Videofluoroscopy Versus Nasopharyngoscopy of Lateral Pharyngeal Wall Movement for Assessment of Velopharyngeal Insufficiency.

BACKGROUND: Competent speech requires closure of the velopharyngeal sphincter by dynamic apposition of the velum and posterior and lateral pharyngeal walls. An accurate estimation of lateral pharyngeal wall motion is an important determinant in the planning and the outcome of any operation to correct velopharyngeal insufficiency (VPI). The purpose was to compare the assessment of lateral pharyngeal wall movement by videofluoroscopy (VP) versus nasopharyngoscopy (NP). METHODS: The authors retrospectively reviewed the charts of 269 consecutive patients in our cleft lip/palate clinic from 1982 to 2008 and culled those treated with a pharyngeal flap for VPI. The authors included patients who were evaluated preoperatively by both VP and NP, and had studies of suitable quality. Percentage of lateral pharyngeal wall motion was estimated with each technique and compared for each patient. RESULTS: The authors identified 25 patients who underwent both VP and NP at the same median age (4.7 years). The estimated percentage of lateral pharyngeal wall motion between the 2 techniques was significantly different ( P <0.001). Average lateral pharyngeal wall motion was estimated to be 59±25% (range: 5%-90%) by VP and only 40%±25% (range: 0%-95%) during NP. CONCLUSIONS: VP and NP are complementary, but assessment of lateral pharyngeal wall motion can vary between the 2 methods. The surgeon should be aware of the difference in estimated lateral pharyngeal wall movement when planning a procedure to correct VPI.

A Quantitative Analysis of Facial Asymmetry in Torticollis Using 3-Dimensional Photogrammetry.

OBJECTIVE: To assess whether children with torticollis have quantifiably greater facial asymmetry than their age-matched controls using 3-dimensional (3D) photogrammetry. DESIGN: We retrospectively analyzed patients diagnosed with torticollis and age-matched volunteers who underwent 3D photogrammetry of their faces. We calculated the root mean square deviation (RMSD) between native and reflected facial images, as a measure of asymmetry. Two observers independently measured RMSD values for all study participants. The Spearman correlation coefficient evaluated interobserver reliability. The Wilcoxon rank-sum test with Bonferroni adjusted P values for multiple comparisons. SETTING: Institutional. PARTICIPANTS: Twenty patients diagnosed with torticollis and 12 age-matched volunteers. Patients were analyzed on a computer database and volunteers were selected and consented in the hospital. We excluded patients with a history of facial trauma, facial operations, or other craniofacial diagnoses. INTERVENTIONS: Facial surface scans were obtained using the Canfield Vectra stereophotogrammetry system. The technology captures surface anatomy without radiation. MAIN OUTCOME MEASURES: RMSD comparisons between patients with torticollis and age-matched controls. RESULTS: Compared to controls, patients with torticollis had statistically significant greater full face, upper third, and middle third facial asymmetry. There was a trend toward greater asymmetry of the lower facial third. CONCLUSIONS: We used 3D photogrammetry to quantitate facial asymmetry from torticollis. We found greater asymmetry in patients with torticollis than in their unaffected peers. All areas of the face appeared to be affected, though the asymmetry in the lower facial third just failed to reach significance.

Recurrent Orbital Trauma Following Repaired Orbital Floor Fracture.

A study of a 22-year-old male who was assaulted and sustained a left orbital floor blowout fracture was presented in this study. The orbital floor was repaired with a titanium-reinforced porous polyethylene implant. Two years postoperatively, the patient sustained repeated left orbital trauma. The orbital floor implant remained stable while the medial wall blew out.

The Natural History of Treated and Untreated Zygomatic Arch Fractures.

The authors present the case of a 32-year-old patient treated for a left, isolated zygomatic fracture following assault. The injury was reduced without fixation via the Keene approach. The same patient presented to the emergency room 16 months later with a right-sided fracture similar to the previous contralateral injury. This fracture was left untreated. Repeated assaults over a 4-year period provide us with a natural history of both injuries, allowing for comparison between the 2 approaches. The authors found that reduction of the arch without fixation led to an outcome without palpable or visible deformity and no impaired mastication. Additionally, considering etiology of injury, such as alcohol or drug use, treatment may provide an important point of intervention to prevent recurrence.

Langerhans Cell Histiocytosis in the Pediatric Population: Treatment of Isolated Craniofacial Lesions.

Langerhans cell histiocytosis (LCH) commonly affects the craniofacial skeleton and prognosis depends on location, extension, and recurrence of the disease. The aim of our study is to better define the treatment of single craniofacial lesions, as to date different treatment modalities have been suggested and recurrence rates for both unifocal and multifocal bony lesion range between 10% and 70%. Between 2000 and 2014, we retrospectively reviewed clinical findings, anatomic location, extent of the disease, therapy, and outcomes in 24 pediatric patients with histologically confirmed LCH. Seventeen patients (67%) had craniofacial involvement, of which 13 had single system involvement and 4 had multisystem involvement. Eight patients (33%) had no craniofacial involvement. Eleven patients affected by unifocal cranial lesions were treated with resection and reconstruction. One patient with a unifocal mastoid lesion was treated with chemotherapy alone (vinblastine and prednisone). Four patients with mandible lesions were treated with curettage alone.There were no recurrences in patients treated with excision alone. One patient (25%) treated with curettage recurred. Two patients with diffuse disease manifested organ dysfunction and diabetes insipidus. Chemotherapy was tolerated in 12 patients treated.Our findings suggest that resection of isolated LCH lesions of the cranium is safe and chemotherapy is effective and well tolerated for nonsurgical cases.

Surgical Treatment for Palatoglossal Arch Cicatrix and Velopharyngeal Insufficiency After Adenotonsillectomy.

Postadenotonsillectomy velopharyngeal incompetence/insufficiency/dysfunction (VPI) is an uncommon but potentially surgically challenging problem. We report a child without cleft palate who developed severe palatoglossal arch cicatrix and VPI after adenotonsillectomy, and describe bilateral palatoglossal arch z-plasty to restore palatal function and speech.

Surgical Correction of Metopic Craniosynostosis: A 3-D Photogrammetric Analysis of Cranial Vault Outcomes.

OBJECTIVE: To evaluate 3-dimensional (3-D) photogrammetry as a tool for assessing the postoperative head shape of patients who had undergone cranial vault remodeling for metopic synostosis. DESIGN: We prospectively analyzed images of patients with metopic craniosynostosis who had undergone anterior cranial vault remodeling and age-matched controls. To ensure standardized facial orientation, each 3-D image was positioned to "best fit" the preoperative face by aligning 6 soft tissue landmarks. Forehead measurements were taken from a standardized position behind the surface of the face to landmarks placed in a ray configuration across the forehead. SETTING: Academic teaching hospital. PATIENTS, PARTICIPANTS: Thirteen pediatric patients with metopic craniosynostosis who had undergone anterior cranial vault remodeling and age-matched controls. INTERVENTIONS: Images were taken preoperatively, immediately postoperatively, and over 1-year postoperatively. MAIN OUTCOME MEASURES: Forehead contours preoperatively and postoperatively, with statistics performed using a multivariate analysis of variance shape analysis. RESULTS: Mean postoperative follow-up was 1.8 (0.6) years. The average distance from the origin to forehead landmarks was 55.1 (3.4) mm preoperatively, 59.3 (0.7) mm immediate postoperatively, 59.1 (1.0) mm 1-year postoperatively, and 59.4 (0.6) mm in controls. Postoperative metopic forehead contours varied significantly from preoperative contours ( P < .01), while there was no statistical difference between the 2 postoperative time points ( P = .70). One-year postoperative patients were not significantly different from their age-matched controls ( P > .99). CONCLUSIONS: Preoperative metopic forehead contours varied significantly from postoperative contours. Cranial reconstructions approximated the foreheads of normal controls, and reconstructions were stable at more than 1-year follow-up.

Three-Dimensional Analysis of Nasal Symmetry Following Primary Correction of Unilateral Cleft Lip Nasal Deformity.

OBJECTIVE: To evaluate nasal symmetry using three-dimensional photogrammetry following primary tip rhinoplasty with or without an internal splint in patients with unilateral complete cleft lip/palate. DESIGN: We captured three-dimensional images of patients with unilateral complete cleft lip/palate who underwent nasolabial repair by rotation-advancement of the lip and primary tip rhinoplasty, either with or without an internal resorbable splint, and normal control subjects. We assessed nasal symmetry by identifying the plane of maximum symmetry and the root-mean-square deviation between native and reflected surfaces. PATIENTS/PARTICIPANTS: We imaged 38 controls and 38 subjects with repaired unilateral complete cleft lip/palate (20 with, 18 without an internal splint). RESULTS: Nasal asymmetry root-mean-square deviation clustered between 0.19 and 0.50 mm (median = 0.24 ± 0.08 mm) for controls; whereas, those with repaired unilateral complete cleft lip/palate ranged from 0.4 to 1.5 mm (median = 0.75 ± 0.40 mm). Although root-mean-square deviation ranges overlapped, patients with repaired unilateral complete cleft lip/palate had significantly greater asymmetry than controls (P < .001). We found no difference in asymmetry between patients with or without an internal splint (P = .5). CONCLUSIONS: Three-dimensional photogrammetry was used to successfully compare symmetry among different patient and control groups. Although "normal" nasal symmetry was attained in some patients following cleft lip/nasal repair, most had persistent asymmetry compared with normal controls. Placement of a resorbable internal splint did not improve symmetry in patients with unilateral complete cleft lip/palate.

Management of Craniosynostosis at an Advanced Age: Controversies, Clinical Findings, and Surgical Treatment.

BACKGROUND: The natural history of unrepaired craniosynostosis is not well defined. Delayed surgical intervention carries greater risk of postoperative complications and its functional benefits for older patients are poorly characterized. The authors reviewed patients in whom children presented beyond 1 year of age to better understand the natural history of craniosynostosis, and the risk-benefit relationship for delayed reconstruction. METHODS: After institutional IRB approval the authors conducted a retrospective review of patients who presented after 1 year of age with craniosynostosis. Type of craniosynostosis, age at evaluation, medical history, surgical findings, developmental abnormalities, ophthalmologic findings, and clinical course were reviewed. RESULTS: Ten patients with delayed presentation for craniosynostosis were identified. The mean age at presentation was 6.8 years ±â€Š4.2 years (range, 3-17 years). Seven of 10 patients presented with developmental delay. Five patients presented with debilitating headaches. Five patients presented with comorbid Chiari malformations, 3 of whom required surgical decompression. Two patients had papilledema. Four patients underwent intracranial pressure monitoring, with elevated pressures found in 3 patients. Six patients underwent delayed cranial vault remodeling. There were no peri- or postoperative complications, including infection or residual bony defects, in those undergoing delayed operation. CONCLUSIONS: Children who present in a delayed fashion with unrepaired craniosynostosis have high rates of debilitating headaches, developmental delays, head shape anomalies, and Chiari malformation. Five patients reporting preoperative headaches noted subjective improvements in headaches following delayed operation. Cranial reconstruction can be safely performed at an older age and is appropriate to consider in carefully selected patients for aesthetic and/or functional concerns.

Pediatric Orbital Depth and Growth: A Radiographic Analysis.

BACKGROUND: Orbital reconstruction requires knowledge of orbital depth in order to prevent optic nerve injury. Numerous analyses of adult orbital dimensions have been undertaken previously in order to characterize this measurement, including skull specimen and computerized tomography studies. However, there is a paucity of information regarding the pediatric orbit. METHODS: The authors used pediatric magnetic resonance imaging (MRI) studies in order to quantify the change in orbital depth in relationship to patient age, and to develop methods to estimate and calculate orbital depth for individual pediatric patients. MRIs of the head in normal pediatric patients were reviewed retrospectively. Orbital depths were measured and correlated with age and cephalometric dimensions. In a randomly selected subgroup of patients, measurements were repeated by an independent investigator to determine interobserver reliability. RESULTS: Measurements were obtained in 72 patients ranging from 3 months to 18 years of age (mean=7.8 years). There was a significant exponential relationship between orbital depth and patient age (r=0.81, F(2,69)=143.97, P<0.001). Depth increased more rapidly in the first 6 years of life, but leveled off in the early teen years toward a horizontal asymptote of approximately 45 mm. There was also a significant relationship between orbital depth and the sum of the biparietal width plus the anterior-posterior length (r=0.72, F(2,69)=87.44, P<0.0001). There was high interobserver reliability in measurements between 2 independent investigators (r=0.79, P<0.0001). CONCLUSION: In children, orbital depth increases predictably with rising age and increasing head size. Knowledge of this growth curve and the relationship between head size and orbital depth can complement careful surgical dissection to improve safety and efficacy in pediatric orbital reconstructions.

Quantitative facial asymmetry: using three-dimensional photogrammetry to measure baseline facial surface symmetry.

BACKGROUND: Although symmetry is hailed as a fundamental goal of aesthetic and reconstructive surgery, our tools for measuring this outcome have been limited and subjective. With the advent of three-dimensional photogrammetry, surface geometry can be captured, manipulated, and measured quantitatively. Until now, few normative data existed with regard to facial surface symmetry. Here, we present a method for reproducibly calculating overall facial symmetry and present normative data on 100 subjects. METHODS: We enrolled 100 volunteers who underwent three-dimensional photogrammetry of their faces in repose. We collected demographic data on age, sex, and race and subjectively scored facial symmetry. We calculated the root mean square deviation (RMSD) between the native and reflected faces, reflecting about a plane of maximum symmetry. We analyzed the interobserver reliability of the subjective assessment of facial asymmetry and the quantitative measurements and compared the subjective and objective values. We also classified areas of greatest asymmetry as localized to the upper, middle, or lower facial thirds. This cluster of normative data was compared with a group of patients with subtle but increasing amounts of facial asymmetry. RESULTS: We imaged 100 subjects by three-dimensional photogrammetry. There was a poor interobserver correlation between subjective assessments of asymmetry (r = 0.56). There was a high interobserver reliability for quantitative measurements of facial symmetry RMSD calculations (r = 0.91-0.95). The mean RMSD for this normative population was found to be 0.80 ± 0.24 mm. Areas of greatest asymmetry were distributed as follows: 10% upper facial third, 49% central facial third, and 41% lower facial third. Precise measurement permitted discrimination of subtle facial asymmetry within this normative group and distinguished norms from patients with subtle facial asymmetry, with placement of RMSDs along an asymmetry ruler. CONCLUSIONS: Facial surface symmetry, which is poorly assessed subjectively, can be easily and reproducibly measured using three-dimensional photogrammetry. The RMSD for facial asymmetry of healthy volunteers clusters at approximately 0.80 ± 0.24 mm. Patients with facial asymmetry due to a pathologic process can be differentiated from normative facial asymmetry based on their RMSDs.

Piezoelectric technology for pediatric autologous cranioplasty.

Objective : Pediatric patients with skull defects larger than available sources for splitting bicortical bone have limited options for autogenous cortical bone cranioplasty. Piezoelectric instruments allow donor bone to be chosen based on the best possible contour rather than the presence of bicortical bone. We present the use of piezoelectric technology to split thin unicortical calvarium for autogenous cranioplasty in a series of pediatric patients. Design : Retrospective review of a series of pediatric patients requiring reconstruction for skull defects. Patients/Intervention : Our series included a 2-year-old with a parietal skull tumor and resultant 3 × 3-cm defect after craniectomy, a 2-year-old with a 3 × 3-cm defect after excision of an occipital skull tumor, a 10-year-old with a 4 × 5-cm skull defect after excision of an occipital skull tumor, and a 13-year-old who suffered a gunshot to the forehead with a 12 × 7-cm frontal skull defect. We used a piezoelectric saw to precisely and safely split unicortical and bicortical cranium that ranged from 1 to 3 mm in thickness. The inner layer was used to reconstruct the donor site; whereas, the outer layer was used for the craniectomy defect. Conclusion : The piezoelectric saw allows unicortical bone to be split and used for cortical bone cranioplasty. This technology allows choice of donor site based on the best contour rather than the presence of bicortical bone. This technique expands the possibilities of autogenous cranioplasty and enables primary repair of cranial defects that would otherwise require secondary cranioplasty with remote donor sites, foreign materials, or unstable particulate cranioplasty.

The pedicled reverse-flow lateral arm flap for coverage of complex traumatic elbow injuries.

PURPOSE: The pedicled reverse-flow lateral arm flap has been described primarily for the reconstruction of nontraumatic elbow wounds. We describe our experience using this flap in staged operations for soft tissue coverage after elbow trauma, including acute coverage of open fractures and salvage of infected hardware. METHODS: Review of patients who underwent staged pedicled reverse-flow lateral arm flap transfer for coverage of traumatic elbow defects. RESULTS: Three patients were identified; all underwent 2-stage repair with flap delay for coverage of traumatic elbow injuries. Each patient had stable wound coverage with this flap. The only complication was 5% distal flap necrosis in 1 patient. CONCLUSIONS: The pedicled reverse-flow lateral arm flap provides reliable soft tissue coverage of traumatic elbow defects with minimal donor-site morbidity.

Utilization of intraoperative 3D navigation for delayed reconstruction of orbitozygomatic complex fractures.

Reconstructive goals for orbitozygomaticomaxillary complex fractures include restoration of orbital volume, facial projection, and facial width. Delayed reconstruction is made more difficult by malunion, nonunion, bony absorption, loss of the soft tissue envelope, and scar. Three-dimensional intraoperative navigation, widely used in neurosurgery and sinus surgery, can improve the accuracy with which bony reduction is performed. This is particularly useful in the setting of bony absorption and comminution. We report a case of delayed reconstruction of an orbitozygomaticomaxillary complex fracture using intraoperative navigation and review this technology's utility in this setting.

Prenatal Diagnosis of Craniosynostosis Using Ultrasound.

BACKGROUND: Craniosynostosis is typically diagnosed postnatally. Prenatal diagnosis would allow for improved parental counseling and facilitate timely intervention. Our purpose was to determine whether prenatal ultrasound can be used to diagnose nonsyndromic craniosynostosis. METHODS: The authors reviewed 22 prenatal ultrasounds of infants known to have nonsyndromic craniosynostosis and 22 age-matched controls. Cross-sectional images at the plane used to measure biparietal diameter were selected and cranial shape of each participant was parameterized and used to discriminate affected patients from controls. The results from quantitative shape analysis were compared with results from a blinded visual inspection alone. RESULTS: Among the 22 patients, the most common diagnosis was sagittal synostosis ( n = 11), followed by metopic synostosis ( n = 6). The average gestational age at time of ultrasound of controls and synostotic patients was 26 weeks and 6.8 days at the junction of the second and third trimesters. The controls and synostotic cases segregated into statistically different populations by their shape profiles ( p < 0.001). An automatic shape classifier using leave-one-out cross-validation correctly classified the 44 images as normal versus synostotic 85 percent of the time (sensitivity, 82 percent; specificity, 87 percent). Cephalic index was a poor indicator of sagittal synostosis (45 percent sensitivity). Visual inspection alone demonstrated only a fair level of accuracy (40 to 50 percent agreement) in identifying cases of synostosis (kappa, 0.09 to 0.23). CONCLUSIONS: Craniosynostosis can be identified on prenatal ultrasound with good sensitivity using formal shape analysis. Cephalic index and visual inspection alone performed poorly. CLINICAL QUESTION/LEVEL OF EVIDENCE: Diagnostic, II.

Predictive value of weight gain and airway obstruction in isolated Robin sequence.

OBJECTIVE: Treatment of airway obstruction and feeding difficulties among newborns with isolated Robin sequence is challenging. The lack of clear guidelines may lead to prolonged hospital stays and delays in treatment. Appropriate risk stratification can facilitate treatment planning. We aim to identify factors that prognosticate prolonged hospital stay in children with isolated Robin sequence. SETTING: We used a retrospective multivariate analysis of 46 patients admitted with isolated Robin sequence at the Hospital for Sick Children, in Toronto, between 2000 and 2007. During the initial 4 weeks following admission, data regarding duration of hospital stay, management of airway obstruction, respiratory rate, management of feeding difficulties, and reflux therapy were collected. RESULTS: Correlation between length of hospital stay, airway management, and weight gain during the initial 4 weeks was noted. No correlation was found between length of hospital stay and respiratory rate, supplemental oxygen requirement, or reflux therapy. CONCLUSIONS: Risk stratification is possible in children with isolated Robin sequence. Delayed weight gain in Robin sequence correlates with the degree of airway obstruction. The need for a nasopharyngeal tube and weight gain during the initial 4 weeks of life in newborns with Robin sequence reliably predict length of hospital stay. These prognosticators should contribute to parent and physician expectations, as well as assist in treatment and discharge planning.

Revisiting the Resolution of Chiari Malformation in Nonsyndromic Craniosynostosis: A Case of Posterior Cranial Vault Reconstruction in Secondary Pan-Suture Synostosis.

BACKGROUND: While commonly seen in syndromic craniosynostosis, the incidence of Chiari malformation (CM) in nonsyndromic craniosynostosis has been reported at 5% and there is a lack of understanding of the pathophysiology and management of CM in this patient population. CASE DESCRIPTION: We present a 5-year-old male patient who underwent a sagittal craniosynostosis repair at the age of 5 months and returned at the age of 5 years with daily headaches associated with behavioral changes. He was found to have pan-synostoses and radiographic evidence of increased intracranial pressure, including a Chiari malformation. Neurologic and genetic workup was unremarkable. A cranial vault reconstruction was performed, and subsequent imaging demonstrated resolution of previously noted Chiari malformation. CONCLUSIONS: In our case, we provided a unique window into the underlying pathophysiology for CM in patients with concurrent nonsyndromic craniosynostosis that we hope will add to the current foundation of literature supporting the intricate relation between cranial vault compliance and Chiari malformation or hindbrain herniation. Furthermore, we provide insight into the management of acquired CM and support isolated cranial vault reconstruction in those who do not appear to have symptomatic suboccipital compression.

Nasal reconstruction after severe facial burns using a local turndown flap.

Reconstruction of the nose after severe burn injury is a challenging problem. There are usually associated facial burns, which limits the availability of local flaps. Reconstruction with unburned distant tissue is often not appropriate because of the resulting mismatch in color and texture. Successful nasal reconstruction can be accomplished in this group of challenging patients using a simple, inferiorly based flap from the nasal dorsum with subsequent skin grafting to the resulting defect. We have used an inferiorly based nasal turndown flap to reconstruct severe nasal deformities after burn injury in 28 patients. The flap tissue consists of the dorsal surface of the nose, which is usually made up of skin graft and scar. The flap base is the scar transition zone between the dorsum of the nose and the lining mucosa. This is turned over to provide nasal length, projection, and to stimulate alar lobules. The resulting defect on the dorsum of the nose is then skin grafted. If further length or refinement is required, the procedure may be repeated. The records of all patients who underwent this procedure were reviewed for demographics, age at burn, percentage of total body surface area burned (%TBSA), availability of the forehead, number of procedures, and complications. Twenty-eight patients underwent nasal reconstruction in our series using this local turndown flap. Most of these patients had severe burns, with an average %TBSA of 46%. The procedure was initially applied to patients with devastating injuries and %TBSA of 80%-95%, with extremely limited donor sites. As the success of the procedure was established, less severely burned patients were included in the series, thereby lowering the mean %TBSA. All patients had partial or complete destruction of their forehead donor site. All patients presented for multiple hospitalizations, with an average of 17 hospital admissions. Using this local turndown flap, adequate nasal length and projection could be achieved. There were few complications. All of the flaps survived, although there were 2 cases of necrosis of the distal edge of the flaps (0.7%). This resulted in decreased length and projection but this problem was successfully addressed with additional staged procedures. Contraction of local scar tissue created bulk and support, eliminating the need for distant tissue transfer or cartilage grafting. Twelve of the 28 patients required repeat turndown flaps to achieve sufficient nasal length and projection. These results were durable over a follow-up period of up to several decades. A simple, multistaged dorsal nasal flap can be used to reconstruct severe nasal deformities after facial burn injury. This can obviate the need for distant tissue transfer. Even in patients with subtotal nasal amputation and complete absence of cartilaginous support, the opportunistic use of scar tissue can restore nasal tip projection and alar lobule architecture without cartilage grafting. The resulting nasal reconstruction blends well into the surrounding facial appearance. This simple technique has been remarkably successful in this selected group of patients with challenging nasal deformities.

Lip replantation and delayed inset after a dog bite: a case report and literature review.

Dog bites to the face are common in children and often involve amputation of the lip or cheek resulting in a devastating facial injury. When feasible, replantation of the amputated lip segment provides the optimal cosmetic outcome. Here, we present the case of a partial upper lip replantation with delayed inset as a new treatment option. Revascularization of the central upper lip segment was enabled by anastomosis to a single labial artery. Inset compression at the time of initial closure caused arterial insufficiency. Therefore, a delayed, sequential inset was performed over the following 2 weeks resulting in an esthetically and functionally successful replantation. A comprehensive review of the literature on published lip replantation techniques is also provided and discussed. We add delayed inset to the armamentarium of the microsurgeon when faced with these difficult injuries.