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1.
Pediatr Neurosurg ; 58(6): 383-391, 2023.
Artículo en Inglés | MEDLINE | ID: mdl-37703848

RESUMEN

INTRODUCTION: Sagittal craniosynostosis (SC) is associated with scaphocephaly, an elongated narrow head shape. Assessment of regional severity in the scaphocephalic head is limited by the use of serial computed tomographic (CT) imaging or complex computer programing. Three-dimensional measurements of cranial surface morphology provide a radiation-free alternative for assessing cranial shape. This study describes the creation of an occipital bulleting index (OBI), a novel tool using surface morphology to assess the regional severity in patients with SC. METHODS: Surface imaging from CT scans or 3D photographs of 360 individuals with SC and 221 normocephalic individuals were compared to identify differences in morphology. Cartesian grids were created on each individual's surface mesh using equidistant axial and sagittal planes. Area under the curve (AUC) analyses were performed to identify trends in regional morphology and create measures capturing population differences. RESULTS: The largest differences were located in the medial regions posteriorly. Using these population trends, a measure was created to maximize AUC. The OBI has an AUC of 0.72 with a sensitivity of 74% and a specificity of 61%. When the frontal bossing index is applied in tandem, the two have a sensitivity of 94.7% and a specificity of 93.1%. Correlation between the two scores in individuals with SC was found to be negligible with an intraclass correlation coefficient of 0.018. Severity was found to be independent of age under 24 months, sex, and imaging modality. CONCLUSIONS: This index creates a tool for differentiating control head shapes from those with SC and has the potential to allow for objective evaluation of the regional severity, outcomes of different surgical techniques, and tracking shape changes in individuals over time, without the need for radiation.


Asunto(s)
Craneosinostosis , Humanos , Lactante , Preescolar , Craneosinostosis/diagnóstico por imagen , Craneosinostosis/cirugía , Cráneo , Tomografía Computarizada por Rayos X/métodos , Estudios Retrospectivos
2.
Cleft Palate Craniofac J ; 58(6): 678-686, 2021 06.
Artículo en Inglés | MEDLINE | ID: mdl-33094638

RESUMEN

INTRODUCTION: This study compares anthropometric outcomes of 2 sagittal synostosis repair techniques: spring-assisted surgery and endoscope-assisted craniectomy with molding helmet therapy. METHODS: Patients undergoing spring-assisted surgery (n = 27) or endoscope-assisted craniectomy with helmet therapy (n = 40) at separate institutions were retrospectively reviewed. Pre- and 1-year postoperative computed tomography (CT) or laser scans were analyzed for traditional cranial index (CI), adjusted cranial index (aCI), and cranial vault volume (CVV). Nine patient-matched scans were analyzed for measurement consistency. RESULTS: The spring-assisted group was older at both time points (P < .050) and spring-assisted group CVV was larger preoperatively and postoperatively (P < .01). However, the change in CVV did not differ between the groups (P = .210). There was no difference in preoperative CI (helmet vs spring: 70.1 vs 71.2, P = .368) between the groups. Postoperatively, helmet group CI (77.0 vs 74.3, P = .008) was greater. The helmet group also demonstrated a greater increase in CI (6.9 vs 3.1, P < .001). The proportion of patients achieving CI of 75 or greater was not significantly different between the groups (helmet vs spring: CI, 65% vs 52%, P = .370). There was no detectable bias in CI between matched CT and laser scans. Differences were identified between scan types in aCI and CVV measurements; subsequent analyses used corrected CVV and aCI measures for laser scan measures. CONCLUSIONS: Both techniques had equivalent proportions of patients achieving normal CI, comparable effects on cranial volume, and similar operative characteristics. The study suggests that there may be greater improvement in CI in the helmet group. However, further research should be performed.


Asunto(s)
Craneosinostosis , Craneosinostosis/diagnóstico por imagen , Craneosinostosis/cirugía , Craneotomía , Endoscopios , Humanos , Lactante , Estudios Retrospectivos , Resultado del Tratamiento
3.
J Craniofac Surg ; 31(7): 2088-2091, 2020 Oct.
Artículo en Inglés | MEDLINE | ID: mdl-32649556

RESUMEN

Spring-assisted surgery (SAS) has been shown to be an effective technique for correction of isolated sagittal craniosynostosis in patients less than 6 months of age. At their institution, the authors adopted a minimally invasive technique in 2010, using a shorter incision and an endoscope. A retrospective chart review of 101 patients with isolated, nonsyndromic, sagittal craniosynostosis, who underwent SAS, was performed in order to compare perioperative and clinical outcomes of the open (n = 51) and minimally-invasive (n = 50) approaches. Surgeries were performed by 2 neurosurgeons and 3 plastic surgeons, between 2005 and 2018. The pre and postoperative cephalic indices were not significantly different in both groups. Minimally-invasive spring placement required a longer operative time than the open approach, with the mean minimally-invasive operative time at 65 minutes, compared to 53 minutes (P < 0.0001). Spring removal operative time was not significantly different, with the minimally-invasive operative time at 31 minutes versus 29 minutes (P = 0.48). There were no significant differences in major or minor complications when comparing the open and minimally-invasive approaches. In conclusion, both the open and the minimally-invasive SAS techniques are effective for early correction of isolated sagittal craniosynostosis, although the minimally-invasive approach requires a longer operative time for spring placement.


Asunto(s)
Craneosinostosis/cirugía , Craneotomía , Humanos , Lactante , Neuroendoscopía/métodos , Complicaciones Posoperatorias , Procedimientos de Cirugía Plástica , Estudios Retrospectivos , Equipo Quirúrgico , Resultado del Tratamiento
4.
J Craniofac Surg ; 31(7): 2101-2105, 2020 Oct.
Artículo en Inglés | MEDLINE | ID: mdl-32890160

RESUMEN

BACKGROUND: Controversy exists regarding the optimal surgical approach for non-syndromic sagittal synostosis. This study provides the first comparative analysis of the long-term behavioral, psychological, and executive function outcomes for patients who underwent either cranial vault remodeling (CVR) or spring-assisted strip craniectomy (SAS). METHODS: Thirty-six CVR patients and 39 SAS patients were evaluated. Parents and caregivers completed the Behavior Rating Inventory of Executive Function (BRIEF) and the Behavior Assessment System for Children, Second Edition (BASC-2) to evaluate behavioral, emotional, social, adaptive, and executive functioning skills. RESULTS: There were no statistically significant differences between the CVR and the SAS groups (P > 0.05) in any of the BRIEF areas of function. Furthermore, the BASC-2 battery illustrated no significant differences in all areas analyzed except one. Among the 2 groups, the CVR group was rated as having fewer social withdrawal symptoms on the BASC-2 (47.00 ±â€Š10.27) compared to the SAS cohort (54.64 ±â€Š10.96), F = 6.79, P = 0.012, Cohen d = 0.688. However, both means were still within the normal range. CONCLUSIONS: Children undergoing SAS and CVR procedures for isolated sagittal synostosis were not rated as having clinically significant behavioral, emotional, social, adaptive, or executive functioning problems on parental forms.


Asunto(s)
Craneotomía/métodos , Craneosinostosis/cirugía , Función Ejecutiva , Femenino , Humanos , Lactante , Masculino , Valores de Referencia , Cráneo/cirugía , Equipo Quirúrgico , Resultado del Tratamiento
5.
Cleft Palate Craniofac J ; 57(9): 1140-1145, 2020 09.
Artículo en Inglés | MEDLINE | ID: mdl-32292043

RESUMEN

The posterior pharyngeal flap is frequently the surgical intervention of choice for the correction of velopharyngeal insufficiency. Our patient initially presented for a superiorly based, posterior pharyngeal flap to correct for velopharyngeal insufficiency. However, the postoperative recovery was complicated by severe obstructive sleep apnea, which warranted division and subsequent takedown of the flap. Despite flap takedown, our patient's obstructive sleep apnea persisted. The patient's clinical course suggests that donor site closure, and not the actual pharyngeal flap, caused the persistent obstructive sleep apnea.


Asunto(s)
Fisura del Paladar , Apnea Obstructiva del Sueño , Insuficiencia Velofaríngea , Fisura del Paladar/cirugía , Humanos , Procedimientos Quirúrgicos Otorrinolaringológicos , Faringe/diagnóstico por imagen , Faringe/cirugía , Apnea Obstructiva del Sueño/etiología , Apnea Obstructiva del Sueño/cirugía , Colgajos Quirúrgicos , Resultado del Tratamiento , Insuficiencia Velofaríngea/etiología , Insuficiencia Velofaríngea/cirugía
6.
Cleft Palate Craniofac J ; 57(11): 1298-1307, 2020 11.
Artículo en Inglés | MEDLINE | ID: mdl-32844676

RESUMEN

OBJECTIVE: To characterize operative care for cleft lip and/or palate (CL/P) based on location (ie, from American Cleft Palate Craniofacial Association [ACPA]-approved multidisciplinary teams or from community providers). DESIGN: Cross-sectional analysis of Healthcare Cost and Utilization Project State Inpatient Database and State Ambulatory Surgery & Services Database databases for North Carolina from 2012 to 2015. SETTING/PATIENTS AND MAIN OUTCOME MEASURES: Clinical encounters for children with CL/P undergoing operative procedures were identified, classified by location as "Team" versus "Community," and characterized by demographic, geographic, clinical, and procedural factors. A secondary evaluation reviewed concordance of team and community practices with an ACPA guideline related to coordination of care. RESULTS: Three teams and 39 community providers performed a total of 3010 cleft-related procedures across 2070 encounters. Teams performed 69.7% of total volume and performed the majority of cleft procedures, including cleft lip repair, palate repair, alveolar bone grafting, and correction of velopharyngeal insufficiency. Community locations principally offered myringotomy and rhinoplasty. Team care was associated with higher guideline concordance. CONCLUSIONS: American Cleft Palate Craniofacial Association -approved team-based care accounts for the majority of cleft-related care in North Carolina; however, a substantial volume of cleft-related procedures was provided by community providers, with 3 providers accounting for the vast majority of community cases.


Asunto(s)
Labio Leporino , Fisura del Paladar , Niño , Labio Leporino/cirugía , Fisura del Paladar/cirugía , Estudios Transversales , Humanos , North Carolina
7.
Ann Plast Surg ; 80(6): 600-606, 2018 Jun.
Artículo en Inglés | MEDLINE | ID: mdl-29664825

RESUMEN

BACKGROUND: Adequate resident training in aesthetic surgery has become increasingly important with rising demand. Chief resident aesthetic clinics allow hands on experience with an appropriate amount of autonomy. The purpose of this study was to compare resident cosmetic clinic outcomes to those reported in the literature. Furthermore, we sought to assess how effective these clinics can be in preparing residents in performing common aesthetic surgery procedures. METHOD: A retrospective chart review of 326 patients and 714 aesthetic procedures in our chief cosmetic clinic over a 13-year period was performed, and complication and revision rates were recorded. In addition, an electronic survey was sent to 26 prior chief residents regarding their experience and impressions of the chief resident aesthetic clinic. RESULT: A total of 713 procedures were performed on 326 patients. Patient ages ranged from 5 to 75 years old (mean, 40.8 years old) with a mean follow-up of 76.2 days. On average, there were 56 procedures performed per year. Of the 714 total procedures performed, there were 136 minor procedures and 578 major procedures. Of the 136 minor procedures, there were no complications and there was 1 revision of a cosmetic injection. Of the 578 major procedures, the overall complication rate was 6.1% and the revision rate was 12.8%. Complication and revision rates for each individual surgery were further analyzed and compared with the literature. The complication rates for these procedures fell within the reference ranges reported. In regards to the chief resident survey, there was a 77% response rate. All respondents reported that the chief resident clinic positively affected their residency education and future practice. Ninety percent of respondents felt "very comfortable" performing facelifts, body contouring, and aesthetic breast surgery. No respondents completed a subsequent cosmetic fellowship, and 60% stated that their positive experience in chief clinic contributed to their decision not to pursue a cosmetic fellowship. CONCLUSIONS: Chief resident clinics can provide results with acceptable complication and revision rates that fall within the acceptable ranges in the literature. In addition, it provides a valuable experience that leaves residents with high comfort levels in performing key procedures in aesthetic surgery.


Asunto(s)
Competencia Clínica , Educación de Postgrado en Medicina , Internado y Residencia , Pautas de la Práctica en Medicina/estadística & datos numéricos , Cirugía Plástica/educación , Adolescente , Adulto , Anciano , Niño , Preescolar , Humanos , Persona de Mediana Edad , Complicaciones Posoperatorias/epidemiología , Reoperación/estadística & datos numéricos , Estudios Retrospectivos , Resultado del Tratamiento
8.
Aesthet Surg J ; 38(7): 793-799, 2018 Jun 13.
Artículo en Inglés | MEDLINE | ID: mdl-29548007

RESUMEN

BACKGROUND: The recently increased minimum aesthetic surgery requirements set by the Plastic Surgery Residency Review Committee of the Accreditation Council for Graduate Medical Education highlight the importance of aesthetic surgery training for plastic surgery residents. Participation in resident aesthetic surgery clinics has become an important tool to achieve this goal. Yet, there is little literature on the current structure of these clinics. OBJECTIVES: The authors sought to evaluate current practices of aesthetic resident-run clinics in the United States. METHODS: A survey examining specific aspects of chief resident clinics was distributed to 70 plastic surgery resident program directors in the United States. Thirty-five questions sought to delineate clinic structure, procedures and services offered, financial cost to the patient, and satisfaction and educational benefit derived from the experience. RESULTS: Fifty-two questionnaires were returned, representing 74.2% of programs surveyed. Thirty-two (63%) reported having a dedicated resident aesthetic surgery clinic at their institution. The most common procedures performed were abdominoplasty (n = 20), breast augmentation (n = 19), and liposuction (n = 16). Most clinics offered neuromodulators (n = 29) and injectable fillers (n = 29). The most common billing method used was a 50% discount on surgeon fee, with the patient being responsible for the entirety of hospital and anesthesia fees. Twenty-six respondents reported feeling satisfied or very satisfied with their resident aesthetic clinic. CONCLUSIONS: The authors found aesthetic chief resident clinics to differ greatly in their structure. Yet the variety of procedures and services offered makes participation in these clinics an effective training method for the development of both aesthetic surgical technique and resident autonomy.


Asunto(s)
Internado y Residencia/organización & administración , Procedimientos de Cirugía Plástica/educación , Clínica Administrada por Estudiantes/organización & administración , Cirugía Plástica/educación , Humanos , Internado y Residencia/estadística & datos numéricos , Ejecutivos Médicos/estadística & datos numéricos , Pautas de la Práctica en Medicina/economía , Pautas de la Práctica en Medicina/organización & administración , Pautas de la Práctica en Medicina/estadística & datos numéricos , Evaluación de Programas y Proyectos de Salud , Procedimientos de Cirugía Plástica/economía , Clínica Administrada por Estudiantes/economía , Clínica Administrada por Estudiantes/estadística & datos numéricos , Encuestas y Cuestionarios/estadística & datos numéricos , Estados Unidos , Carga de Trabajo/estadística & datos numéricos
9.
J Craniofac Surg ; 28(1): 26-29, 2017 Jan.
Artículo en Inglés | MEDLINE | ID: mdl-27831975

RESUMEN

BACKGROUND: Resorbable plating in cranial reconstruction for craniosynostosis has fewer reported complications than rigid hardware. Few long-term outcome studies exist for pediatric patients treated with this technology for cranial vault reconstruction. METHODS: A retrospective review was performed on pediatric patients undergoing cranial vault reconstruction for craniosynostosis by 3 surgeons over a 15-year period. MacroPore (Cytori Therapeutics, San Diego, CA) or Lactosorb (Walter Lorenz Surgical Inc, Jacksonville, FL), composed of polyglycolic and polylactic acids, was used for resorbable plate fixation. RESULTS: A total of 203 patients underwent resorbable plate fixation with a mean age of 15.8 months at surgery. Mean length of follow-up was 6.4 years. Lactosorb plating system was used in the majority of patients (74%) compared with MacroPore plating system (26%). Overall, unplanned reoperations were required in 5.4% of patients. Palpable hardware was noticed in 10.3% of patients. Only 3 patients (1.5%) developed exposure of the resorbable hardware requiring removal, all MacroPore plates. Four patients (2%) developed surgical site infection and 3 patients (1.5%) developed a seroma. There were 15.8% requiring later surgical revision with cranial vault expansion or cranioplasty with grafts for residual cranial defects. The majority of revisional reoperations (81%) occurred in the first half of the study before the addition of Allogenix. CONCLUSIONS: Resorbable plating systems, specifically Lactosorb, for cranial reconstruction are a safe, reproducible, inexpensive modality with very low complication rates. They have 3-dimensional stability, rigid fixation without causing growth restriction, and lower likelihood of need for removal.


Asunto(s)
Implantes Absorbibles , Placas Óseas , Craneosinostosis/cirugía , Craneotomía/métodos , Ácido Láctico , Procedimientos de Cirugía Plástica/métodos , Ácido Poliglicólico , Placas Óseas/efectos adversos , Femenino , Humanos , Lactante , Masculino , Copolímero de Ácido Poliláctico-Ácido Poliglicólico , Complicaciones Posoperatorias/cirugía , Falla de Prótesis , Reoperación , Estudios Retrospectivos
10.
J Craniofac Surg ; 27(3): 636-43, 2016 May.
Artículo en Inglés | MEDLINE | ID: mdl-27159856

RESUMEN

Spring-assisted surgery (SAS) can effectively treat scaphocephaly by reshaping crania with the appropriate spring force. However, it is difficult to accurately estimate spring force without considering biomechanical properties of tissues. This study presents and validates a reliable system to accurately predict the spring force for sagittal craniosynostosis surgery. The authors randomly chose 23 patients who underwent SAS and had been followed for at least 2 years. An elastic model was designed to characterize the biomechanical behavior of calvarial bone tissue for each individual. After simulating the contact force on accurate position of the skull strip with the springs, the finite element method was applied to calculating the stress of each tissue node based on the elastic model. A support vector regression approach was then used to model the relationships between biomechanical properties generated from spring force, bone thickness, and the change of cephalic index after surgery. Therefore, for a new patient, the optimal spring force can be predicted based on the learned model with virtual spring simulation and dynamic programming approach prior to SAS. Leave-one-out cross-validation was implemented to assess the accuracy of our prediction. As a result, the mean prediction accuracy of this model was 93.35%, demonstrating the great potential of this model as a useful adjunct for preoperative planning tool.


Asunto(s)
Fenómenos Biomecánicos/fisiología , Craneosinostosis/fisiopatología , Craneosinostosis/cirugía , Craneotomía/instrumentación , Análisis de Elementos Finitos , Instrumentos Quirúrgicos , Simulación por Computador , Diseño de Equipo , Femenino , Estudios de Seguimiento , Humanos , Masculino , Cráneo , Estudios de Validación como Asunto
11.
J Craniofac Surg ; 26(5): 1609-10, 2015 Jul.
Artículo en Inglés | MEDLINE | ID: mdl-26114536

RESUMEN

Microstomia is rarely seen in pediatric patients, but usually results from burns, trauma, or caustic ingestions. There have been multiple studies reporting various techniques for oral commissure reconstruction, but few reports in infants. The authors present another modification of previous techniques of microstomia repair performed in a 10-week-old infant using multiple z-plasties and bilateral mucosal rhomboid flaps.


Asunto(s)
Países en Desarrollo , Microstomía/cirugía , Procedimientos de Cirugía Plástica/métodos , Colgajos Quirúrgicos/cirugía , Técnicas de Sutura , Cicatriz/cirugía , Estética , Estudios de Seguimiento , Humanos , Lactante , Masculino , Microstomía/etiología , Boca/patología , Boca/cirugía , Necrosis , Togo , Lengua/patología , Lengua/cirugía , Enfermedades de la Lengua/cirugía
12.
J Craniofac Surg ; 26(3): 616-9, 2015 May.
Artículo en Inglés | MEDLINE | ID: mdl-25974764

RESUMEN

Le Fort III osteotomy is commonly used in the surgical correction of midface hypoplasia, specifically in patients with syndromic craniosynostosis. These osteotomies can be associated with significant complications, which are often the result of incomplete or inaccurate osteotomies. Brainlab, a technology first developed for neurosurgery, has been applied to numerous surgical subspecialties. The aim of this study was to report our initial experience using the Brainlab VectorVision2 and Brainlab Curve (Brainlab, Westchester, IL) as an intraoperative guidance system for osteotomy placement during Le Fort III advancement. Three pediatric patients with syndromic craniosynostosis and midface hypoplasia scheduled to undergo Le Fort III advancement were scanned preoperatively with 0.6-mm computed tomography cuts, which were then uploaded to the Brainlab system. All surgeries commenced with rigid fixation of the Brainlab registration device to the patient's skull. The navigation system was used intraoperatively to accurately determine osteotomy sites and trajectories. External distractors were placed without complication. Mean length of surgery was 331 minutes, and mean estimated blood loss was 500 mL. No transfusion was required with a mean postoperative hemoglobin of 8.3 g/dL. The application of Brainlab technology to Le Fort III advancement proved useful in establishing precise osteotomy lines and trajectories. Looking forward, this technology could be applied to a minimal dissection technique in order to avoid extensive blood loss. Further study would be needed to determine possible benefits such as reduced complications or operative time when using an intraoperative navigation system for image-guided osteotomy placement during Le Fort III advancement.


Asunto(s)
Anomalías Craneofaciales/cirugía , Craneosinostosis/cirugía , Craneotomía/instrumentación , Craneotomía/métodos , Neuronavegación/instrumentación , Neuronavegación/métodos , Osteotomía Le Fort/instrumentación , Osteotomía Le Fort/métodos , Adolescente , Niño , Anomalías Craneofaciales/diagnóstico , Craneosinostosis/diagnóstico , Disección/instrumentación , Disección/métodos , Diseño de Equipo , Femenino , Humanos , Procedimientos Quirúrgicos Mínimamente Invasivos/instrumentación , Procedimientos Quirúrgicos Mínimamente Invasivos/métodos , Tempo Operativo , Complicaciones Posoperatorias/etiología , Tomografía Computarizada por Rayos X/instrumentación
13.
J Craniofac Surg ; 26(8): 2368-74, 2015 Nov.
Artículo en Inglés | MEDLINE | ID: mdl-26517461

RESUMEN

Maxillofacial fractures in pediatric trauma patients require significant force and frequently are associated with concomitant injuries. The anatomic and developmental differences between the adult and child that impact patterns of injury also affect management and outcomes. The aim of this study was to analyze fracture location, mechanism, concomitant injuries as well as methods of surgical treatment and outcomes, to improve management of this patient population. A retrospective review was conducted of pediatric patients with maxillofacial fractures presenting to a level-1 trauma center during an 8-year span. Only patients requiring surgical intervention, 204, were included in this study. Data pertaining to the location of injury, mechanism, associated injuries, surgical treatment, outcomes, and complications were analyzed. The most common fracture location was the mandible (36.3%), then the nasal bone (35.3%), followed by the tripod fracture (10.8%). A total of 30.7% of patients were involved in motor vehicle accidents, with the next most common mechanisms being sports (24.4%), and assault (13.7%). A total of 46% of the patients sustained concomitant injuries, with the majority involving cerebral trauma (14.7%) or the extremities (9.3%). Total 75.4% of all fractures, excluding the nose, were treated with open reduction and internal fixation (ORIF). Our complication rate was 11.2%. Pediatric craniofacial trauma remains a frequent presentation to the emergency department of trauma centers. Facial fracture patterns and mechanism of trauma observed in the pediatric population presenting to this facility are consistent with incidences reported in the literature. Knowledge of treatment options and potential complications is an important tool in the management of the pediatric trauma patient.


Asunto(s)
Traumatismos Maxilofaciales/diagnóstico , Traumatismos Maxilofaciales/cirugía , Traumatismo Múltiple/cirugía , Complicaciones Posoperatorias/etiología , Fracturas Craneales/diagnóstico , Fracturas Craneales/cirugía , Adolescente , Niño , Estudios Transversales , Femenino , Fijación Interna de Fracturas/efectos adversos , Humanos , Masculino , Traumatismos Maxilofaciales/epidemiología , Traumatismo Múltiple/diagnóstico , Traumatismo Múltiple/epidemiología , Hueso Nasal/lesiones , North Carolina , Complicaciones Posoperatorias/epidemiología , Centros Traumatológicos
14.
J Craniofac Surg ; 26(7): e599-602, 2015 Oct.
Artículo en Inglés | MEDLINE | ID: mdl-26468835

RESUMEN

INTRODUCTION: Head and neck wounds can present a reconstructive challenge for the plastic surgeon. Whether from skin cancer, trauma, or burns, there are many different treatment modalities used to dress and manage complex head and neck wounds. Vacuum-assisted closure (VAC) therapy has been used on wounds of nearly every aspect of the body but not routinely in the head and neck area. This study was conducted to demonstrate our results using the VAC in the treatment of complex head and neck wounds. METHODS: This is an IRB-approved, retrospective review of 69 patients with 73 head and neck wounds that were managed using the VAC between 1999 and 2008. The wound mechanism, location, and size, length of VAC therapy, patient comorbidities, use of radiation, complications, and ultimate outcome were assessed. In this patient population, the VAC was utilized because the standard reconstructive ladder was not a good option or had previously failed. RESULTS: Sixty-nine patients with complex head and neck wounds were treated with the wound VAC. The mean age of the patients was 66 years, with a range of 5-96 years. Males outnumbered females in this study nearly 2:1. Eighty-six percent of patients had wounds secondary to cancer, 8% secondary to trauma, 3% secondary to infection, and 3% secondary to burns. The VAC was used as a dressing over skin grafts in 50%, over Integra in 21%, and over open debrided wounds in 29%. Wounds healed without complication in 44% of the skin grafts, 67% of Integra-covered wounds, and 71% of debrided wounds. Minor complications included failure of complete graft take, failure of granulation tissue formation in open debrided wounds, infection, and hematoma formation under skin grafts. Major complications included positive cancer margins requiring reexcision and death secondary to pulmonary embolism, sepsis, and metastatic cancer. Most complications resolved with dressing changes, repeat grafting, or the administration of antibiotics. CONCLUSIONS: Our results demonstrate that the wound VAC provides a reliable, effective, and durable dressing for a multitude of complex head and neck wounds. Additionally, it is a valuable tool when traditional surgical procedures are not a viable option.


Asunto(s)
Neoplasias de Cabeza y Cuello/cirugía , Terapia de Presión Negativa para Heridas/métodos , Procedimientos de Cirugía Plástica/métodos , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Quemaduras/cirugía , Niño , Preescolar , Sulfatos de Condroitina , Colágeno , Traumatismos Craneocerebrales/cirugía , Desbridamiento/métodos , Femenino , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Traumatismos del Cuello/cirugía , Complicaciones Posoperatorias , Estudios Retrospectivos , Trasplante de Piel/métodos , Piel Artificial , Resultado del Tratamiento , Cicatrización de Heridas/fisiología , Adulto Joven
15.
J Craniofac Surg ; 26(1): 147-50, 2015 Jan.
Artículo en Inglés | MEDLINE | ID: mdl-25569393

RESUMEN

BACKGROUND: In 1992, the American Academy of Pediatrics discouraged prone sleeping positions because of its association with sudden infant death syndrome. After this was an increased incidence of deformational plagiocephaly (DP). METHODS: A retrospective review was completed for patients with DP and craniosynostosis seen by plastic surgeons at a tertiary medical center during a 19-year period. Two groups of patients were evaluated before (1988-1995) and after (1996-2007) implementation of the "Back to Sleep" campaign. RESULTS: Of the 5169 patients, those with craniosynostosis (n = 279) had a mean age at initial evaluation before and after 1996 of 12.4 versus 5.6 months (P = 0.0008). There was a trend of decreasing age at initial evaluation and first surgery after 1996. For patients with DP (n = 4890), the mean age at initial evaluation before and after 1996 was 11.5 versus 6.0 months (P = 0.10). There was a trend of decreasing age at initial evaluation and DP correction after 1996. The majority of patients had right-sided DP (50.2%), followed by left-sided (24.7%) and bilateral (18.9%). There was no significant difference in DP correction rate (67% versus 87%) or the mean age that DP was corrected (12.8 versus 11.8 mo) before and after 1996. Compared with 1996 to 1999, there was a 214% and 390% increase in DP referrals from 2000 to 2003 and 2004 to 2007. For craniosynostosis, there was a 27% and 129% increase in referrals. CONCLUSIONS: The increasing incidence of DP since the Back to Sleep campaign is concerning, but a positive outcome is that patients are being referred and treated at a younger age.


Asunto(s)
Craneosinostosis/diagnóstico , Craneosinostosis/cirugía , Plagiocefalia no Sinostótica/diagnóstico , Plagiocefalia no Sinostótica/cirugía , Posición Prona , Acrocefalosindactilia/epidemiología , Edad de Inicio , Comorbilidad , Craneosinostosis/epidemiología , Femenino , Humanos , Incidencia , Lactante , Recién Nacido , Enfermedades del Prematuro/epidemiología , Masculino , Otitis/epidemiología , Plagiocefalia no Sinostótica/epidemiología , Procedimientos de Cirugía Plástica/estadística & datos numéricos , Derivación y Consulta/estadística & datos numéricos , Estudios Retrospectivos , Muerte Súbita del Lactante/prevención & control , Estados Unidos/epidemiología
16.
J Craniofac Surg ; 26(3): 606-10, 2015 May.
Artículo en Inglés | MEDLINE | ID: mdl-25901672

RESUMEN

INTRODUCTION: A stratification system is useful in deformational plagiocephaly (DP) to help categorize patients and reproduce a consistent treatment strategy. The Argenta classification is a clinical 5-point scale for unilateral DP and 3-point scale for central DP (CDP). METHODS: A retrospective review was completed for patients with DP and classified using the Argenta clinical classification by plastic surgeons at a tertiary medical center over a 12-year period. RESULTS: In the 4483 patients, type III was the most prevalent DP type (42%) followed by II, IV, I, and V. Within CDP, VIB was the most common (6%) followed by VIA and VIC. Right-sided DP (56.8%) was more common than left-sided (28.3%) and bilateral (20.4%) (P < 0.0001). For treatment, 89.8% used molding helmet therapy, 9.3% used positioning only, and 0.4% used sock hat. Helmet use increased with increasing type to 98% with type V. In CDP, there was a significant increase in helmet use between VIA and VIB, but helmet use decreased in VIC. There was a higher rate of positioning only in types I, II, and VIA, which diminished as severity increased. Deformational plagiocephaly corrected to type I or 0 in 83.5% of the patients with the highest correction rate in type I (90.7%). Mean age of correction was 11.4 months and time to correction was 5.7 months. Both significantly increased with severity of type in the patients with DP but not in those with CDP. CONCLUSIONS: The Argenta classification scale allows reliable evaluation for cranial deformities and may help predict the optimal type duration of treatment.


Asunto(s)
Plagiocefalia no Sinostótica/clasificación , Plagiocefalia no Sinostótica/diagnóstico , Niño , Preescolar , Femenino , Estudios de Seguimiento , Dispositivos de Protección de la Cabeza , Humanos , Lactante , Recién Nacido , Enfermedades del Prematuro/clasificación , Enfermedades del Prematuro/diagnóstico , Enfermedades del Prematuro/terapia , Masculino , Plagiocefalia no Sinostótica/terapia , Pronóstico , Estudios Retrospectivos
17.
J Craniofac Surg ; 26(5): 1500-3, 2015 Jul.
Artículo en Inglés | MEDLINE | ID: mdl-26106995

RESUMEN

There has been a profound increase in the number of patients undergoing head computed tomography after minor injuries and the identification of epidural hematomas has risen concurrently. Although emergent craniotomy and evacuation has been the conventional standard for management, some epidural hematomas can be managed nonoperatively in carefully selected patients. Because of the difficulty in clinically monitoring epidural hematoma absorption and resolution because of the attributed risks of imaging radiation exposure in pediatric patients, the exact incidence of epidural hematoma ossification is unknown. Integrating epidural hematoma calcification into management algorithms is not clearly defined in the literature. The authors report a case of a 2-year-old girl with a calcified epidural hematoma requiring surgical treatment. With the incidence of epidural hematomas rising, providers should be aware of the rare but consequential incidence of epidural hematoma ossification. After literature review and discussion of the pathophysiology, the authors present an algorithmic approach to account for this rare entity. For conservative management of asymptomatic epidural hematomas, providers should consider follow-up magnetic resonance imaging to evaluate resolution in 2 to 3 months. If the magnetic resonance imaging indicates a failure to resolve, a computed tomography scan should then be performed to evaluate ossification and possible need for surgical intervention.


Asunto(s)
Calcinosis/etiología , Hematoma Epidural Craneal/complicaciones , Calcinosis/diagnóstico por imagen , Preescolar , Craneotomía , Duramadre/diagnóstico por imagen , Femenino , Hematoma Epidural Craneal/diagnóstico , Hematoma Epidural Craneal/cirugía , Humanos , Imagen por Resonancia Magnética , Tomografía Computarizada por Rayos X
18.
J Craniofac Surg ; 26(1): 104-7, 2015 Jan.
Artículo en Inglés | MEDLINE | ID: mdl-25534062

RESUMEN

BACKGROUND: Blood loss is the leading cause of mortality after major craniofacial surgery. Autologous blood donation, short-term normovolemic hemodilution, and intraoperative blood salvage have shown low efficacy in decreasing transfusions. Tranexamic acid (TXA) is a synthetic antifibrinolytic drug that competitively decreases the conversion of plasminogen to plasmin, thereby suppressing fibrinolysis. The purpose of this study was to investigate the impact that TXA administration has on intraoperative blood loss and blood product transfusion in pediatric patients undergoing cranial vault reconstruction. METHODS: An Internal Review Board-approved retrospective study was conducted on a consecutive series of pediatric patients undergoing cranial vault reconstruction from January 2009 to June 2012. Seventeen consecutive patients who received TXA at the time of cranial vault reconstruction were compared with 20 patients who did not receive TXA. Criteria for blood product transfusion were identical for both groups. Outcomes including perioperative blood loss, volume of blood transfused, and adverse effects were analyzed. RESULTS: The TXA group had a significantly lower perioperative blood loss (9.4 versus 21.1 mL/kg, P < 0.0001) and lower volume of perioperative mean blood product transfusion (12.8 versus 31.3 mL/kg, P < 0.0001) compared with the non-TXA group. There was no significant difference in demographic data, infection rate, change in preoperative to postoperative hematocrit, duration of surgery, or complication rates between the TXA and non-TXA groups. No drug-related adverse effects were identified in patients who received TXA. CONCLUSIONS: The use of TXA in pediatric cranial vault reconstruction significantly reduces perioperative blood loss and blood product transfusion requirements. The TXA administration is safe and may improve patient outcomes by decreasing the likelihood of adverse effects related to blood product transfusion.


Asunto(s)
Antifibrinolíticos/uso terapéutico , Craneosinostosis/cirugía , Procedimientos de Cirugía Plástica/métodos , Ácido Tranexámico/uso terapéutico , Antifibrinolíticos/administración & dosificación , Pérdida de Sangre Quirúrgica/prevención & control , Transfusión Sanguínea/estadística & datos numéricos , Preescolar , Estudios de Cohortes , Craneotomía/métodos , Femenino , Estudios de Seguimiento , Hematócrito , Humanos , Lactante , Masculino , Tempo Operativo , Complicaciones Posoperatorias , Premedicación , Estudios Retrospectivos , Seguridad , Ácido Tranexámico/administración & dosificación , Resultado del Tratamiento
19.
Ann Plast Surg ; 72(6): S116-20, 2014.
Artículo en Inglés | MEDLINE | ID: mdl-24374398

RESUMEN

INTRODUCTION: Tissue expander and implant-based breast reconstruction after mastectomy is the most common method of breast reconstruction. Modifications of the traditional total submuscular reconstruction (TSR) have been made using acellular dermal matrix (ADM) to create an inferolateral sling and a more natural implant pocket for superior aesthetic results. The objective of this study was to assess aesthetic outcomes when using ADM in breast reconstruction. METHODS: A retrospective chart review identified all patients who underwent implant-based breast reconstruction from 2005 to 2009 at our institution. Demographic information, complications, reoperations, and aesthetic outcome data were collected for all patients meeting inclusion criteria related to adequate follow-up and postoperative photographs. Five aesthetic outcomes were evaluated for all study patients by 18 blinded evaluators using postoperative photographs. Outcomes were scored on a scale of 1 to 5, with 5 representing the best possible aesthetic score. RESULTS: A total of 122 patients underwent 183 tissue expander-based reconstructions (ADM, n = 58; TSR, n = 125). The infection rate in patients with ADM was 16.2% compared to 5.9% in TSR patients, but this was not statistically significant (P = 0.09). Capsular contracture was more common in TSR patients (23.5%), compared to those with ADM (8.1%), P = 0.048. Aesthetic scores from the attending plastic surgeons were as follows: natural contour (ADM, 3.36; TSR, 3.02; P = 0.0001), symmetry of shape (ADM, 3.57; TSR, 3.27; P = 0.005), symmetry of size (ADM, 3.68; TSR, 3.42; P = 0.002), position on chest wall (ADM, 3.75; TSR, 3.45; P = 0.004), and overall aesthetic appearance (ADM, 3.56; TSR, 3.20; P = 0.0001). CONCLUSIONS: For all 5 aesthetic parameters evaluated, the ADM group scored significantly higher than the TSR group by 18 blinded evaluators. These consistent findings suggest that the use of ADM in breast reconstruction does confer a significant advantage in aesthetic outcomes for breast reconstruction. This is likely at the cost of a higher infection rate when using ADM; however, that may be offset by the advantage of a lower rate of capsular contracture in patients with ADM.


Asunto(s)
Dermis Acelular , Implantación de Mama/métodos , Neoplasias de la Mama/epidemiología , Neoplasias de la Mama/cirugía , Comorbilidad , Humanos , Masculino , Persona de Mediana Edad , Expansión de Tejido , Resultado del Tratamiento
20.
Ann Plast Surg ; 72(6): S165-9, 2014.
Artículo en Inglés | MEDLINE | ID: mdl-24374400

RESUMEN

BACKGROUND: Clinical infection remains a significant problem in implant-based breast reconstruction and is a physical and emotional strain to the breast reconstruction patient. Bacterial strikethrough of draping and gown material is a likely source of infection. Strategies to reduce infection in implant-based breast reconstruction are essential to improve patient outcomes. OBJECTIVE: The aim of this study is to determine if a disposable draping system is superior to reusable draping materials in the prevention of implant-based breast reconstruction infection. METHODS: This single-institution, prospective, randomized, single-blinded, IRB-approved study enrolled women with breast cancer who were eligible for implant-based breast reconstruction. The primary endpoint was clinical infection by postoperative day 30. Secondary endpoints included all other complications encountered throughout the follow-up period and culture data. Demographic data recorded included patient age, body mass index, diabetes, smoking, chemotherapy, radiation, and follow-up. Procedural data recorded included procedure type, procedure length, estimated blood loss, use of acellular dermal matrix, use of muscle flap, and inpatient versus outpatient setting. RESULTS: From March 2010 through January 2012, 107 women were randomized and 102 completed the study. Five patients were determined not to be candidates for reconstruction after randomization. There were 43 patients in the Reusable Group and 59 patients in the Disposable Group. There were no significant differences in patient demographic data, procedural data, or the type of procedure performed between groups. In the Reusable Group, there were 5 infections (12%) within 30 days compared to 0 (0%) infections in the Disposable Group (P = 0.012). There was no significant difference in secondary complications. There was a trend for positive wound cultures (11% vs. 3%, P = 0.10) and positive drape cultures (17% vs.4%, P = 0.08) in patients with clinical infection. There were no differences in the number of colony-forming units or positive cultures between groups. CONCLUSIONS: Disposable draping material is superior to a reusable draping system in the prevention of clinical infection within the immediate postoperative period. This study did not demonstrate a clear link between intraoperative culture data and the development of clinical infection. A completely disposable gown and draping system is recommended during implant-based breast reconstruction.


Asunto(s)
Implantación de Mama , Neoplasias de la Mama/cirugía , Paños Quirúrgicos , Infección de la Herida Quirúrgica/prevención & control , Adulto , Equipos Desechables , Equipo Reutilizado , Femenino , Humanos , Persona de Mediana Edad , Estudios Prospectivos , Paños Quirúrgicos/microbiología
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