Utilization of carbonated calcium phosphate cement for contouring cranioplasty in patients with syndromic craniosynostosis.

PURPOSE: Carbonated calcium phosphate (CCP) cement is an alloplastic material which has been increasingly utilized for cranioplasty reconstruction; however, there is a paucity of data investigating its use in patients with syndromic craniosynostosis. The purpose of this study was to characterize our institutional experience with CCP cement for secondary contouring cranioplasty in these patients to establish safety and aesthetic efficacy. METHODS: Patients with syndromic craniosynostosis undergoing cranioplasty with CCP cement from 2009 to 2022 were retrospectively reviewed for prior medical and surgical history, cranioplasty size, cement usage, and postoperative complications. Aesthetic ratings of the forehead region were quantified using the Whitaker scoring system at three timepoints: preoperative (T1), < 6 months postoperative (T2), and > 1 year postoperative (T3). RESULTS: Twenty-one patients were included. Age at surgery was 16.2 ± 2.8 years, forehead cranioplasty area was 135 ± 112 cm2, and mass of cement was 17.2 ± 7.8 g. Patients were followed for 3.0 ± 3.1 years. Whitaker scores decreased from 1.9 ± 0.4 at T1 to 1.4 ± 0.5 at T2 (p = 0.005). Whitaker scores at T2 and T3 were not significantly different (p = 0.720). Two infectious complications (9.5%) were noted, one at 4.5 months postoperatively and the other at 23 months, both requiring operative removal of CCP cement. CONCLUSION: Our results suggest that aesthetic forehead ratings improve after CCP contouring cranioplasty and that the improvement is sustained in medium-term follow-up. Complications were uncommon, suggesting that CCP is relatively safe though longer-term follow-up is needed before reaching definitive conclusions.

Spring forces and calvarial thickness predict cephalic index changes following spring-mediated cranioplasty for sagittal craniosynostosis.

BACKGROUND: Variables interacting to predict outcomes following spring-mediated cranioplasty (SMC) for non-syndromic craniosynostosis, including spring parameters and calvarial thickness, are poorly understood. This study assessed interactions between spring parameters and calvarial thickness to predict changes in cephalic index (CI) following SMC. METHODS: Patients undergoing SMC for non-syndromic sagittal craniosynostosis at our institution between 2014 and 2021 were included. Calvarial thickness was determined from patient preoperative CTs using Materalise Mimics at 27 points in relation to the sagittal suture. Linear mixed effects models were used to determine interactions between anterior, middle, and posterior calvarial thickness with spring force and length. RESULTS: Sixty-nine patients undergoing surgery at mean age 3.7 months were included in this study. Stronger posterior spring force interacted with thinner posterior calvarial thickness to predict greater changes in CI at 3 months postoperatively (p = 0.022). When evaluating spring force and calvarial thickness set distances from the sagittal suture, stronger posterior spring force interacted with thinner posterior calvarial thickness 5 mm (p = 0.043) and 10 mm (p = 0.036) from the sagittal suture to predict changes in CI. Interactions between spring parameters and calvarial thickness in the anterior and middle positions did not significantly predict changes in CI. CONCLUSIONS: Stronger posterior spring force interacted with thinner posterior calvaria to predict greater changes in CI 3 months following SMC for non-syndromic sagittal craniosynostosis. These results suggest dynamic interactions between several variables may impact outcomes following SMC.

Comprehensive Long-Term Outcomes Following Mandibular Distraction Osteogenesis.

OBJECTIVE: To describe long-term outcomes and complications following mandibular distraction osteogenesis (MDO) in a diverse patient cohort. DESIGN: Cross-sectional study. SETTING: Single tertiary-care pediatric center. PATIENTS: Forty-eight patients previously undergoing MDO with minimum 4-year follow-up. MAIN OUTCOME MEASURES: Respiratory outcomes, feeding patterns, dental development, motor/sensory nerve function, temporo-mandibular joint function, and postsurgical scarring. RESULTS: Forty-six patients with a median age of 7 years were evaluated. Of 20 nonsyndromic patients, none required additional airway procedures, none required continuous positive airway pressure (CPAP) during sleep, and 19 (95%) fed exclusively by mouth. Among 26 syndromic patients, 7 (27%) required CPAP and 8 (31%) were tube fed. Permanent first molar differences were seen in the majority of subjects; patterns of damage interfering with function were more common in syndromic (13/28, 46%) compared to nonsyndromic (5/24, 21%; P = .014) subjects. MDO prior to age two was associated with more frequent and worse dental damage (P = .001). Inferior alveolar nerve and marginal mandibular nerve function were fully intact in 37 (80%) and 39 (85%) of patients, respectively. Three patients (6%), all with associated genetic syndromes, demonstrated severe nerve impairment. By the Vancouver scar scale, ≥ 80% of surgical scars were rated in the most favorable category for each quality assessed. Temporomandibular joint dysfunction was rare. CONCLUSIONS: MDO shows highly favorable long-term respiratory, feeding, nerve, and scar outcomes in nonsyndromic patients, although permanent molar changes not precluding tooth viability are commonly seen. Patients with associated syndromes demonstrate respiratory and feeding benefits, but higher rates of dental and nerve abnormalities.

Dual-Innervated Free Gracilis Muscle Transfer for Facial Reanimation in Children.

BACKGROUND: Facial palsy may have deleterious effects for pediatric patients. The most common reconstruction is 2-stage free gracilis muscle transfer (FGMT) after cross-face nerve graft (CFNG). This requires a prolonged period from time of surgery to smile. New techniques using both a CFNG and motor nerve to masseter (MNM) as dual power sources in a single-stage surgery have been described in adults. Here, we examine our experience with this technique in children. METHODS: A retrospective study was performed examining patients who underwent dual-innervated single-stage FGMT at 2 pediatric hospitals from 2016 to 2019. Demographics, etiology, perioperative characteristics, time to mandibular and emotional smile, and Sunnybrook scores were recorded. RESULTS: Five patients met inclusion criteria with a mean age of 11.8 (range, 8-20). Two patients had congenital facial palsy while 3 had acquired facial palsy. Four patients (80%) received dual end-to-end neural coaptations of the CFNG and MNM to the obturator nerve. One (20%) had end-to-side coaptation of the CFNG to the obturator nerve and end-to-end of the MNM to the obturator nerve. The average time to mandibular smile was 103 ± 15.4 days. The average time to emotional smile was 245 ± 48.1 days. The preoperative Sunnybrook scale was 32 ± 7.5 and improved to 55.3 ± 20.6 at 8 months postoperatively. CONCLUSIONS: Dual-innervated FGMT is effective for facial reanimation in children with unilateral facial palsy. Patients can harness a stronger motor source (MNM) and the component of an emotional stimulus (CFNG). This approach may be the new criterion standard pediatric facial reanimation.

Degree of Sagittal Suture Fusion, Cephalic Index, and Head Shape in Nonsyndromic Sagittal Craniosynostosis.

BACKGROUND: Sagittal craniosynostosis may present with complete or partial fusion of the sagittal suture, but relationships between degree of sagittal suture fusion and head shape are currently poorly described. The aim of this study was to characterize sagittal suture fusion patterns and determine associations with head shape in a cohort of patients with nonsyndromic sagittal craniosynostosis. METHODS: Patients with nonsyndromic sagittal craniosynostosis at a tertiary care center with available computed tomography imaging were included in this study. The anterior and posterior distances of sagittal suture patency were measured along 3-dimensional parietal bones. Degree of sagittal suture fusion was compared to head shape characteristics, including cephalic index (CI), frontal bossing, and occipital bulleting. RESULTS: Ninety patients (69 male) were included in this retrospective study. The sagittal suture was on average 85.6±20.1% fused, and 45 (50.0%) patients demonstrated complete fusion of the sagittal suture. CI was associated with increased degree of fusion for the anterior one-half (ρ=0.26, P =0.033) and anterior one-third (ρ=0.30, P =0.012) of the sagittal suture. Complete fusion of the anterior one-third of the sagittal suture predicted higher CI (ß=13.86, SE=6.99, z =-0.25, P =0.047). Total degree of sagittal suture fusion was not predictive of CI or head shape in any analysis. CONCLUSIONS: Decreased fusion of the anterior one-third of the sagittal suture, but not total suture, may paradoxically predict increased severity of scaphocephaly as quantified by CI in nonsyndromic sagittal craniosynostosis.

Predicting Changes in Cephalic Index Following Spring-mediated Cranioplasty for Nonsyndromic Sagittal Craniosynostosis: A Stepwise and Machine Learning Algorithm Approach.

BACKGROUND: Spring-mediated cranioplasty (SMC) is an increasingly utilized technique to treat patients with nonsyndromic sagittal craniosynostosis, but variables impacting outcomes are incompletely understood. The purpose of this study was to determine variables most predictive of outcomes following SMC, primarily changes in cephalic index (CI). METHODS: Patients with nonsyndromic sagittal craniosynostosis undergoing SMC at our institution between 2014 and 2021 were included. Cephalic index was measured from patient computed tomography scans, x-rays, or by caliper-based methods. Parietal bone thickness was determined from patient preoperative computed tomography. Stepwise multiple regression analysis, least absolute shrinkage and selection operator, and random forest machine learning methods were used to determine variables most predictive of changes in CI. RESULTS: One hundred twenty-four patients were included. Stepwise multiple regression analysis identified duration of spring placement ( P =0.007), anterior spring force ( P =0.034), and anterior spring length ( P =0.043) as statistically significant predictors for changes in CI. Least absolute shrinkage and selection operator analysis identified maximum spring force (ß=0.035), anterior spring length (ß=0.005), posterior spring length (ß=0.004), and duration of spring placement (ß=0.0008) as the most predictive variables for changes in CI. Random forest machine learning identified variables with greatest increase in mean squared error as maximum spring force (0.0101), anterior spring length (0.0090), and posterior spring length (0.0056). CONCLUSIONS: Maximum and total spring forces, anterior and posterior spring lengths, and duration of spring placement were the most predictive variables for changes in CI following SMC. Age at surgery and other demographic variables were inferior predictors in these models.

A critical appraisal of surgical outcomes following orbital hypertelorism correction: what is the incidence of true bony relapse versus soft tissue telecanthus?

BACKGROUND: Orbital hypertelorism (OHT) represents a congenital condition defined by lateralization of the bony orbit, unlike soft tissue telecanthus in which there is an increase in intercanthal distance without true bony lateralization. Existing literature remains very limited in its postoperative assessment of bony versus soft tissue relapse, which may both clinically present as telecanthus. We performed a critical appraisal of the literature to determine the postoperative incidence of bony versus soft tissue relapse following OHT repair. METHODS: The PubMed, MEDLINE, EMBASE, Scopus, Cochrane Central Register of Controlled Trials, and clinicaltrials.org were searched systematically for all English studies published in any time frame reporting relapse rates following primary OHT repair. The primary outcome was incidence of bony and soft tissue relapse defined as orbital lateralization and medial canthal drift, respectively. The secondary outcome measures include postoperative complications, predictors of postoperative complications, timing and type of surgery, and revision rates. RESULTS: Eleven articles were included. A total of 84 (35.3%) patients experienced bony relapse while 43 (27.2%) patients experienced soft tissue relapse. Age at time of intervention (p < 0.92), severity at presentation (p < 0.90), and surgical technique (p < 0.09) were not found be significantly associated with relapse rate. Methods for long-term follow-up were not standardized, and there was no consistent measure to objectively assess telecanthus. CONCLUSIONS: There is no general consensus on predictive factors of long-term relapse following OHT repair in the form of box osteotomy or facial bipartition. These findings call for cross-sectional outcome standardization to better understand long-term outcomes across institutional, provider, and patient differences.

What is the Role of Force in Correcting Scaphocephaly Through Spring-Mediated Cranial Vault Expansion for Sagittal Craniosynostosis?

OBJECTIVES: Spring-mediated cranial vault expansion (SMC) may enable less invasive treatment of sagittal craniosynostosis than conventional methods. The influence of spring characteristics such as force, length, and quantity on cranial vault outcomes are not well understood. Using in vivo and ex vivo models, we evaluate the interaction between spring force, length, and quantity on correction of scaphocephalic deformity in patients undergoing SMC. METHODS: The authors retrospectively studied subjects with isolated sagittal craniosynostosis who underwent SMC between 2011 and 2019. The primary outcome measure of in vivo analysis was head shape determined by cephalic index (CI). Ex vivo experimentation analyzed the impact of spring length, bend, and thickness on resultant force. RESULTS: Eighty-nine subjects underwent SMC at median 3.4 months with median preoperative CI 69% (interquartile range: 66, 71%). Twenty-six and 63 subjects underwent SMC with 2 and 3 springs, with mean total force 20.1 and 27.6 N, respectively (P < 0.001).Postoperative CI increased from 71% to 74% and 68% to 77% in subjects undergoing 2- and 3-spring cranioplasty at the 6-month timepoint, respectively (P < 0.001). Total spring force correlated to increased change in CI (P < 0.002). Spring length was inversely related to transverse cranial expansion at Postoperative day 1, however, directly related at 1 and 3 months (P < 0.001). Ex vivo modeling of spring length was inversely related to spring force regardless of spring number (P < 0.0001). Ex vivo analysis demonstrated greater resultant force when utilizing wider, thicker springs independent of spring arm length and degree of compression. CONCLUSIONS: A dynamic relationship among spring characteristics including length, bend, thickness, and quantity appear to influence SMC outcomes.

Atlantoaxial Rotatory Subluxation: A Rare Complication of Craniofacial Surgery.

INTRODUCTION: Neck pain is common in the post-operative period after craniofacial procedures. If patients present with neck pain and torticollis, it could be a manifestation of atlantoaxial rotatory subluxlation (AARS), which describes a rare condition in which there is lateral displacement of C1 relative to C2. When this occurs in the post-operative patient, it is termed Grisel syndrome. In this case series, we report on 3 patients diagnosed with Grisel syndrome after a craniofacial procedure. METHODS: A retrospective chart review of a single craniofacial surgeon at a pediatric hospital was conducted over the last 3 decades. Demographics, procedures performed, and management strategies of AARS were included for review. RESULTS: Three patients were identified who were diagnosed with Grisel syndrome after a craniofacial procedure and required inpatient cervical traction. All patients presented with torticollis within 1 week of their operation. Conservative management was ineffective, and all 3 patients were admitted for inpatient cervical traction, for an average of 13 days followed by an average of 47 days of outpatient therapy. No patients showed any signs of recurrence after removal of outpatient traction device. CONCLUSION: Grisel syndrome is a rare, but serious complication of craniofacial procedures. Physicians caring for these patients must have a high degree of suspicion if a patient with a recent craniofacial procedure presents with torticollis. Delaying the initiation of therapy has been shown to lead to higher rates of recurrence and increases the likelihood that patients will require surgical intervention.

Hope Springs Eternal: Insights Into the Durability of Springs to Provide Long-Term Correction of the Scaphocephalic Head Shape.

Spring-mediated cranial vault expansion (SMC) has become a primary treatment modality at our institution to correct scaphocephalic head shape in the setting of isolated sagittal craniosynostosis (CS). Spring-mediated cranioplasty is associated with minimal procedural morbidity and reliable clinical efficacy, although long-term outcomes are not well elucidated. Herein we describe our institutional experience and lessons learned with SMC. We hypothesize that SMC performed in young infants offers durable scaphocephalic correction as measured by cephalic index (CI) at the 1, 3, and 5-year postoperative timepoints.Patients with isolated sagittal CS who underwent SMC at our institution during an 8-year period were retrospectively studied. The primary outcome measure was long-term head shape determined by CI at the 1, 3, and 5-year postoperative timepoints. Secondary outcomes included patient and spring factors associated with change in CI, including age and spring force. All statistical tests were 2-tailed with P < 0.05 denoting significance.In total, 88 patients underwent SMC at a median age of 3.3 months with a median preoperative CI 69 (interquartile range: [66, 71]). The postoperative CI increased to 73 [71, 76] at postoperative day 1. At 1 month, the CI increased by 8.6 to 77 (P < 0.0001) and appeared to reach a plateau at 3 months (76, [74, 78]) without further improvement (P < 0.10). At 5 years, CI remained stable without relapse (76, [75, 81], demonstrating an 8.9 increase from preoperative CI. Age at time of spring placement and change in CI were inversely related (P < 0.005). Total spring force directly correlated with increased change in postoperative CI at the 6-month postoperative timepoint (P < 0.02).In summary, SMC offers durable correction of scaphocephaly as measured by CI for patients with isolated sagittal CS at the 5-year postoperative timepoint. The cranial expansion observed 1-month post-spring implantation may serve as a proxy for long-term CI.

Perioperative Outcomes in the Treatment of Isolated Sagittal Synostosis: Cranial Vault Remodeling Versus Spring Mediated Cranioplasty.

BACKGROUND: Patients undergoing cranial expansion including spring-mediated cranioplasty (SMC) and cranial vault remodeling (CVR) receive costly and high acuity post-operative intensive care (ICU) given concerns over neurologic and hemodynamic vulnerability. The authors analyzed perioperative and post-operative events for patients presenting with sagittal craniosynostosis (CS) undergoing SMC and CVR in order to compare complication profiles. METHODS: The authors performed a single center retrospective cohort study of patients undergoing SMC and CVR for the treatment of nonsyndromic, isolated sagittal CS from 2011 to 2018. Perioperative and post-operative factors were collected, focusing on hemodynamic instability and events necessitating ICU care. Mann-Whitney U and Fisher exact tests were used to compare data with significance defined as P < 0.05. RESULTS: Among 106 patients, 65 (61%) underwent SMC and 41 (39%) CVR. All CVR patients received prophylactic whole blood transfusion at time of scalp incision. Acute blood loss anemia was the most common post-operative complication, prompting n = 6 (9.2%) and n = 7 (17.1%) blood transfusions in the SMC and CVR cohorts, respectively (P < 0.24). Hemodynamic instability requiring blood transfusion was rare, occurring post-operatively in n = 2 (3.1%) and n = 2 (4.9%) patients in the SMC and CVR cohorts, respectively (P < 0.64). Two patients in the CVR cohort exhibited new neurologic symptoms that self-resolved, compared to no patients in the SMC cohort (P < 0.15). CONCLUSION: Despite differing degrees of operative invasiveness, post-operative hemodynamic and neurologic decompensation following CVR and SMC for isolated sagittal CS repair remains similarly rare. Indications necessitating post-operative intensive care are infrequent. Post-operative hemoglobin monitoring may enable early prediction for hemodynamic instability.

Free Flap Reconstruction of Complex Oncologic Scalp Defects in the Setting of Mesh Cranioplasty: Risk Factors and Outcomes.

INTRODUCTION: Soft-tissue reconstruction of the scalp has traditionally been challenging in oncologic patients. Invasive tumors can compromise the calvarium, necessitating alloplastic cranioplasty. Titanium mesh is the most common alloplastic material, but concerns of compromise of soft-tissue coverage have introduced hesitancy in utilization. The authors aim to identify prognostic factors associated with free-flap failure in the context of underlying titanium mesh in scalp oncology patients. METHODS: A retrospective review (2010-2018) was conducted at a single center examining all patients following oncologic scalp resection who underwent titanium mesh cranioplasty with free-flap reconstruction following surgical excision. Patient demographics, comorbidities, ancillary oncological treatment information were collected. Operative data including flap type, post-operative complications including partial and complete flap failure were collected. RESULTS: A total of 16 patients with 18 concomitant mesh cranioplasty and free-flap reconstructions were identified. The majority of patients were male (68.8%), with an average age of 70.5 years. Free-flap reconstruction included 15 ALT flaps (83.3%), 2 latissimus flaps (11.1%), and one radial forearm flap (5.5%). There were three total flap losses in two patients. Patient demographics and comorbidities were not significant prognostic factors. Additionally, post-operative radiation therapy, ancillary chemotherapy, oncological histology, tumor recurrence, and flap type were not found to be significant. Pre-operative radiotherapy was significantly associated with flap failure (P < 0.05). CONCLUSION: Pre-operative radiotherapy may pose a significant risk for free-flap failure in oncologic patients undergoing scalp reconstruction following mesh cranioplasty. Awareness of associated risk factors ensures better pre-operative counseling and success of these reconstructive modalities and timing of pre-adjuvant treatment.

The Role of a Resident Aesthetic Clinic in Addressing the Trainee Autonomy Gap.

BACKGROUND: Our institution supports a chief resident aesthetic clinic with the goal of fostering autonomy and preparedness for independent practice in a safe environment. OBJECTIVES: The aim of this study was to compare safety profiles and costs for common aesthetic procedures performed in our resident versus attending clinics. METHODS: A retrospective review was conducted of all subjects presenting for aesthetic face, breast, and/or abdominal contouring surgery at our institution from 2008 to 2017. Two cohorts were identified: subjects undergoing surgery through the chief resident versus attending clinics. Aesthetic procedures queried included: (1) blepharoplasty, rhinoplasty, or rhytidectomy; (2) augmentation mammaplasty, reduction mammaplasty, or mastopexy; (3) abdominoplasty; and (4) combination. Demographics, perioperative characteristics, costs, and postoperative complications were analyzed. RESULTS: In total, 262 and 238 subjects underwent aesthetic procedures in the resident and attending clinics, respectively. Subjects presenting to the residents were younger (P < 0.001), lower income (P < 0.001), and had fewer comorbidities (P < 0.001). Length of procedure differed between resident and attending cohorts at 181 and 152 minutes, respectively (P < 0.001), although hospital costs were not significantly increased. Total costs were higher in the attending cohort independent of aesthetic procedure (P < 0.001). Hospital readmissions (P < 0.05) and cosmetic revisions (P < 0.002) were more likely to occur in the attending physician cohort. Postoperative complications (P < 0.50) and reoperative rates (P < 0.39) were not significantly different. CONCLUSIONS: The resident aesthetic clinic provides a mechanism for increased autonomy and decision-making, while maintaining patient safety in commonly performed cosmetic procedures.

Buccal Myomucosal Flap Reconstruction After Resection of Palatal Mucoepidermoid Carcinoma.

Salivary gland tumors are rare, constituting approximately 0.5% of pediatric malignancies, yet account for over 50% of malignant salivary gland neoplasms, of which a majority are mucoepidermoid carcinomas (MECs). We present a case of MEC involving the palatal minor salivary gland of an adolescent patient successfully reconstructed using buccal myomucosal flap. The subject presented as a 17-year-old male with a painless left hard palatal mass found to have imaging suspicious for minor salivary gland tumor and punch biopsy consistent with a low-grade MEC. The subject underwent wide local excision of a 1.0 × 1.2 cm mass with 1.0 cm margins down to hard palate nasal mucosa excluding the abutting first and second molars of the ipsilateral maxilla. Pathology confirmed low-grade MEC confined to hard palate. Two weeks, thereafter, the subject underwent buccal myomucosal flap reconstruction inset into the palatal defect and divided 2 weeks thereafter. Postoperative course was complicated by a pinpoint oronasal fistula at the posterior aspect of the flap-palate junction requiring reelevation and advancement. The subject subsequently recovered without complication. Mucoepidermoid carcinomas represent rare, malignant minor salivary gland tumors with nonspecific presentations that require multidisciplinary workup and management. The authors recommend reconstruction of resultant palatal defects to prevent progression to oronasal fistulae or speech and swallow impairment.

Pediatric Dog Bite Prevention: Are We Barking Up the Wrong Tree or Just Not Barking Loud Enough?

OBJECTIVES: The objectives of this study were (1) to evaluate dog bite-related injuries and associated medical documentation and (2) to compare these results with a study of dog bites from the same institution 10 years prior. METHODS: Data were retrospectively collected from a pediatric emergency department from July 2007 to July 2011 for patients treated for dog bites. These data were then compared with data from the same institution from 10 years prior. RESULTS: A total of 1017 bite injuries were treated (average, 254.25 bites/year), which represents a 25% increase compared with 10 years prior. Comparing the 1997 and 2007 to 2011 cohorts, patient demographics, bite rate among children less than 5 years old, rate of dog breed documentation, and setting of injury were similar. Dog breed was reported in 47% (95% confidence interval [CI], 40.2-53.9) and 41% (95% CI, 38.0-44.0) of cases, respectively, in the 2 cohorts. Bites to the craniofacial region were most common (face only reported for 1997: 43.2%; 95% CI, 36.4-50 versus 2007-2011: 66.1%; 95% CI, 63.2-69.0). In both cohorts, the child's home was the most frequent setting, accounting for 43% of bites (1997: 95% CI, 30.2-55.9 and 2007-2011: 95% CI, 39.3-46.7). CONCLUSIONS: Pediatric dog bites continue to occur frequently, and the associated factors did not change over the 10-year period: young age of child, bites to the craniofacial region, and dogs familiar to the child. Although accurate medical documentation of dog bites is a prerequisite to develop effective prevention strategies, current medical documentation of dog bites may be misguided.

Components Separation for Abdominal Wall Reconstruction in the Recalcitrant, High-Comorbidity Patient: A Review of 311 Single-Surgeon Cases.

PURPOSE: Components separation of the abdominal musculature remains a mainstay for closure of complicated midline and paramedian abdominal wall defects. The authors critically analyzed their experience with this technique to identify prognosticators affecting long-term clinical outcomes. METHODS: A retrospective review was performed of patients undergoing components separation by a single senior surgeon (J.M.R.) between 2000 and 2010. Numerous perioperative patient characteristics were collected and analyzed to determine their effects on long-term clinical outcomes. Multivariable logistic regression was used to predict hernia recurrence and other adverse clinical outcomes. RESULTS: A total of 311 patients were identified (male, 51.1%). Mean age was 53.1 ± 14.0 years, preoperative body mass index was 33.1 ± 8.2 kg/m, and defect width was 11.4 ± 7.5 cm. Patients who had prior hernia repair were 97.4%, with 38.3% having prior mesh placement. Average follow-up was 2.9 ± 2.4 years. Overall hernia recurrence rate was 18.3%. Postoperative complications included seroma (9.3%), superficial wound infection (9.0%), skin dehiscence (4.82%), hematoma (3.2%), deep vein thrombos or pulmonary emolbus (3.2%), and skin flap ischemia (1.0%). Respiratory comorbidity (odds ratio, [OR], 2.02; P < 0.029), prior failed mesh repair (OR, 1.86; P < 0.045), and occurrence of any postoperative complication (OR, 2.02; P < 0.034) significantly increased the risk of eventual hernia recurrence. Preoperative body mass index was not associated with hernia recurrence (P < 0.351) or increased incidence of any aforementioned postoperative complications. CONCLUSIONS: This study provides a comprehensive review of one of the largest single-surgeon experiences using components separation to date. Patients with respiratory comorbidities, prior failed mesh repair, and the occurrence of any postoperative complication are at significantly increased risk for hernia recurrence.

Speech Outcomes After Clinically Indicated Posterior Pharyngeal Flap Takedown.

BACKGROUND: Velopharyngeal insufficiency affects as many as one in three patients after cleft palate repair. Correction using a posterior pharyngeal flap (PPF) has been shown to improve clinical speech symptomatology; however, PPFs can be complicated by hyponasality and obstructive sleep apnea. The goal of this study was to assess if speech outcomes revert after clinically indicated PPF takedown. METHODS: The cleft-craniofacial database of the Children's Hospital of Pittsburgh at the University of Pittsburgh Medical Center was retrospectively queried to identify patients with a diagnosis of velopharyngeal insufficiency treated with PPF who ultimately required takedown. Using the Pittsburgh Weighted Speech Score (PWSS), preoperative scores were compared to those after PPF takedown. Outcomes after 2 different methods of PPF takedown (PPF takedown alone or PPF takedown with conversion to Furlow palatoplasty) were stratified and cross-compared. RESULTS: A total of 64 patients underwent takedown of their PPF. Of these, 18 patients underwent PPF takedown alone, and 46 patients underwent PPF takedown with conversion to Furlow Palatoplasty. Patients averaged 12.43 (range, 3.0-22.0)(SD: 3.93) years of age at the time of PPF takedown, and 58% were men. Demographics between groups were not statistically different. The mean duration of follow-up after surgery was 38.09 (range, 1-104) (SD, 27.81) months. For patients undergoing PPF takedown alone, the mean preoperative and postoperative PWSS was 3.83 (range, 0.0-23.0) (SD, 6.13) and 4.11 (range, 0.0-23.0) (SD, 5.31), respectively (P = 0.89). The mean change in PWSS was 0.28 (range, -9.0 to 7.0) (SD, 4.3). For patients undergoing takedown of PPF with conversion to Furlow palatoplasty, the mean preoperative and postoperative PWSS was 6.37 (range, 0-26) (SD, 6.70) and 3.11 (range, 0.0-27.0) (SD, 4.14), respectively (P < 0.01). The mean change in PWSS was -3.26 (range, -23.0 to 4.0) (SD, 4.3). For all patients, the mean preoperative PWSS was 5.66 (range, 0.0-26) (SD, 6.60) and 3.39 (range, 0.0-27) (SD, 4.48), respectively (P < 0.05). The mean change in PWSS was -2.26 (range, -23.0 to 7) (SD, 5.7). There was no statistically significant regression in PWSS for either surgical intervention. Two patients in the PPF takedown alone cohort demonstrated deterioration in PWSS that warranted delayed conversion to Furlow palatoplasty. Approximately 90% of patients, who undergo clinically indicated PPF takedown alone, without conversion to Furlow Palatoplasty, will show no clinically significant reduction in speech. CONCLUSIONS: Although there is concern that PPF takedown may degrade speech, this study finds that surgical takedown of PPF, when clinically indicated, does not result in a clinically significant regression of speech.

Repair of a Complicated Calvarial Defect: Reconstruction of an Infected Wound With rhBMP-2.

BACKGROUND: Management of the previously infected craniofacial defect remains a significant clinical challenge, posing obstacles such as wound healing complications, lack of donor site availability, and predisposition to failure of the repair. Optimal therapy would reconstruct like with like, without donor site morbidity. The purpose of this study was to compare the efficacy of recombinant human bone morphogenetic protein-2 (rhBMP-2)-mediated bone regeneration with the current standard of autologous bone graft for repair of previously infected calvarial defects. METHODS: Nineteen adult New Zealand white rabbits underwent subtotal calvariectomy. Bone flaps were inoculated with Staphylococcus aureus and replanted. After 1 week of infection, bone flaps were removed, and wounds were debrided, followed by 10 days of antibiotic treatment. After 6 weeks, animals underwent scar debridement followed by definitive reconstruction in 1 of 4 groups: empty control (n = 3), vehicle control (buffer solution on absorbable collagen sponge [ACS], n = 3), autologous bone graft (n = 3), or rhBMP-2 repair (rhBMP-2/ACS, n = 10). Animals underwent computed tomography imaging at 0, 2, 4, and 6 weeks postoperatively, followed by euthanization and histological analysis. Percent healing was determined by 3-dimensional analysis. A (time × group) 2-way analysis of variance was performed on healing versus treatment group and postoperative time. RESULTS: At 6 weeks postoperatively, rhBMP-2/ACS and autologous bone graft resulted in 93% and 68% healing, respectively, whereas the empty and vehicle control treatment resulted in 27% and 26% healing (P < 0.001). Histologically, compared to autologous bone graft, bone in the rhBMP-2/ACS group was more cellular and more consistently continuous with wound margins. CONCLUSIONS: The rhBMP-2 therapy is effective in achieving radiographic coverage of previously infected calvarial defects.

Pediatric Craniofacial Fractures: Trajectories and Ramifications.

BACKGROUND: The pediatric craniofacial skeleton fractures in patterns distinct from those typical in adults; this has implications pertinent to management that may go unrecognized. The authors reviewed multilevel pediatric craniofacial fractures presenting to their institution, surmising that they would display an oblique trajectory of fracture patterns, and would be at increased risk of growing skull fractures (GSFs), compared with adults. METHODS: A retrospective review was performed of pediatric patients presenting with multilevel craniofacial fractures between 2004 and 2010. Demographics, cause of injury, fracture patterns, associated injuries, management, and follow-up information were gathered. Computed tomography scans were reviewed to characterize fracture length, displacement, and trajectory. Adverse outcomes were documented, with particular attention to GSFs. RESULTS: One hundred fifty-one patients met our inclusion criteria, which included a follow-up of >3 years. Average age at injury was 9.5 ±â€Š4.7 years. Patterns of fracture displayed near consistent obliquity, with only 4 patients (2.6%) displaying a LeFort-type facial fracture. LeFort patterns were associated with older patients over the age of 12, but without statistical significance (P = 0.07). Five patients (3.3%) died as a result of their injuries. 3.3% of patients developed a GSF. All craniofacial fracture patients demonstrated radiographic and/or clinical evidence of healed fractures at their last follow-up. CONCLUSIONS: This series of pediatric craniofacial fractures near consistently demonstrated oblique fracture patterns, in contrast to the typical adult fracture patterns described by LeFort. Pediatric craniofacial fractures are also at increased risk of GSFs. Understanding of these principles is fundamental to successful therapy in this population.