Primary Premaxillary Ostectomy and Setback: Dealing With the "Fly-away" Premaxilla.

OBJECTIVE: This study aimed to analyze our outcomes of primary premaxillary ostectomy and setback combined with lip adhesion as the first stage in repair of the bilateral cleft lip with fly-away premaxilla. METHODS: This retrospective study included all patients who required primary premaxillary setback by a single surgeon to achieve successful lip repair between 2011 and 2017 at a tertiary children's hospital. All patients had bilateral cleft lip and complete cleft palate with significant premaxillary protrusion. All patients either had failed presurgical orthodontic manipulation or were thought to be poor candidates because of the rigidity of the premaxilla on clinical examination. Patient data were obtained from review of medical records and photographs. Surgical technique is described. RESULTS: Eleven patients with bilateral cleft lip, all of whom also had complete cleft palate, underwent primary premaxillary setback and lip adhesion at an average age of 8.2 months. The mean follow-up was 1.9 years (range, 139 days to 4.5 years). All patients subsequently completed formal lip repair, of which 10 have undergone palatoplasty. Serial photography documented stable premaxillary position and successful lip repair within the follow-up time frame. No patient had postoperative premaxillary instability or vascular compromise. One patient had dehiscence of the lip adhesion requiring reoperation. CONCLUSIONS: Primary premaxillary ostectomy and setback allows for successful staged formal lip repair in patients with bilateral cleft lip and palate who have failed presurgical infant orthopedics. Further research is required regarding longterm follow-up with respect to midfacial growth.

Repair of Congenital Enlarged Parietal Foramina With Porous Polyethylene Implants.

Enlarged biparietal foramina is an autosomal dominant disorder that is caused by a failure of completion of ossification within the parietal bones. Enlarged parietal foramina measuring more than a few millimeters are uncommon. Even though spontaneous regression has been described, closure is rarely complete, and depending on the size of the resulting defect, an unprotected brain is a concern. There are few reports on the surgical management of persistent enlarged biparietal foramina. This is the first report describing our experience with a custom porous polyethylene implant.

Pediatric Dog Bites: A Review of 1422 Cases Treated at a Level One Regional Pediatric Trauma Center.

BACKGROUND: Children under the age of 14 account for over 40% of the almost 900,000 annual hospital visits associated with dog bites. Care for dog bites ranges from simple wound irrigation to complex surgical reconstruction. Due to a number of factors, children frequently sustain dog bites to highly vulnerable regions, often necessitating intervention by plastic surgeons. METHODS: This retrospective study analyzed data from the 1422 pediatric patients who sustained dog bites and presented to the Le Bonheur Children's Hospital Emergency Room from January 2011 to May 2017. RESULTS: The typical pediatric dog bite case was male (63.5%), African-American (57.4%), and less than 10 years old (69.4%). The head and neck were the most commonly affected areas (64.7%). Of the head and neck regions, the cheeks and lips were the most frequently injured structures (34.5%). Hospital admission was required for 188 patients (13.2%) and operative repair was deemed necessary in 16.9% of all cases. Of the patients requiring inpatient operative repair, most (78.3%) were discharged in less than 24 hours. Operative complications occurred in 5.8% of all cases, with infections accounting for the majority (92.9%). No fatal dog bites occurred in this study. CONCLUSIONS: Age, bite location, and number of bites sustained are several factors of significance, which may aid the novice plastic surgeon in identifying, which pediatric dog bite cases will require surgical intervention.

Distraction Osteogenesis in Craniofacial Surgery: Past, Present, and Future.

ABSTRACT: Distraction osteogenesis (DO) is considered one of the treatments of choice for the surgical correction of malformations of the craniofacial skeleton. This is due to its ability to generate bone at the distraction site along with the accompanying soft tissue changes, the possibility to combine DO with traditional orthognathic procedures and the successful reported long-term outcomes following its application to various craniofacial deformities. The aim of this review is to present an overview of the literature on the evolution of DO applications in craniofacial surgery through the last 35 years.

Anterior Tongue Microglossia: Impact on Face Development.

Microglossia is an extremely rare developmental condition that might impact the patient's respiratory, feeding and speech functions, in addition to other intraoral structures. Embryologically, the tongue has 2 origins, which when affected, will determine whether the patient has microglossia or aglossia. A multidisciplinary team should adopt an organized approach based on confirmation by direct laryngoscopy, determination whether associated airway anomalies, mandibular deformities are present; followed by assessment of the ventilatory and feeding status. The involvement of multiple factors, the presence of several anatomical anomalies and the growth exerted by patients, confer microglossia a rather dynamic clinical entity. Two cases of microglossia depicting these features are presented along with review of the literature and a management algorithm.

Isolated Frontosphenoidal Suture Craniosynostosis: Treatment Approaches and Literature Review for a Unique Condition.

BACKGROUND: Craniosynostosis isolated to the frontosphenoidal suture is an extremely rare entity, distinct from other types of synostotic anterior plagiocephaly, from the embryologic, phenotypic and endocranial morphology viewpoints. Embryologically, the sphenoid bone has two origins, which morphogenetically represent 2 distinct subunits. Depending on the region involved, unique craniofacial features involving the forehead, temporal region and orbit will be demonstrated. A case of frontosphenoidal suture synostosis depicting these features is presented. In addition, a literature review was performed and a treatment algorithm is proposed.

Depressor Reanimation After Facial Nerve Paralysis.

Facial expressions play a fundamental role in interpersonal communication and interaction; consequently, facial palsy has profound effects on the quality of life of patients. Reanimation of lower lip depressors is rarely addressed during facial reanimation but is as important as treating the eye sphincter and the lip levators. Depressors of lower lip are vital for full denture smile and the expression of facial emotions. Static and dynamic techniques are used to reanimate the lower lip depressors. Static techniques provide stationary results either by weakening the contralateral normal side to achieve symmetry using botulinum toxin injection, depressor labi inferioris myectomy and marginal mandibular nerve neurectomy, or by creating static slings and tightening procedures on the affected side. Dynamic techniques provide functional results by reanimating the affected depressor complex using nerve transfers, muscle transfers, and direct muscle neurotization. The purpose of this article is to present an overview of the literature on the applications of these techniques in lower lip reanimation. Furthermore, preoperative evaluation and indications are also discussed.

Innovation to Pediatric Cranioplasty.

Pediatric cranioplasty poses a reconstructive challenge because of children's developing anatomy and dynamic growth. Although several studies have advocated the use of autologous bone over synthetic material in pediatric population, the full coverage of the cranioplasty defect can be not fulfilled in the majority of the cases due to the size of the defect and the limited bone stock. There is an ongoing research for the development of alloplastic bone substitutes that avoid rigid fixation and promote graft transformation into viable tissue to improve outcomes in alloplastic pediatric cranioplasty. The aim of this study is to offer a detailed review on evolution, evaluation, planning, materials, and outcomes of cranioplasty in pediatric patients.

Mid-Term Outcome of Mandibular Distraction Osteogenesis in Pierre Robin Sequence.

The aim of the present study was to present a single center's experience with mandibular distraction osteogenesis (MDO) in Pierre Robin sequence (PRS) patients. A retrospective chart review was performed to identify patients with PRS that underwent MDO at our institution from 2003 to 2012. Inclusion criteria were as follows:Evaluation included demographic information, postoperative complications, and surgical outcomes. Twenty-four patients met the inclusion criteria. No complications related to our distraction technique were reported. Most of the patients who had a tracheostomy were successfully decannulated and the rest were able to avoid a tracheostomy. Two patients had superficial infections that were treated conservatively with topical antibiotics. One patient, who was our first case in the series, required 3 episodes of distraction osteogenesis. Another patient demonstrated recurrent symptoms of obstructive sleep apnea after MDO and was treated with continuous positive airway pressure. Over-correction during MDO in PRS is an efficient method for preventing future airway problems. Patients who required a tracheotomy pre-distraction and cases in whom distraction was performed at older age (>2 months of age), had a lower success rate in achieving de-cannulation and a higher rate of complications. Laryngomalacia, gastro-esophageal reflux disease, cardiac, and GI anomalies are not associated with increased failure rates of MDO in PRS.

End-to-Side Nerve Repair: Current Concepts and Future Perspectives.

Peripheral nerves injuries are extremely debilitating and have been a perennial challenge to the reconstructive surgeon. End-to-side (ETS) neurorrhaphy is a potential strategy for treating nerve lesions without usable proximal nerve stump. A number of interesting clinical and experimental studies have been carried out on ETS nerve repair during the first years of the 20th century. End-to-side nerve repair was then almost abandoned for more than 50 years. The rediscovery of ETS nerve repair was attributed to the experimental work of Viterbo.Two mechanisms have been suggested for axonal regeneration: terminal and collateral sprouting. While in collateral sprouting axonal outgrowth occurs along the length of the uninjured axons, in terminal sprouting, axonal regeneration takes place at the distal most aspect of either injured or uninjured axons. Clinical experience with ETS nerve repair includes management of upper extremity nerve injury, facial reanimation, reconstruction after tumor ablation, and the prevention of neuroma formation.The aim of this review article was 2-fold: (1) overviewing the most interesting experimental investigations and clinical studies published so far; (2) calling for more basic research on ETS nerve repair indicating the several unanswered questions that this concept asks to the microsurgical community.

The Surgical Management of Nerve Gaps: Present and Future.

Peripheral nerve injuries can result in significant morbidity, including motor and/or sensory loss, which can affect significantly the life of the patient. Nowadays, the gold standard for the treatment of nerve section is end-to-end neurorrhaphy. Unfortunately, in some cases, there is segmental loss of the nerve trunk. Nerve mobilization allows primary repair of the sectioned nerve by end-to-end neurorrhaphy if the gap is less than 1 cm. When the nerve gap exceeds 1 cm, autologous nerve grafting is the gold standard of treatment. To overcome the limited availability and the donor site morbidity, other techniques have been used: vascularized nerve grafts, cellular and acellular allografts, nerve conduits, nerve transfers, and end-to-side neurorrhaphy. The purpose of this review is to present an overview of the literature on the applications of these techniques in peripheral nerve repair. Furthermore, preoperative evaluation, timing of repair, and future perspectives are also discussed.

Painful Neuroma Treatment of the Supraorbital Nerve and Forehead Neurotization Using Human Cadaveric Nerve Allograft.

Neuroma pain can be severe, persistent, and treatment-resistant. Forehead and scalp anesthesia is troublesome for patients. Following an iatrogenic ablative injury to the right supraorbital nerve, with subsequent painful neuroma formation, a human cadaveric nerve allograft (AxoGen, Alachua, FL) was used to restore sensation of the right forehead and treat pain. At 1-year follow-up, the patient was pain-free, and protective sensation to the right forehead was recovered with comparable static and dynamic 2-point discrimination between the injured (20 mm, 12 mm respectively) and the normal side (15 mm, 10 mm respectively). This is the first reported case of using a cadaver nerve allograft for successful direct neurotization of the skin and restoration of sensation in the upper part of the face, and for treating painful neuromas. Moreover, a brief review of the available techniques for treating neuromas of the supraorbital and supratrochlear nerves is provided.

Long-Term Outcomes With Porous Polyethylene Implant Reconstruction of Large Craniofacial Defects.

BACKGROUND: Porous polyethylene (PP) has been used in craniofacial reconstruction but has been primarily relegated to small and moderate size defects. This series evaluates the long-term outcomes after alloplastic reconstruction of cranial defects larger than 5 cm using PP implants. METHODS: Eighteen patients who had reconstruction of large cranial defects, owing to tumor resection or trauma, using PP implants, with at least 2 years of postoperative follow-up, were included in the study. If soft tissue coverage was inadequate, tissue expansion was planned before final cranioplasty. RESULTS: The frontal region was the most common area reconstructed (n = 10). Four patients required tissue expansion owing to soft tissue deficit. The major complication observed was implant exposure, seen in 3 patients (15%). Two of these healed with local wound care; 1 required removal of the implant. A statistically significant difference in risk of implant exposure was observed when tissue expansion was employed in reconstruction (P = 0.001). CONCLUSIONS: This study confirms the material's low rate of infection and extrusion even in large craniofacial defects. Its neuroprotection properties are comparable with other first line alloplastic materials used for cranioplasty. Moreover, it can be shaped as required, there is no resorption with time and no concern for donor site morbidity. The higher exposure rate, in cases in which tissue expansion was also used, was owing to the poor quality of the soft tissue overlying the defect. These qualities make it an attractive option in alloplastic cranioplasty.

Variations in Current Procedural Terminology Coding for Craniofacial Surgery: A Need for Review and Change.

BACKGROUND: A survey was utilized to study the coding practices of surgeons performing craniofacial procedures, in order to determine whether coding for these procedures might be standardized or expanded. METHODS: An online survey was designed with 6 sample cases to cover a variety of procedures encountered in the field of craniofacial surgery which was sent to members of 3 professional organizations centered around the practice of craniofacial/maxillofacial surgery. Surgeons were asked to read the vignettes and choose from a series of multiple-choice responses to code the cases, or write in their own response. Codes were based on the American Medical Association current procedural terminology listings. Responses were compiled and tabulated. RESULTS: One hundred twenty-eight people initiated the survey. The largest common coding responses for each vignette were selected by 45.2% of respondents for the case describing placement of an internal mandibular distractor; 45.3% for the case of scaphocephaly remodeling; 67.1% for a case of cranioplasty for trigonocephaly; 47.2% for hypertelorism repair with periorbital osteotomies; 60% for LeFort III advancement with external distractors; and 53.6% for the case describing the removal of an internal mandibular distractor. Between 4 and 12 codes were identified for possible use in each clinical scenario. CONCLUSION: There appears to be wide variability among those who routinely perform craniofacial surgery as to the appropriate ways to code these procedures. We hope to bring this to the attention of coding committees for further discussion to hopefully bring about more accurate and descriptive codes for craniofacial surgical procedures.

Superiorly Based Pharyngeal Flap for the Surgical Treatment of Velopharyngeal Insufficiency and Speech Outcomes.

A retrospective chart review comparing pre and postoperative speech in 19 patients who underwent pharyngeal flap surgery for the diagnosis of velopharyngeal insufficiency. Eighteen of the patients had a history of cleft palate. Patients were assigned a speech grade between 1 and 5 based on the objective and subjective quality of their speech. Comparison of pre and postoperative speech showed significant improvement in speech quality from a mean grade of 3.37 to 2.00 (P < 0.001). This study demonstrates that a wide, superiorly based pharyngeal flap did lead to significant improvement in speech outcomes in this group of patients independent of gender or age.

Correction of Pterygium Colli in Turner Syndrome: A Clinical Report and Review of the Surgical Management.

The aim of surgery for pterygium colli (PC) is to correct the contour deformity, redistribute or remove the horizontal excess of skin, address the abnormal posterior hairline, avoid excessive scarring, and prevent recurrence. The purpose of this study is to review the available methods to correct the deformity and highlight a recent patient performed by the senior author. A modified bilateral Z-plasty technique was used for correcting PC on a 5-year-old African American girl diagnosed with Turner syndrome. The patient had an uneventful postoperative period and satisfactory functional and esthetic results were demonstrated at 1 year follow-up. The approach used was a variation of a lateral approach. Using the proposed approach, excision and complete release of the scar contracture and less tension, which reduces the rate of recurrence compared with the posterior approaches, is achieved. Moreover, the current technique avoids myotomies, which can put the spinal accessory nerve at risk, and lateral Z-plasties which the authors find unnecessary. Instead, the advancement of each anterior flap is limited in the posterosuperior direction so that the flaps do not meet in the posterior midline. This limits the pull and tension on the entire closure. Although several techniques have been described over the years, the search for the ideal type of surgical treatment is still ongoing.

Excision and Fat Grafting of Nasal Tip Dermoid Cysts Through an Open Rhinoplasty Approach.

Nasal tip dermoid cysts that are present in pediatric patients can be complicated by mass effect causing compression and distortion of underlying cartilaginous structures. The purpose of this report is to describe a single surgeon's technique and results of nasal tip dermoid cyst excision in pediatric patients through an open rhinoplasty approach followed by tip reconstruction and immediate fat grafting. A series of 3 pediatric patients presented with 1 to 1.5 cm nasal tip dermoid cysts that were causing distortion of the lower lateral cartilages. All 3 underwent excision of the cyst through an open rhinoplasty approach. The nasal tip was reconstructed with interdomal sutures and immediate fat grafting. Fat grafts were harvested from the abdominal wall and implanted in the nasal tip. The grafts filled the resulting dead space and were secured with the fibrin glue. The soft tissue was redraped, and the skin was closed. The final postoperative result, 2 years after surgical intervention, included a well-proportioned and appropriately shaped nasal tip without obvious incisional scars in all patients. The skin overlying the previously excised dermoid cyst was supple and healthy. Excision of nasal tip dermoid cysts in pediatric patients can be approached through an open rhinoplasty approach, tip reconstruction, and immediate fat grafting. This approach can provide assistance in correcting contour deformities and may help preserve an at-risk soft-tissue envelope.

The Role of Resorbable Mesh as a Fixation Device in Craniosynostosis.

The purpose of the study was to present our experience with endocranial fixation using the Resorb-X mesh (KLS Martin, Jacksonville, FL) in frontoorbital reconstruction. A retrospective review of all patients underwent frontoorbital advancement at our institution from 2003 to 2012 was performed. Inclusion criterion included: pediatric patients who underwent frontoorbital advancement for craniosynostosis; patients underwent treatment of the craniosynostosis only at our center; resorbable fixation devises were applied only endocranially; and follow-up was ≥ 2 years. Patients' evaluation included demographic information, postoperative complications, surgical outcomes, and postoperative computed tomographic imaging if accessible. Thirty-nine patients met the inclusion criteria. Resorbable plates were used in 16 patients and Resorb-X mesh in 23 patients. Observed complications were unrelated to the fixation system used. Resorption of fixation devices was evident in all patients after 20 months following reconstruction. There were no incidents of local reaction to the fixation system. Frontoorbital area contour was deemed good in 24 patients and excellent in 15 patients by both families and attending surgeon. There was a statistical significant difference (P = 0.030) between patients ≤ 12 months and >12 months regarding the complications rate. Endocranial fixation using the Resorb-X mesh is easily applicable, avoids material palpability, and provides stable and secure fixation. This technique is superior to the conventional endocranial osseous fixation with absorbable plates, as it avoids some of its possible complications while providing all the benefits of resorbable fixation.