Facial Trauma Operative Volume Demonstrates Consistent and Significant Yearly Periodicity.

PURPOSE: Facial trauma requiring operative care increases during the summer and fall months, which is colloquially referred to as trauma season. The purpose of this study is to determine if there is a quantifiable and statistically significant yearly periodicity of operative facial trauma volume. MATERIALS AND METHODS: To confirm the existence and quantify the magnitude of trauma season, we conducted a retrospective cohort study. The Plastic Surgery divisional billing database was queried for Current Procedural Terminology (CPT) codes related to acute facial trauma. The outcome variable is monthly CPT code volume and calendar month is the predictor. Monthly CPT volume was tabulated for 120 consecutive months. Raw data were plotted as a time series and transformed as a ratio to the moving average. Autocorrelation was applied to the transformed dataset to detect yearly periodicity. Multivariable modeling quantified the proportion of volume variability (R2) attributable to yearly periodicity. Subanalysis assessed presence and strength of periodicity in 4 age groups. Patient identifiers, demographic information, surgeon, and date of surgery were collected as covariates. RESULTS: One thousand six hundred fifty eight CPT codes obtained through Plastic Surgery billing records were included. Mean age at presentation was 32.5 ± 16.3 years (range = 85.05). Monthly trauma-related CPT volume was highest in June-September and lowest in December-February. Time series analysis revealed yearly oscillation, in addition to a growth trend. Autocorrelation revealed statistically significant positive and negative peaks at a lag of 12 and 6 months, respectively, confirming the presence of yearly periodicity. Multivariable linear modeling revealed R2 attributable to periodicity of 0.23 (P = .008). Periodicity was strongest in younger populations and weaker in older populations. R2 = 0.25 for ages 0-17, R2 = 0.18 for ages 18-44, R2 = 0.16 for ages 45-64, and R2 = 0.034 for ages ≥ 65. CONCLUSION: Operative facial trauma volumes peak in the summer and early fall and reach a winter nadir. This periodicity is statistically significant and accounts for 23% of overall trauma volume variability at our Level 1 trauma hospital. Younger patients drive the majority of this effect. Our findings have implications for operative block time and personnel allocation, in addition to expectation management over the course of the year.

Timing of Cleft Palate Repair in Patients With and Without Robin Sequence.

BACKGROUND: This cohort study aimed to assess how age at repair affects outcomes in nonsyndromic patients with and without Robin Sequence using a national database of commercial healthcare claims. METHODS: Children under 4 years of age undergoing palatoplasty were identified in the IBM MarketScan Commercial Database based on ICD-9-CM and CPT procedure codes. They were divided into Robin and non-Robin cleft palate groups, and further divided by time of initial cleft palate repair: Robin Sequence into 2 groups: age ≤10 months or >10 months; non-Robin cleft palate into 3 groups: age ≤10 months, >10-14 months, or >14 months age. Time to cleft palate revision within each group was assessed using Cox proportional-hazard models. RESULTS: A total of 261 patients with Robin Sequence and 3046 with non-Robin cleft palate were identified. In patients with Robin, later repair was associated with decreased risk of secondary procedures compared with early repair (Hazard Ratio (HR) 0.19, 95%CI 0.09-0.39, P < 0.001). In patients with non-Robin cleft palate, decreased risk of revision compared to early repair was associated both with repair at >10-14 months (adjusted HR 0.40, 95%CI 0.31-0.52, P < 0.001) and > 14 months (adjusted HR 0.71, 95%CI 0.57-0.88, P = 0.002). Adjusting for timing of repair, patients with non-Robin cleft palate were at significantly increased risk of secondary procedure if diagnosed with failure to thrive or anemia in the 30 days prior to palatoplasty. CONCLUSIONS: In patients with and without Robin sequence, cleft palate repair at or before 10 months of age was associated with higher risk for secondary procedures.

Cutting Edge Craniomaxillofacial Trauma Reconstruction.

Facial injuries remain a significant source of morbidity in trauma. Due to the variety and unpredictable patterns of injuries associated with either blunt or ballistic mechanisms, advanced diagnostic imaging and complex management options are necessary. Multidisciplinary collaboration is essential to optimize the care of craniomaxillofacial trauma.

Partial Suture Fusion in Nonsyndromic Single-Suture Craniosynostosis.

INTRODUCTION: Partial synostosis of cranial sutures has been shown to have clinical and diagnostic significance. However, there is limited published information about how suture fusion progresses over time. In this study, we evaluate patients with nonsyndromic single-suture synostosis. We aim to define the incidence of partial versus complete suture fusion and whether a correlation exists between the degree of suture fusion and age. METHODS: Two hundred fifty-four patients with nonsyndromic single-suture synostosis were evaluated. Preoperative computed tomography (CT) scans were rendered in 3-dimensions, all sutures were visualized and assessed for patency or fusion, and length of fusion was measured. Findings were grouped according to suture type (sagittal, coronal, metopic, or lambdoid), the degree of fusion (full, >50%, or <50%), and patient age at time of CT scan (0-90, 91-180, 181-360, or >360 days). Data were analyzed to correlate patient age versus the degree of suture fusion. RESULTS: For all patients, 72% had complete and 28% had partial synostosis. Ratios of full to partial fusion for each suture type were as follows: sagittal 97:36, coronal 35:22, metopic 46:4, and lambdoid 4:10. The sagittal, coronal, and metopic groups demonstrated greater probabilities of complete suture fusion as patient age increases (P = .021, P < .001, P = .001, respectively). This trend was also noted when all sutures were considered together by age-group (P < .001). CONCLUSION: We note a partial suture fusion rate of 28.3%. Our analysis shows a correlation between the extent of suture synostosis and patient age. Finally, we demonstrate that different sutures display different patterns of partial and complete fusion.

Evaluation of Direct Surgical Remodeling of Frontal Bossing in Patients With Sagittal Synostosis.

BACKGROUND: The need for surgical correction of frontal bossing in patients with sagittal synostosis is currently debated. The authors retrospectively analyzed frontal bossing in patients with isolated, nonsyndromic sagittal synostosis who underwent calvarial remodeling with and without frontal craniotomy and compared with control subjects. METHODS: The authors analyzed computed tomography (CT) scans of patients with sagittal synostosis <9 months of age (6.2 ±â€Š1.6 months) who underwent modified-pi procedure either with frontal craniotomy (FC, n = 15) or without frontal craniotomy (NFC, n = 10). Only patients treated with both pre-operative and 1-year post-operative CT scans were included. Non-synostotic age-matched control scans were also analyzed. Cephalic index (CI), 3 previously validated measures of frontal bossing (bossing angle, horizontal bossing ratio, and vertical bossing ratio), and pre-nasion volume ratio were obtained. Additionally, three-dimensional photographs of 10 FC patients were evaluated for frontal bossing between 1 and 8 years post-operatively. RESULTS: Pre-operatively, no significant differences were found between the 2 groups (.064

A Comparison of the Need for Speech Therapy After 2 Palatal Repair Techniques.

BACKGROUND: Reconstruction of the levator musculature during cleft palate repair has been suggested to be important in long-term speech outcomes. In this study, we compare the need for postoperative speech therapy between 2 intravelar veloplasty techniques. METHODS: Chart review was performed for patients with nonsyndromic cleft palate who underwent either primary Kriens or overlapping intravelar veloplasty before 18 months of age. All subjects completed a follow-up visit at approximately 3 years of age. Data obtained included documentation of ongoing or recommended speech therapy at age 3 years and reasons for speech therapy, which were categorized as cleft-related and non-cleft-related by a speech-language pathologist. RESULTS: One surgeon performed all Kriens procedures (n = 81), and the senior author performed all overlapping procedures (n = 25). Mean age at surgery (Kriens = 13.5 ± 1.4 months; overlapping = 13.1 ± 1.5 months; P = 0.188) and age at 3-year follow-up (Kriens = 3.0 ± 0.5 years; overlapping = 2.8 ± 0.5 years; P = 0.148) were equivalent in both groups. Cleft severity by Veau classification (P = 0.626), prepalatoplasty pure tone averages, (P = 0.237), pure tone averages at 3-year follow-up (P = 0.636), and incidence of prematurity (P = 0.190) were also similar between the 2 groups. At 3 years of age, significantly fewer overlapping intravelar veloplasty patients required cleft-related speech therapy (Kriens = 47%; overlapping = 20%; P = 0.015). The proportions of patients requiring non-cleft-related speech therapy were equivalent (P = 0.906). CONCLUSIONS: At 3 years of age, patients who received overlapping intravelar veloplasty were significantly less likely to need cleft-related speech therapy compared with patients who received Kriens intravelar veloplasty. Cleft severity, hearing loss, and prematurity at birth did not appear to explain the difference found in need for speech therapy.

Fenestration of Solid Orbital Implants: Reducing Retrobulbar Hematoma Rate.

PURPOSE: Retrobulbar hematoma is an uncommon but potentially devastating complication following repair of orbital fractures. Since 2007, the senior author routinely fenestrates the solid porous polyethylene implants commonly used for orbital reconstruction. The perforated implant may facilitate drainage of postoperative bleeding and may potentially reduce the risk of retrobulbar hematoma. This study examines the rates of retrobulbar hematoma in patients who underwent orbital fracture reconstruction with placement of fenestrated or nonfenestrated implants. METHODS: A retrospective chart review of patients with orbital fracture reconstruction using an implant performed by the senior author between 2006 and 2016 was conducted. Data collected included age, sex, implant type, and presence of retrobulbar hematoma. RESULTS: One hundred four patients were included in the study. One patient who was treated with a nonperforated implant was found to have a postoperative retrobulbar hematoma. The retrobulbar hematoma did not cause visual changes or increased intraocular pressure, so the patient was observed and did not undergo any surgical intervention. The hematoma resolved spontaneously without further sequela. No patients with fenestrated implants had a retrobulbar hematoma. CONCLUSIONS: Fenestration of solid implants used in orbital floor reconstruction is simple and easy to perform, and may reduce the incidence of postoperative retrobulbar hematoma.

Anthropometric Outcome Measures in Patients With Metopic Craniosynostosis.

PURPOSE: Treatment of metopic craniosynostosis is performed by either fronto-orbital advancement (FOA) or endoscopic-assisted techniques. Interfrontal angle (IFA) is a validated measure of trigonocephaly, but requires a computed tomography scan. The most common direct measure to assess surgical outcome in patients with trigonocephaly is frontal width (ft-ft). The aim of this study is to determine if frontal width correlates with IFA and successful surgical correction 1 year after treatment. A review of current morphologic assessment techniques is also provided. METHODS: Three-dimensional computed tomography scans (preoperative and 1 year postoperative) of patients who underwent FOA (n = 13) or endoscopic (n = 13) treatment of metopic craniosynostosis were reviewed. Age-matched scans of unaffected patients served as controls. Frontal width was measured by a straight line between the bilateral frontotemporal points. Measurements were performed by 2 experienced observers and compared to IFA. RESULTS: Mean frontal width at preoperative scan for endoscopic and open patients was 55 ±â€Š0.6 and 64 ±â€Š0.7 mm, respectively (Z-score 1.6 and -3.7). Mean frontal width at postoperative scan for endoscopic and open patients was 80 ±â€Š0.4 and 81 ±â€Š0.7 mm (Z-score 0.0 for both groups). Frontal width for endoscopic correction significantly correlated with IFA (r = 0.536, P = 0.005), as well as for the open patients (r = 0.704, P < 0.001). CONCLUSION: Frontal width normalizes 1 year after operation, regardless of technique. Advantage of frontal width is that it can be measured in the clinic using a spreading vernier caliper. It correlates well with IFA and can be used as a metric for morphologic outcome.

Single Z-Plasty Versus Double-Opposing Z-Plasty: A Cadaveric Study of Palatal Lengthening.

OBJECTIVE: The double-opposing Z-plasty is an effective method of repairing the cleft palate due to its reorientation of the palatal musculature and lengthening of the soft palate. A technique for lengthening the palate with a single oral Z-plasty has also been described. The authors hypothesize that these 2 techniques have equivalent effects on palate length. METHODS: A cadaver study was performed. Ten fresh adult cadaver heads were used.All palates were divided in the midline. In 5 specimens, a modified double-opposing Z-plasty technique was used; 5 other specimens underwent an oral Z-plasty with a straight-line repair of the nasal mucosa. In both groups, the levator veli palatini muscles were separately dissected and reapproximated with an intravelar veloplasty. The velar length, defined in this study as the distance from the posterior nasal spine to the tip of uvula, was measured before and after the surgical procedure. RESULTS: The double-opposing Z-plasty produced a mean increase of 1.0 ±â€Š0.6 cm in velar length (P = 0.023). The single Z-plasty repair resulted in a mean gain of 1.1 ±â€Š0.3 cm (P = 0.001). There was no difference in change in palate length between the 2 procedures (P = 0.941), and no difference in the percentage of soft palate lengthening (24% vs 29%, respectively; P = 0.565). CONCLUSIONS: A single oral Z -plasty provides palatal lengthening equivalent to that of a double-opposing Z-plasty procedure.

Comparison of Resorbable Plating Systems: Complications During Degradation.

INTRODUCTION: Several bioresorbable plating systems have become standard in pediatric craniosynostosis reconstruction. A comparison of these systems is needed to aid surgeons in the preoperative planning process. The authors aim to evaluate 1 institution's experience using Resorb-X by KLS Martin and Delta Resorbable Fixation System by Stryker (Stryker Craniomaxillofacial, Kalamazoo, MI). METHODS: A sample of patients with single-suture nonsyndromic craniosynostosis treated at St Louis Children's Hospital between 2007 and 2014 using either Resorb-X or Delta bioresorbable plating systems were reviewed. Only patients with preoperative, immediate, and long-term 3-dimensional photographic images or computed tomography scans were included. A comparison of plating system outcomes was performed to determine the need for clinic and emergency room visits, imaging obtained, and incidence of subsequent surgical procedures due to complications. RESULTS: Forty-six patients (24 Resorb-X and 22 Delta) underwent open repair with bioabsorbable plating for single suture craniosynostosis. The mean age at each imaging time point was similar between the 2 plating systems (P > 0.717). Deformity-specific measures for sagittal (cranial index), metopic (interfrontotemporale), and unicoronal (frontal asymmetry) synostosis were equivalent between the systems at all time points (0.05 < P < 0.904). A single Delta patient developed bilateral scalp cellulitis and abscesses and subsequently required operative intervention and antibiotics. CONCLUSION: Bioabsorbable plating for craniosynostosis in children is effective and has low morbidity. In our experience, the authors did not find a difference between the outcomes and safety profiles between Resorb-X and Delta.

Adult Quality of Life Post Cleft Palate Repair: A Comparison of Two Techniques.

BACKGROUND AND PURPOSE: In 1989, the Cleft Palate-Craniofacial Journal published the first randomized prospective cleft surgery study, comparing the Kriens intravelar veloplasty (IVV) with a non-IVV 2-flap repair. Results in that and follow-up publications yielded no difference between the 2 groups for need for secondary velopharyngeal management. The subjects have now reached adulthood. This study was designed to ask: Is there any difference between the groups in the outcomes that multidisciplinary team care addresses: speech intelligibility, facial growth, breathing while awake and asleep, attainment of education, and long-term socioeconomic status? METHODS: Enrollees from the original published study were invited to participate in a survey. Subjects responded to questions about speech therapy and speech satisfaction, additional surgery, breathing patterns, sleep quality/sleep disorder, and dental occlusion. Demographic information, information on education level, profession, and socio-economic status were queried. Student t test and Fisher exact test were used to compare results. RESULTS: Forty-two of the original 200 patients (20 Kriens IVV and 19 non-IVV) chose to participate. Average age at survey was 25 ±â€Š3 years. Analysis yielded no difference between the 2 respondent groups for need for secondary velopharyngeal management. There were no differences in speech outcome and satisfaction (8 questions, 0.30 < P < 0.97), sleep concerns (3 questions, 0.16 < P < 0.39), and dental occlusion (P = 0.69). Equivalent proportions of the 2 groups had been in speech therapy (P = 0.22). There was no difference in education attainment of the 2 groups (P = 0.26). CONCLUSIONS: The original randomized prospective trial suggested that there was no difference between the 2 surgery types in need for secondary velopharyngeal management. This long-term survey study on the same group of patients suggests that in young adulthood, the 2 groups have similar outcomes in terms of education, career choice, speech satisfaction, dental occlusion, and sleep disorder.

An Alternative Method of Intermaxillary Fixation for Simple Pediatric Mandible Fractures.

PURPOSE: Mandibular fractures represent a substantial portion of facial fractures in the pediatric population. Pediatric mandibles differ from their adult counterparts in the presence of mixed dentition. Avoidance of injury to developing tooth follicles is critical. Simple mandibular fractures can be treated with intermaxillary fixation (IMF) using arch bars or bone screws. This report describes an alternative to these methods using silk sutures and an algorithm to assist in treating simple mandibular fractures in the pediatric population. PATIENTS AND METHODS: A retrospective chart review was performed and the records of 1 surgeon were examined. Pediatric patients who underwent treatment for a mandibular fracture in the operating room from 2011 to 2015 were identified using Common Procedural Terminology codes. Data collected included age, gender, type of fracture, type of treatment used, duration of fixation, and presence of complications. RESULTS: Five patients with a mean age of 6.8 years at presentation were identified. Fracture types were unilateral fractures of the condylar neck (n = 3), bilateral fractures of the condylar head (n = 1), and a unilateral fracture of the condylar head with an associated parasymphyseal fracture (n = 1). IMF was performed in 4 patients using silk sutures, and bone screw fixation was performed in the other patient. No post-treatment complications or malocclusion were reported. Average duration of IMF was 18.5 days. CONCLUSIONS: An algorithm is presented to assist in the treatment of pediatric mandibular fractures. Silk suture fixation is a viable and safe alternative to arch bars or bone screws for routine mandibular fractures.

Evidence for Use of Frontozygomaticus and Contralateral Eurion as Hand-Caliper Landmarks for Assessment of Deformational Plagiocephaly.

The severity of deformational plagiocephaly is frequently measured by cranial vault asymmetry (CVA). Cranial vault asymmetry is a simple linear proxy for the three-dimensional deformity. Different anthropometric landmarks have been suggested as the endpoints of the cross-cranial diagonals that determine CVA. One promising albeit counterintuitive set of digital landmarks is the frontozygomaticus and contralateral eurion. The validity of nondigital caliper measures associated with the diagonals defined by the frontozygomaticus and contralateral eurions has not been tested. In this study, the authors compare caliper measures against stereophotogrammetric measures that have been documented to correlate strongly with overall skull asymmetry.Cranial vault asymmetry was assessed by direct anthropometry with 2 different measures on 36 patients. Frontozygomaticus and contralateral eurion (fz-eu) and 30 degrees off the anteroposterior diameter (30offAP). Three-dimensional photographs were obtained and also used to quantify CVA in these subjects; digital measures of fz-eu and an overall measure of plagiocephaly (Global) were calculated. Global and 30offAP obtained at 31 patient visits in 2011 were also included.The measure best-correlated with overall Global asymmetry was digital fz-eu (R = 0.80). Caliper fz-eu was not strongly correlated with Global asymmetry (R = 0.27) or with digital fz-eu (R = 0.34). Differences between the digital and caliper fz-eu measures were 5 ±â€Š4 mm (mean ±â€Šst. dev.). Differences between the caliper fz-eu and 30offAP measures were 6 ±â€Š4 mm.Digital fz-eu shows an excellent correlation to Global asymmetry. However, attempts to replicate this result in the clinical setting by measuring fz-eu with calipers were unsuccessful.

Natural history of preoperative subcentimeter pulmonary nodules in patients with resectable pancreatic adenocarcinoma: a retrospective cohort study.

OBJECTIVE: To determine the detection rate, radiologic characteristics, and natural history of incidental subcentimeter pulmonary nodules (SCPN) among patients with resectable pancreatic adenocarcinoma and to clarify whether further preoperative evaluation should be considered. BACKGROUND: The clinical significance of SCPN detected by routine preoperative abdominal imaging in patients with pancreatic adenocarcinoma is unknown. METHODS: Patients who underwent resection for pancreatic adenocarcinoma between 2000 and 2010 were queried from a prospectively maintained database at a single institution. Pre- and postoperative computed tomographic (CT) imaging was independently reviewed and the presence and radiologic features of SCPNs were analyzed for associations with overall survival (OS). RESULTS: Of the 463 patients who met inclusion criteria, 329 (71%) had reviewable preoperative imaging. Preoperative SCPNs were described in 59 patients (18%), and 41 patients had follow-up imaging available for review. Only increasing age (67.1 vs 63.5 years; P = 0.005) was associated with the presence of SCPN. Six patients (1.8%) had new or enlarging nodules after surgery, of whom 5 (1.5%) had confirmed metastatic adenocarcinoma. There was no difference in OS between patients with or without preoperative SCPN (16.1 vs 19.1 months; P = 0.201). No radiographic criterion of SCPN (including number, size, laterality, calcification, or contour) was associated with OS. CONCLUSIONS: Neither the presence of preoperative SCPN nor nodule characteristics was associated with OS among patients who underwent pancreaticoduodenectomy (PD) for pancreatic cancer. These data do not support routine additional workup of preoperative SCPN in patients with resectable pancreatic adenocarcinoma.

Comparison of Direct and Digital Measures of Cranial Vault Asymmetry for Assessment of Plagiocephaly.

Measurement of cranial vault asymmetry (CVA) is a common feature in the treatment of patients with deformational plagiocephaly (DP). In many cases, this measure is the primary marker of improvement. CVA is typically measured with calipers and is subject to interrater variability. There is little research comparing results of calipers with those of three-dimensional (3D) photogrammetry.Fifty nine visits were made by 51 children previously diagnosed with DP. Thirty eight were male and 13 were female. Thirty one of the visits included a 3D photograph. Direct measures were obtained by 2 experienced anthropometrists and included head length, width, circumference, and CVA. Their results were compared to digital measures including measures unobtainable with calipers, asymmetry of head circumference and global asymmetry.The interrater reliability of all caliper measures was excellent (intraclass correlation coefficients > 0.94). Caliper and digital measures of length, width, cephalic index, and circumference were strongly correlated (R > 0.90). There was a consistent bias, caliper measures being 1 to 4 mm shorter than their digital analogues. Caliper measured CVA was highly correlated (R > 0.90) with the directly corresponding digital measures. It was poorly correlated with measures of overall hemispheric asymmetry (R < 0.10).The cranial measurements of children with DP taken independently by 2 experienced anthropometrists showed excellent interrater reliability. Caliper measures are consistently smaller than the digital measures, presumably due to pressure of the calipers and/or the use of skullcaps during photography. Like circumference and other assessments, cranial vault asymmetry measures correlate well with their analogous digital measurements.

Are endoscopic and open treatments of metopic synostosis equivalent in treating trigonocephaly and hypotelorism?

BACKGROUND: Patients with metopic craniosynostosis are traditionally treated with fronto-orbital advancement to correct hypotelorism and trigonocephaly. Alternatively, endoscopic-assisted treatment comprises narrow ostectomy of the fused suture followed by postoperative helmet therapy. Here we compare the preoperative and 1-year postoperative results in open versus endoscopic repairs. METHODS: We reviewed preoperative and 1-year postoperative three-dimensional reconstructed computed tomography scans of patients treated for nonsyndromic metopic craniosynostosis by either open (n = 15) or endoscopic (n = 13) technique. Hypotelorism was assessed by interzygomaticofrontal distance and intercanthal distance. Trigonocephaly was assessed by 2 independent angles: first, an axial-plane two-dimensional angle between zygomaticofrontal suture bilaterally and the glabella (ZF(R)-G-ZF(L)); second, an interfrontal angle (IFA) between the most anterior point from a reconstructed midsagittal plane and supraorbital notch bilaterally. Age-matched scans of unaffected patients (n = 28) served as controls for each postoperative scan. RESULTS: Patients with open repair (9.5 ± 1.8 months) were older at time of surgery than patients with endoscopic repairs (3.3 ± 0.4 months) (P = 0.004). Male-to-female ratios were equivalent at roughly 7:3 in both groups. Preoperatively, the endoscopic group had worse hypotelorism and ZF(R)-G-ZF(L) than the open group (P ≤ 0.04). After accounting for preoperative differences, all of the postoperative measurements (ie, interzygomaticofrontal distance, intercanthal distance, ZF(R)-G-ZF(L) angle, IFA) of the 2 groups were statistically equivalent (P ≥ 0.135). Trigonocephaly was significantly improved after repair in both the open (8 degrees [ZF(R)-G-ZF(L)] and 18 degrees [IFA]) and endoscopic (13 degrees [ZF(R)-G-ZF(L)] and 16 degrees [IFA]) groups (P < 0.001). Postoperative measures in both groups were equivalent to controls (0.12 < P < 0.89). Intrarater reliability ranged from 0.93 to 0.99 for all measurements. CONCLUSION: Our retrospective series shows that endoscopic and open repairs of metopic craniosynostosis are equivalent in improving hypotelorism and trigonocephaly at 1-year follow-up. Additional studies are necessary to better define minor differences in morphology, which may result from the different techniques.

Endoscopic-assisted treatment of sagittal craniosynostosis and calcified cephalohematoma.

Craniosynostosis and its associated abnormalities can pose unique challenges to surgeons caring for these patients. Cephalohematomas, although rare, add to the complexities of managing a patient with craniosynostosis. Here, we present the case of a 4-month-old male infant with concurrent sagittal craniosynostosis and a calcified cephalohematoma who underwent an endoscopic-assisted strip craniectomy and management of the hematoma with good results.

Calvarial thickness and diploic space development in children with sagittal synostosis as assessed by computed tomography.

Following surgical management of craniosynostosis, residual calvarial defects may require reconstruction, frequently with the use of cranial bone grafts. Knowledge of optimal sites for harvest would be beneficial in such situations. The goal of this study is to compare calvarial thickness (CALV) and diploic thickness (DIPL) in children with corrected sagittal synostosis to normal controls (n = 47) using postoperative CT scans. We also compare the results from children who had undergone open (OPEN) (n = 26) and endoscopic (ENDO) (n = 26) surgery. On each skull, CALV and DIPL were measured at 44 points over 5 regions. Multiple regression analysis was used to compare CALV and DIPL controlling for gender and age. Children who had undergone previous craniosynostosis correction tended to have thinner CALV compared to controls in operated regions but thicker CALV in unoperated regions (P < 0.001). Adjusted mean CALV was thinner overall in ENDO compared to OPEN (P = 0.020). Children with corrected sagittal synostosis have thinner DIPL than controls (P = 0.002). No difference was found in DIPL comparing OPEN and ENDO (P = 0.977) approaches. Children who had undergone previous craniosynostosis correction tended to have thinner CALV when compared to controls in operated regions but thicker CALV in unoperated regions. ENDO calvaria were thinner than OPEN calvaria. Children with corrected sagittal synostosis have thinner DIPL than controls; no difference was found in DIPL comparing OPEN and ENDO approaches. Due to irregularities in bone development among children who had previously undergone calvarial reconstruction, individualized preoperative CT assessment is recommended in all patients undergoing secondary split calvarial bone grafting procedures.

Algorithm for Management of Mandibular Condylar Base Fractures.

BACKGROUND: Increasing evidence suggests that open reduction and internal fixation of condylar base fractures in adults results in improved outcomes in regard to interincisal opening, jaw movement, pain, and malocclusion. However, most of the condylar fractures are managed by maxillomandibular fixation alone due to the need for specialized training and equipment. Our aim was to present an algorithm for condylar base fractures to simplify surgical management. METHODS: A retrospective review was performed of patients (n = 22) with condylar base fractures treated from 2016 to 2020. Patients who presented with operative fractures that require open treatment underwent 1 of 2 different techniques depending on the fracture type: a preauricular approach with a transoral approach if the condyle was dislocated (n = 2) or a transoral only approach (n = 20) in nondislocated cases. Operative time, occlusion, range of motion, and postoperative complications were assessed. RESULTS: Condylar base fractures were combined with other mandibular fractures in 16 of 22 patients. Patients with condylar dislocation were managed with a preauricular approach with a secondary transoral incision (n = 2, median 147 minutes). Those without dislocation were treated with a transoral approach (n = 20, median 159 minutes). Most patients were restored to their preoperative occlusion without long-term complications. CONCLUSIONS: We present a simplified algorithm for treating condylar base fractures. Our case series suggests that reduction in operative time and clinical success can be achieved with open reduction and internal fixation using a transoral approach alone or in combination with a preauricular approach for dislocated fractures.