Intraoperative Anaphylaxis to Gelatin during Alveolar Bone Grafting for Cleft Palate.

Intraoperative anaphylaxis can be life threatening. Anaphylaxis to gelatin-based topical hemostatic agents is an underrecognized hypersensitivity. To date, only 21 cases of intraoperative anaphylaxis have been reported for gelatin-based hemostatic agents. In this article, we report the case of a 10-year-old male patient who sustained anaphylaxis after the use of Gelfoam during harvest of a bone graft. Rapid diagnosis and treatment of intraoperative anaphylaxis is imperative to prevent adverse outcomes. Referral to an allergist for identification of the allergen and appropriate notation in the medical record are paramount to avoid future anaphylactic events. Surgeons should avoid gelatin-based hemostatic agents, such as Gelfoam, in patients with reported intolerance of gelatin-based foods and medicines.

Wound infection: A review of qualitative and quantitative assessment modalities.

Surgical site infections (SSI) and chronic wounds represent a burden to patients and the health care system. One in 24 surgical patients will develop an SSI, making SSI the most common nosocomial infection in the USA. Early detection and monitoring of wound infection are critical for timely healing and return to normal function. However, the mainstay of wound infection diagnostic entails subjective clinical examination and semi-quantitative, invasive microbiological tests. In this review, we present current wound infection assessment modalities in the clinical and translational fields. There is a need for a point-of-care assessment tool that provides fast, accurate, and quantitative information on wound status, with minimal to no contact with the patient. In the next ten years, the evolution of wound diagnostic tools reported here may allow medical providers to optimize patient care while minimizing patient discomfort.

Alveolar Bone Graft Timing in Patients With Cleft Lip & Palate.

ABSTRACT: Cleft lip with or without cleft palate (CLP) is the most common craniofacial condition. Alveolar clefts are present in approximately 75% of patients with a cleft lip or CLP and often do not have sufficient support of surrounding teeth. Alveolar bone graft is commonly performed to reconstruct alveolar ridge in patient with osseous defects. Objective of this review is to critically analyze the literature to provide recommendations on appropriate timing for orthodontic preparation and surgical correction of alveolar clefts in the setting of unilateral or bilateral CLP. Search of PubMed database, MEDLINE, and EMBASE was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, 15 studies were included. Majority of studies used chronological age to classify patients versus dental age. Most studies reported orthodontic treatment concomitant with surgery (12/15; 80.0%), and used orthodontics before alveolar bone grafting (8/12; 66.7%). No consensus on the best method to evaluate the success of alveolar bone grafting. Alveolar bone grafting with pre- and post-operative orthodontics is currently the standard of care for treatment of alveolar defects in patients with CLP. Authors recommend grafting during early mixed dentition phase, just before the eruption of the permanent central incisors, typically between 6 and 8 years old. Preoperative orthodontics for appropriate incisor alignment around cleft, and may be resumed 6 months postoperative.

Evolution of Bandeau Shape, Orbital Morphology, and Craniofacial Twist after Fronto-Orbital Advancement for Isolated Unilateral Coronal Synostosis: A Case-Control Study of 2-Year Outcomes.

BACKGROUND: The authors' purpose was to quantify the change in unicoronal synostosis symmetry between presentation (time 0), after fronto-orbital advancement (time 1), and 2 years later (time 2). METHODS: Bandeau/orbital symmetry ratios and skull base/midface twists were measured on computed tomographic scans of consecutive isolated unicoronal synostosis patients. Comparisons were made across three time points and against normal controls. RESULTS: Forty-three unicoronal synostosis patients and 36 controls were included. The mean bandeau ratio (symmetry = 1) changed from 0.76 (time 0), to 1.13 (time 1), and then to 1.01 (time 2). The median bandeau ratio change from time 1 to time 2 was -9.1 percent and was impacted by the degree of time 1 asymmetry. The odds of a desired symmetric or overcorrected result (bandeau ratio > 1.0) at time 2 were increased in patients with less severe preoperative asymmetry (OR, 4.2; p = 0.04) and in those who obtained symmetry or overcorrection at surgery (OR, 4.9; p = 0.02). Craniofacial twist did not significantly change after surgery but decreased at time 2. Orbital height ratios were 1.08, 1.00, and then 1.02 at time 2, respectively. The orbital width ratio was not significantly impacted by surgery, remaining at 0.89 at time 2. CONCLUSIONS: Overcorrection of the unicoronal synostosis bandeau resulted in these patients being five times more likely to have a desired result at time 2. Patients with a more severe brow presentation were four times more likely to be asymmetric at time 2. Orbital height was improved, but attention should be directed at addressing orbital width. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

Custom CAD/CAM implants for complex craniofacial reconstruction in children: Our experience based on 136 cases✰.

BACKGROUND: CAD-CAM patient-specific implants offer cerebral protection and improved facial balance without the disadvantages of autologous bone grafting such as donor site morbidity and unpredictable resorption. Several alloplastic materials are available, but titanium, polymethylmethacrylate (PMMA), and polyetheretherketone (PEEK) are the current popular choices. We reviewed our experience of applying different alloplastic CAD-CAM materials in the reconstruction of complex pediatric craniofacial deformities. METHODS: A retrospective review was performed of all pediatric patients who underwent a complex inlay or onlay implant craniofacial reconstruction using CAD-CAM PEEK, PMMA, or titanium implants at a single institution. Demographics, cost, operative time, complications, and outcomes were assessed. RESULTS: Between 2003 and 2014, 136 patients (69 male; 67 female; mean age 11.5 years (3-22 years); mean follow-up 30 months) had custom patient-specific craniofacial reconstruction with PEEK (n = 72), PMMA (n = 42), and titanium (n = 22) implants (inlay = 93; onlay = 43). Indications included congenital anomalies (26.5%), decompressive craniectomies (25.0%), craniofacial syndromes (25.7%), tumor defects (14.0%), and post-trauma (6.6%). Implant cost varied significantly for PEEK ($7703 CAD) and PMMA ($8328 CAD) compared with that for titanium ($11,980 CAD) (p < 0.0005). Six patients (4.4%) required surgery due to infection consisting of irrigation and antibiotic administration with successful implant salvage in three patients. All infections occurred in the PEEK group. Five patients (3.7%) ultimately had implants removed due to infection (n = 3), late exposure (titanium; n = 1), or late fracture (PMMA; n = 1). CONCLUSIONS: CAD-CAM alloplast reconstruction in the management of complex pediatric craniofacial deformities is effective although expensive. Implant infection does not always require explantation. A reconstruction algorithm is presented.

Surgical management of a nasal AVM in a pediatric patient: A case report.

Arteriovenous malformations (AVMs) are a type of high-flow vascular malformation that are characterized by abnormal capillary communications between the arterial and venous systems. While they are most commonly located in the head and neck region, their appearance in the nose is considerably rare, resulting in a paucity of literature regarding the surgical management of these lesions. We present the case of a 13-year-old male with a 6.5 × 6 cm AVM of the nose with a history of frequent nosebleeds since early childhood, often requiring aggressive measures, such as silver nitrate cauterization for control. Use of nasal decongestants and aminocaproic acid provided only transient improvement. After determination of arterial supply, AVM was approached with a combination of preoperative selective embolization and surgical excision with subsequent forehead flap defect coverage. Due to the size and complexity of this AVM, extra precautions were taken to avoid severe intraoperative bleeding, and femoral sheaths were placed prior to excision. The patient tolerated the procedure well, and with subsequent debulking surgery and Laser Hair Removal achieved an acceptable cosmetic outcome.

Designing a Fibular Flow-Through Flap with a Proximal Peroneal Perforator-Free Flap for Maxillary Reconstruction.

Reconstruction of a composite maxillary defect is frequently performed with a fibular osteocutaneous free flap to address both the bony and mucosal defect. If during the harvest of the fibula a distal skin perforator is not present due to vascular variations, reconstruction can potentially be done using the soleus muscle for filling of the palatal mucosal defect. An additional challenge arises when the accompanying skin paddle that has been harvested is not perfused, but the fibula remains viable. This case report describes salvage following loss of the skin paddle in an osteocutaneous fibular free flap by designing a fibular flow-through flap using a proximal peroneal perforator free flap. The use of this second free flap allows a skin paddle to be positioned on the distal fibular segment, provides a surgical backup, and limits the donor sites to the same extremity.

Identical Twins with Crouzon Syndrome: Eight-Year Follow-up, Genetic Considerations, and Operative Management.

A case report of monozygotic (MZ) twins with Crouzon syndrome was previously published to highlight variables in clinical presentation. The postnatal and epigenetic causes for this variation are not well understood. An 8-year follow-up discusses their pertinent clinic course with consideration of genetic and nongenetic variables. The phenotypic and symptomatic obstacles encountered since their initial assessment are reviewed, and the use of three-dimensional Medical Modeling (Golden, CO) as a preoperative planning strategy is addressed. Analyzing the longitudinal clinical course of MZ twins with syndromic craniosynostosis will help better predict and provide optimal treatment.

Surgical Outcomes for Speech Surgery in 22q11.2 Deletion Syndrome: The Dilemma of Persistent Velopharyngeal Insufficiency After Pharyngeal Flap Operation.

INTRODUCTION: The majority of patients with 22q11.2 deletion syndrome suffer from velopharyngeal insufficiency (VPI). Patients with 22q11.2 deletion syndrome (22qDS) commonly present with a large central velopharyngeal gap in the setting of poor velar and pharyngeal wall motion. The posterior pharyngeal flap is considered the most effective technique to treat VPI in this complex patient group. This study aims to critically evaluate success rates of surgical management of VPI in 22qDS patients and discuss options for management of a failed posterior pharyngeal flap (PPF) with persistent VPI. METHODS: A systematic review was performed through MEDLINE and Scopus to examine the outcomes of PPF surgery to treat VPI in patients with 22qDS. Complications were defined as persistent VPI, hyponasal speech, and obstructive sleep apnea. To demonstrate an approach to management, the authors outline a recent patient with a failed PPF in this patient population at the authors' institution. RESULTS: The authors comprehensively reviewed 58 articles, 13 of which contained relevant information with extractable data. Of the 159 patients with 22qDS who underwent PPF to treat VPI, successful outcomes were reported in 135 patients (80%; range: 0%-100%). Complications were reported in 14% of patients, with need for revision operations in 3%. DISCUSSION: Surgical management of VPI in patients with 22qDS is challenging, with variable success rates reported in the literature. If unsuccessful, the surgeon faces additional challenges with the revision surgery including a scarred PPF donor site, distorted palatal recipient site, and further medialization of internal carotid arteries. Surgical revision of a failed PPF requires meticulous preoperative planning and technical execution.

Separation of Thoraco-Omphalo-Ischiopagus Conjoined Twins: Surgical Planning, Management, and Outcomes.

BACKGROUND: Conjoined twins are a rare medical phenomenon that offers a unique challenge for medical professionals. The complex anatomy of conjoined twins dictates their survival and amenability to separation, making each case different in terms of medical management, surgical planning, and patient outcomes. Thoraco-omphalo-ischiopagus twins, joined from the thorax to the pelvis, are one of the rarest orientations recorded in the medical literature, and successful separation of this subset of conjoined twins has not been documented. This report presents a novel case of thoraco-omphalo-ischiopagus tetrapus twins who were successfully separated at 10 months of age. The preoperative planning, operative details, and postoperative course are discussed as they relate to the reconstructive effort. METHODS: Three-dimensional medical modeling was pursued early in the planning process and was used to estimate the soft-tissue requirements for reconstruction and to design custom tissue expanders. RESULTS: The reconstructive effort required postponement until respiratory status was optimized. Even with elaborate preoperative planning, primary closure of the abdomen was limited because of tissue edema and other less predictable patient factors. Delayed closure of the abdominal wall was made possible with negative-pressure wound therapy and secondary flap advancements. CONCLUSION: Preoperative coordination with necessary vendors, a multidisciplinary surgical effort, and optimal timing of the surgical intervention all contribute to the successful separation and long-term survival of thoraco-omphalo-ischiopagus conjoined twins. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, V.

Review of quantitative outcome analysis of cranial morphology in craniosynostosis.

Outcome measures in craniosynostosis surgery have progressed from those based on the need for surgical revision to linear anthropometric measurements, 2D CT vector analysis and 3D CT vector analysis. However, finding an objective means to assess postoperative cranial morphological improvement remains challenging. A critical review of previous studies used to measure craniosynostosis surgery outcomes is presented. We also introduce and briefly discuss the key features of the computational algorithm that is being utilized in our center for evaluating craniosynostosis surgical outcomes. This has addressed a number of the previous challenges encountered in quantitative measurement of cranial morphological change. Point cloud representation and 3D stereophotogrammetry have made it possible to compare pre and post-operative images of children undergoing surgical correction for craniosynostosis. These pre- and post-operative images can also be compared to age, sex and race-matched controls throughout the patient's lifetime allowing longitudinal changes to be measured on follow up.

Cranial Fasciitis: A Systematic Review and Diagnostic Approach to a Pediatric Scalp Mass.

Cranial fasciitis is an uncommon, benign fibroproliferative condition of the scalp or skull that arises in children. Clinically, it manifests as a firm, nontender, subcutaneous, enlarging mass. The purpose of our study was to review the literature on cranial fasciitis to create a diagnostic algorithm using the latest patient at our institution as an example. The authors conducted a systematic review examining all published cases of cranial fasciitis in English literature. The authors then created a diagnostic algorithm to help distinguish cranial fasciitis from other similarly presenting cranial masses. To demonstrate this algorithm, the authors detailed the latest patient with cranial fasciitis at our institution. The authors extracted data from 53 published reports documenting 72 patients of cranial fasciitis. Our patient presented similarly to what was reported in the literature. A 7-week-old boy presented with 2 small parietal scalp masses that were noted shortly after birth. After noncontrast computed tomography imaging, the enlarging masses were resected and found to have eroded the outer cranial vault cortex. Histological analysis revealed cranial fasciitis. The differential diagnosis for an enlarging scalp mass in an infant or child is broad. Cranial fasciitis cannot be diagnosed based on clinical presentation alone. Imaging is usually employed to further characterize lesions after initial examination but histopathological analysis is essential for diagnosis. The locally invasive nature of cranial fasciitis makes it difficult to distinguish from malignant conditions such as sarcomas. However, if the diagnosis of cranial fasciitis is considered early, patients can achieve prompt clinical resolution following simple resection.

Prenatal Identification of Pierre Robin Sequence: A Review of the Literature and Look towards the Future.

Fetal ultrasonography is an important tool used to prenatally diagnose many craniofacial conditions. Pierre Robin sequence (PRS) is a rare congenital deformation characterized by micrognathia, glossoptosis, and airway obstruction. PRS can present as a perinatal emergency when the retropositioned tongue obstructs the airway leading to respiratory compromise. More predictable and reliable diagnostic studies could help the treating medical team as well as families prepare for these early airway emergencies. The medical literature was reviewed for different techniques used to prenatally diagnose PRS radiologically. We have reviewed these techniques and suggested a possible diagnostic pathway to consistently identify patients with PRS prenatally.

Cephalometric outcomes of orthognathic surgery in hemifacial microsomia.

Hemifacial microsomia is a hypoplastic disorder of the first and second branchial arches that significantly impacts on the development of the jaws, leading to malocclusion and facial asymmetry. There is little in the literature regarding the application of orthodontic/orthognathic approaches to the correction of these deformities and the stability of the surgical results. To address this, a retrospective chart review of 10 patients with complete orthodontic records and greater than 1 year of follow-up was performed. Posteroanterior cephalograms were assessed by modified Grummons analysis to determine mandibular offset (deviation of the chin point from the skeletal midline) and occlusal cant. These measurements were performed at 3 time points (T1: preoperative, T2: immediate postoperative, T3: follow-up) to elucidate the surgical movement (T2-T1), the postoperative relapse (T3-T2), and the net gain movement (T3-T1). Maxillary movements were quantified, and the occlusal cant was expressed as a ratio between vertical heights of the maxilla at the first molar on each side. One sample t test demonstrated statistically significant surgical movement and net gain. Relapse was statistically insignificant. Repeated-measures analysis of variance demonstrated similar results for chin point position relative to the putative midline. Our results suggest that a combined orthodontic/orthognathic approach at skeletal maturity delivers improved occlusal outcomes in the long term as assessed by chin point deviation and occlusal cant, but secondary surgery rates are higher than those for orthognathic surgery in other patient groups. We advocate limiting surgery to skeletal maturity whenever possible to achieve stable long-term results while limiting morbidity and number of procedures.

Secondary lip and palate surgery.

To properly treat a patient with a secondary cleft lip or palate deformity, one must make an accurate diagnosis of the underlying problem. Recognition of specific recurring patterns and common deformities will help facilitate the surgical planning process and assist the surgeon during future procedures. Through a combination of accurate analysis, clinical patience, and technical precision, successful correction of secondary cleft lip and palate deformities can be delivered.

Surgical outcomes in craniosynostosis reconstruction: the use of prefabricated templates in cranial vault remodelling.

Cranio-orbital reshaping for anterior cranial-vault deformities associated with craniosynostosis traditionally relies on the surgeon's subjective estimate of the shape and appearance of a normal forehead. Computer-aided design/computer-aided manufacture (CAD/CAM) bandeau templates to guide reconstruction were introduced in our centre to eliminate this subjectivity and to effect more reproducible surgical results. The aim of this study was to compare two groups of patients (template, n = 14 vs. no template, n = 23) to measure surgical outcomes. The virtual, computational version of the template was used as an outcome assessment tool. It was used to calculate an intervening area under the curve (AUC) between the normative template and the patient's reconstructed supra-orbital bar on a representative computed tomography (CT) axial section. A comprehensive chart review was conducted of patients in both groups to examine the preoperative and postoperative variables. Based on the analysis performed on the immediate postoperative CT scans, in the template group - as compared to the control, no-template group - the use of the bandeau template led to a greater reduction in AUC (74% vs. 56%, p = 0.016), indicating a better conformity between the reconstructed supra-orbital bar and the ideal, normal bandeau shape. The duration of operation was significantly reduced with the use of the template (212 vs. 258 min, p < 0.001). The application of prefabricated templates in cranio-orbital reshaping is highly useful for accurate preoperative planning; reproducible and efficient intra-operative correction of dysmorphology; and objective surgical outcomes assessment.

Management of pediatric mandible fractures.

When determining the optimal treatment strategy for a pediatric mandible fracture, planning must factor in the patient's age, anatomy, stage of dental development, fracture site, and ability to cooperate with the proposed treatment plan. Careful consideration must be given to the possibility of long-term growth disturbance with various fracture locations and types of treatment. This article reviews the current principles of the management of pediatric mandibular fractures.

Orthognathic surgery: general considerations.

ORTHOGNATHIC SURGERY IS A UNIQUE ENDEAVOR IN FACIAL SURGERY: a patient's appearance and occlusal function can be improved significantly, impacting the patient's sense of self and well-being. Successful outcomes in modern orthognathic surgery rely on close collaboration between the surgeon and the orthodontist across all stages of treatment, from preoperative planning to finalization of occlusion. Virtual computer planning promotes a more accurate analysis of dentofacial deformity and preoperative planning. It is also an invaluable aid in providing comprehensive patient education. In this article, the author describes the general surgical principles that underlie orthognathic surgery, highlighting the sequence of treatment, preoperative analysis of dentofacial deformity, surgical execution of the treatment plan, and possible complications.