTS: Histologic investigation demonstrated spindle-shaped endothelial cells with surrounding crescentic vessels, which were GLUT-1 receptor-negative and D2-40 receptor-positive, consistent with KHE. Surgical excision of the periorbital KHE successfully cleared the neonate's visual axis. At 1 year of follow-up, there was no evidence of tumor recurrence, and visual development was progressing normally. A pleasing surgical result was achieved without periorbital distortion. CONCLUSIONS: Pediatric vascular tumors have historically been wrought with diagnostic confusion. With recent advances in immunohistochemistry, this previously uncharacterized group of tumors has been differentiated into multiple distinct clinical entities. Accurate and timely diagnosis is paramount because these tumors vary greatly in their clinical behavior, prognosis, and recommended treatment. Surgical excision is preferred and necessary in a neonate with visual access obstruction to prevent amblyopia and irreversible blindness.

Single-stage frontalis muscle flap for full-thickness reconstruction of the upper eyelid.

BACKGROUND: Full-thickness upper eyelid defects present a reconstructive challenge. Defects greater than 50% of the upper eyelid have traditionally been reconstructed with bulky full-thickness forehead flaps, Cutler-Beard flaps, Mustarde eyelid switches, and cheek rotation advancements, all mandating a second-stage surgical procedure. We propose a novel technique for full-thickness upper eyelid reconstruction based on a frontalis muscle flap elevated from the resection defect, thus resulting in no additional forehead scar. METHODS: Our patient is a 48-year-old woman with an enlarging right upper eyelid sebaceous cell carcinoma. A subsequent single-stage resection resulted in a medial full-thickness defect of 75% of the upper eyelid. The lateral and medial canthi were preserved. A palatal mucoperiosteal graft was harvested for the reconstruction of the posterior lamella. Dissection was carried through the excision defect in a preseptal plane over the supraorbital rim and subcutaneously over the frontalis muscle. A caudally pedicled frontalis muscle flap was elevated and inset to the defect edges with mild tension. Reconstruction of the skin defect of the upper eyelid was completed with a full-thickness preauricular skin graft. RESULTS: The patient had no complications and demonstrated good function and aesthetic result at 15 weeks and at 9 months postoperatively. CONCLUSIONS: Frontalis muscle flap-based reconstruction offers a viable option for upper eyelid defects that are full thickness and encompass more than 50% of the eyelid. We obtained a functionally and aesthetically pleasing outcome with this single-stage procedure using a preexisting incision with minimal donor-site morbidity.

A donor-site preference utility study for three flaps used in lower extremity microvascular reconstruction.

Fasciocutaneous free flaps are commonly used in reconstruction of the lower extremity. The purpose of this study was to compare preferences in donor-site scar location among 3 flaps capable of covering a wound that is 4 to 6 cm wide with primary closure of the donor-site. The locations chosen were the lateral arm, the anterolateral thigh, and the proximal lateral calf. Survey participants were presented a hypothetical scenario of a trauma patient with an open anterior tibial wound, requiring free flap reconstruction. In an internet-based survey, respondents were asked to take on the role of the patient and to rate the 3 donor-site scar locations with a visual analog scale and rank them in order of preference. One hundred ninety-eight respondents (mean age 24.7 ± 2.9 years, 49.1% men) responded to the survey, and 171 were included. The anterolateral thigh was the most preferred donor site (88.9% ranked first, rated 8.24 ± 1.86), followed by the proximal lateral calf (8.7% ranked first, rated 5.03 ± 1.96), and the lateral arm was last (2.3% ranked first, rated 2.18 ± 1.62). Survey participants clearly preferred the anterolateral thigh as a donor site. This preference may be related to the ability to conceal the scar under clothing, whereas the proximal lateral calf could keep scars in a smaller topographical area of the body. When other aspects of the reconstruction are equal, it may be important for the surgeon and patient to discuss the goals of concealing the donor-site scar versus keeping the wound and reconstruction-related scars in a smaller topographical area of the body.

Transverse ulnar forearm flap.

INTRODUCTION: The transverse ulnar forearm flap (TUFF) was used to reconstruct different recipient sites in 5 consecutive cases based on the specific requirement for a small thin, hairless flap with a long pedicle. Recent studies have clarified the benefits of the ulnar forearm flap: a less inconspicuous donor site and a primary donor site closure with a radially based fasciocutaneous flap. METHODS: The TUFF is designed with its long axis transverse and distal margin parallel with a wrist flexion crease. An incision is extended proximally along the ulnar artery pedicle as far as the takeoff from the brachial artery if needed. After elevating the ulnar forearm flap in the standard fashion, transverse primary closure of the donor site is obtained by elevating a large volar forearm fasciocutaneous flap based on the radial artery and advanced distally with a V-Y advancement. Any dog ear is tailored, and the wrist is flexed at 30 degrees. RESULTS: All TUFF and radial fasciocutaneous flaps survived completely without partial or total losses or ischemic hand complications. One patient had a wide scar at the proximal forearm Y junction that was revised. Two-point fingertip discrimination and range of motion were satisfactory. CONCLUSIONS: The TUFF is a synthesis of variations of previously described forearm flap techniques and provides a specialized flap in situations where small, thin, pliable, hairless fasciocutaneous flap with a long vascular pedicle are necessary. These characteristics make it appropriate in orbital reconstruction and palatal surgery.