Otologic and audiologic outcomes with the Furlow and von Langenbeck with intravelar veloplasty palatoplasties in unilateral cleft lip and palate.

OBJECTIVE: Cleft palate increases the risk of chronic middle ear disease and hearing loss. The goal of this report was to determine which of two palate surgeries and which timing of palate surgery were associated with better otologic and audiologic outcomes in children with unilateral cleft lip and palate at 5 to 6 years of age. DESIGN: Subjects were randomly assigned to the von Langenbeck with intravelar veloplasty or Furlow palate repair, to palate surgery at 9 to 12 months or 15 to 18 months of age, and to the Spina or Millard lip repair. SETTING: Centralized, tertiary care craniofacial treatment center. PATIENTS: A total of 673 infants with unilateral cleft lip and palate. INTERVENTIONS: Palate and lip were repaired using established techniques. Serial otoscopic and audiometric evaluations were performed. MAIN OUTCOME MEASURES: Hearing and otoscopic findings at 5 to 6 years old. RESULTS: There were 370 children available for analysis. Hearing and need for tympanostomy tube placement did not differ by palatoplasty, age at palatoplasty, cheiloplasty, or surgeon. Risk of developing cholesteatoma or perforation was higher with Millard cheiloplasty (odds ratio  =  5.1, 95% confidence interval  =  1.44 to 18.11, p  =  .012). Type and age at palatoplasty were not significantly associated with either the rate of developing these sequelae or the rate of achieving bilaterally normal hearing and ear examinations. CONCLUSIONS: Type of palatoplasty did not influence otologic and audiologic outcomes in 5- to 6-year-olds with unilateral cleft lip and palate. The potential influence of lip repair on otologic outcomes warrants further investigation.

Prospective clinical trial comparing outcome measures between Furlow and von Langenbeck Palatoplasties for UCLP.

The goal of this prospective randomized clinical trial was to compare 2 cohorts of standardized cleft patients with regard to functional speech outcome and the presence or absence of palatal fistulae. The 2 cohorts are randomized to undergo either a conventional von Langenbeck repair with intravelar velarplasty or the double-opposing Z-plasty Furlow procedure. A prospective 2 × 2 × 2 factorial clinical trial was used in which each subject was randomly assigned to 1 of 8 different groups: 1 of 2 different lip repairs (Spina vs. Millard), 1 of 2 different palatal repair (von Langenbeck vs. Furlow), and 1 of 2 different ages at time of palatal surgery (9-12 months vs. 15-18 months). All surgeries were performed by the same 4 surgeons. A cul-de-sac test of hypernasality and a mirror test of nasal air emission were selected as primary outcome measures for velopharyngeal function. Both a surgeon and speech pathologist examined patients for the presence of palatal fistulae. In this study, the Furlow double-opposing Z-palatoplasty resulted in significantly better velopharyngeal function for speech than the von Langenbeck procedure as determined by the perceptual cul-de-sac test of hypernasality. Fistula occurrence was significantly higher for the Furlow procedure than for the von Langenbeck. Fistulas were more likely to occur in patients with wider clefts and when relaxing incisions were not used.

A case of dual thoracoabdominal impalement in vehicular trauma.

Impalement injuries are relatively uncommon during vehicular trauma. We present a dual case report of patients sustaining simultaneous impalement injuries during a high-speed motor vehicle collision in a rural (austere) environment. After Institutional Review Board approval, we performed a review of the patients' medical records. Two young men were traveling in an automobile at high speed when the driver lost control of the vehicle, causing it to strike a wooden fence. Portions of the fence were dislodged, penetrated the windshield, and impaled both the driver and passenger. Both patients were extricated rapidly and transported to our trauma center. Multidisciplinary teams consisting of trauma, thoracic, plastic, and hepatobiliary surgeons addressed the injuries of both patients. Both survived their injuries and have since returned to their homes. This case of dual impalements highlights three key points: first, the principles of management of thoracoabdominal impalement injuries; second, the importance of rapid action of first responders in complex traumas; and finally, the value of using a multidisciplinary surgical team in complicated trauma cases.

History of craniosynostosis surgery and the evolution of minimally invasive endoscopic techniques: the University of Florida experience.

Craniosynostosis is the premature and abnormal fusion of 1 of the 6 suture lines that form the living skull and can occur as part of a syndrome or as an isolated defect (nonsyndromic). The first reported surgical procedure for correction of craniosynostosis was performed in 1890 by Lannelongue who advocated releasing, but not resecting, the fused suture. Craniofacial surgery has developed its own identity in the last 3 decades, with the Frenchman Tessier seen as the founding father. There have been many new developments such as distraction osteogenesis, biodegradable miniplate fixation, and the development of minimally invasive endoscopic techniques. Through the pioneering work of Jimenez and Barone, minimally invasive approaches to the surgical correction of craniosynostosis are now gaining wider acceptance. Here the authors review the history of craniosynostosis, the current literature and technique for endoscopic repair of craniosynostosis, as well as their own experience at the University of Florida, with minimally invasive endoscope-assisted techniques.

Promoting a culture of patient safety: a review of the Florida moratoria data: what we have learned in 6 years and the need for continued patient education.

Patient safety and medical error reduction are topics of extreme importance. Although there has been considerable media controversy regarding reports of decreased patient safety and errors that have occurred in operating rooms of hospitals, ambulatory surgery centers, and doctors' offices, the majority of data across various specialties demonstrate a very low incidence of adverse events resulting from office-based surgery. Limited research has been conducted in patient safety on the topic of outpatient surgery. Since the release of the Institute of Medicine's (IOM) report To Err Is Human, significant progress has been made in patient safety. According to the IOM's report in 2000, between 48,000 and 98,000 annual US hospital deaths result from medical errors. Following the report, there have been numerous calls to improve patient safety and place it at the forefront of the national agenda. The Florida Board of Medicine restricted office procedures in 2000 after a series of incidents occurred in the outpatient setting. The objectives of this paper are to review the Florida moratoria data over the last 6 years to discuss what we have learned as a specialty and to continue a culture of safety in plastic surgery. One of the remaining challenges is the need to continually improve this culture of safety and emphasize the need for continued patient education, specifically related to esthetic procedures administered in nonclinical settings by amateur, unlicensed, or unqualified practitioners, with a misrepresentation of their credentials and training. This is a long-term proposition and one that has been driven foremost by our leaders in plastic surgery.

A review of the surgical and medical treatment of Frey syndrome.

Frey syndrome represents a fascinating example of how nerve regeneration can go awry. The syndrome is characterized by profuse facial sweating and flushing that occurs when salivation is stimulated. It can develop following a variety of insults but is most commonly encountered as a complication of parotidectomy. Consequently, it is mainly head and neck surgeons who see and treat this disorder; however, it is important for other clinicians to recognize what these unusual symptoms represent. Diagnosis may be based either on clinical presentation or through objective testing methods. Potential negative social and psychologic implications of this condition can be significant, and treatment ranging from topical agents to local injections of botulinum toxin (Botox) to surgical intervention should be offered to patients. In this article, we present an up-to-date review of the surgical and medical treatment of this syndrome.

Palatal fistula repair using acellular dermal matrix: the University of Florida experience.

Palatal fistulas represent a challenging problem for surgeons caring for patients with cleft palate. The purpose of this study was to examine the rate of fistula closure using conventional surgical techniques (Group 1) versus a newer technique (Group 2) employing the use of acellular dermal matrix (AlloDerm). We reviewed the charts of all patients who underwent palatal fistula repair between July 1994 and February 2005. The surgical techniques in Group 1 varied and were considered a historical control. In the second group, a piece of dermal matrix was interposed between the nasal and oral mucoperiosteum after closure of these layers. The primary fistula closure rate for Group 1 was 83.3% (10/12 patients). Fistula closure was obtained in 100% of the patients in Group 2. There were no complications noted other that the failure of the 2 patients in Group 1. The use of AlloDerm in palatal fistula repair has reduced our failure rate from 16.7% to 0%. The use of AlloDerm during palatal fistula repair is safe, effective over time, and has the potential to reduce palatal fistula recurrence rates.

A comparison of the LeJour and Wise pattern methods of breast reduction.

Supporters of the vertical mammoplasty state the resultant breast shape and scar are superior to the Wise pattern breast reduction. This study contains a comparison of the LeJour vertical reduction with the Wise pattern reduction by analysis of pre- and postoperative photographs, as well as a retrospective review comparing operative times, blood loss, complications, and a postoperative patient questionnaire. Of the 112 women who had moderate to large reductions (>500 g/breast) between 1999 and 2002, 65 subjects had adequate standard perioperative photographs. Esthetic appearance, symmetry, nipple quality, and scarring were assessed using a Likert scale (10 = superior, 1 = poor) by 30 evaluators. Based on the photographic analysis, there is no difference in the esthetic outcome between the vertical reduction mammaplasty and the inferior pedicle Wise pattern mammaplasty. Additionally, this study indicates that vertical patients with moderate to large reductions have a significantly higher rate of complications when their body mass index is greater than 30 kg/m.

Endoscopic-assisted repair of craniosynostosis.

OBJECT: The goal of the craniofacial surgeon has always been the correction of form and function with prevention of associated morbidity and death. Through the pioneering work of Jimenez and Barone, minimally invasive approaches to the surgical correction of craniosynostosis are now gaining wider acceptance. Here the authors review the technique for endoscopic-assisted repair of craniosynostosis from the perspective of a new minimally invasive approach. They also assess the safety, efficacy, and results of the early treatment of infants with craniosynostosis in a small series of children who underwent surgery at this institution. METHODS: Data regarding synostosis type, operative time, patient age, blood loss, transfusion rates, duration of hospitalization, and complications were collected. Nineteen patients (12 girls and seven boys) between the ages of 1.2 and 5 months of age were treated with the endoscope-assisted technique. The mean operative time was 97 minutes. Five (26%) of 19 children received a blood transfusion. Most patients were discharged home the morning after surgery. The clinical courses of two patients who required additional major craniofacial reconstructions are discussed. There were no deaths, dural sinus tears, cerebrospinal fluid leaks, neurological injuries, or infections, and there were no complications related to the use of helmet therapy. Seventeen of the 19 patients achieved excellent cosmetic results with a single surgery. CONCLUSIONS: This small series supports larger experiences and indicates that early treatment of craniosynostosis with minimally invasive, endoscope-assisted techniques is safe; limits blood transfusion, hospital stay, and operative time; and represents a valuable alternative to the traditional calvarial reconstruction methods.

Muscle reconstruction in cleft lip repair.

This article presents a method of muscle reconstruction in the cleft lip patient that grossly reproduces the interlacing muscle anatomy in the central portion of the upper lip and thereby addresses both the static and the functional requirements of cleft lip repair. This lip repair procedure is combined with paranasal muscle reconstruction, preoperative nasoalveolar molding, and postoperative nasal stenting to constitute a comprehensive approach to cleft lip/nose repair.

Evaluation and treatment of velopharyngeal insufficiency: the University of Florida experience.

This retrospective study spans the years 1988 to 2000 and looks specifically at the treatment procedures and outcomes for the correction of velopharyngeal insufficiency (VPI). Ninety-eight patients underwent preoperative assessment by speech pathologists that included perceptual speech evaluation, videofluoroscopy, and, for some, nasendoscopy. Based on this evaluation protocol, a specific surgical procedure was chosen to serve the patients' needs. The four procedures of choice were the palatal pushback with a pharyngeal flap lining, sphincter pharyngoplasty, a superiorly based obturating pharyngeal flap, and Furlow palatoplasty. The criteria for selecting these procedures are reviewed. The results revealed VPI resolution and the establishment of normal nonnasal speech in more than 95% of the 75 patients for whom outcomes were determined. This study reiterates the importance of thorough preoperative evaluation and the individualization of the secondary corrective procedure.