Nasolabial Appearance in 5-Year-Old Patients with Repaired Complete Unilateral Cleft Lip and Palate: A Comparison of Two Different Techniques of Lip Repair.

Different surgical techniques are available to adequately correct the primary cleft lip deformity; however, when compared, none of these techniques have proven superior with regard to achieving optimal aesthetic results. Thus, the aim of this retrospective study was to assess the nasolabial appearance in patients with unilateral cleft lip and palate (UCLP) at age five with reference to two techniques for primary cleft lip repair used in our service: Pfeifer's wave-line procedure and Randall's technique. A modified Asher-McDade Aesthetic Index was applied to appraise the nasolabial area by means of 2D photographs of non-syndromic five-year-old patients with a UCLP. In this context, three parameters were assessed: 1. nasal frontal view; 2. shape of the vermilion border and philtrum length; and 3. the nasolabial profile. Five professionals experienced in cleft care were asked to rate the photographs on two occasions. Overall, 53 patients were included in the final analysis, 28 of whom underwent lip repair according to Pfeifer; 25 were treated employing Randall's technique. Statistically significant differences between the two techniques regarding philtrum length and vermilion border were found (p = 0.046). With reference to the other parameters assessed, no significant differences were determined. The results suggest that Randall's cleft lip repair may allow for more accurate alignment of the vermilion border and more adequate correction of the cleft lip length discrepancy in comparison to Pfeifer's wave-line technique.

Gender-specific differences in haemostatic parameters and their influence on blood loss in bimaxillary surgery.

OBJECTIVE: The objectives of this prospective cohort study were to establish gender-related differences in blood loss and haemostatic profiles associated with bimaxillary surgery. In addition, we aimed to identify if any gender differences could be established which might help predict blood loss volume. MATERIALS AND METHODS: Fifty-four patients (22 males; 32 females) undergoing bimaxillary surgery for skeletal dentofacial deformities were eligible for inclusion. Blood samples were taken 1 day preoperatively and 48 h postoperatively for detailed gender-specific coagulation analysis incorporating global coagulation assays (endogenous thrombin potential) and specific coagulation parameters. Blood loss was measured at two different time points: (1) the end of surgery, visible intraoperative blood loss (IOB) using 'subtraction method'; and (2) 48 h postoperatively perioperative bleeding volume (CBL-48 h) using 'haemoglobin-balance method' and Nadler's formula. Correlation and regression analyses were performed to identify relevant parameters affecting the amount of blood loss. RESULTS: Significant differences in IOB and CBL-48 h were observed (p < 0.001). Men had higher IOB versus women, lacking statistical significance (p = 0.056). In contrast, men had significantly higher CLB-48 h (p = 0.019). Reduced CBL-48 h was shown to be most closely associated with the level of Antithrombin-III being decreased in females. CONCLUSIONS: Male gender is associated with higher IOB and CBL-48 compared with females. Gender does not affect IOB regarding haemostatic profile but does correlate strongly with procedure length. Conversely, CBL-48 is closely associated with gender-specific imbalances in the anticoagulant system. CLINICAL RELEVANCE: Knowledge of gender-related differences will help clinicians establish predictive factors regarding excessive blood loss in orthognathic surgery and identify at-risk patients.

Effects of Pre-Operative Risk Factors on Intensive Care Unit Length of Stay (ICU-LOS) in Major Oral and Maxillofacial Cancer Surgery.

OBJECTIVE: This study aimed to investigate the effect of certain pre-operative parameters directly on the post-operative intensive care unit (ICU)-length of stay (LOS), in order to identify at-risk patients that are expected to need prolonged intensive care management post-operatively. MATERIAL AND METHODS: Retrospectively, patients managed in an ICU after undergoing major oral and maxillofacial surgery were analyzed. Inclusion criteria entailed: age 18-90 years, major primary oral cancer surgery including tumor resection, neck dissection and microvascular free flap reconstruction, minimum operation time of 8 h. Exclusion criteria were: benign/borderline tumors, primary radiation, other defect reconstruction than microvascular, treatment at other centers. Separate parameters used within the clinical routine were set in correlation with ICU-LOS, by applying single testing calculations (t-tests, variance analysis, correlation coefficients, effect sizes) and a valid univariate linear regression model. The primary outcome of interest was ICU-LOS. RESULTS: This study included a homogenous cohort of 122 patients. Mean surgery time was 11.4 (±2.2) h, mean ICU-LOS was 3.6 (±2.6) days. Patients with pre-operative renal dysfunction (p < 0.001), peripheral vascular disease-PVD (p = 0.01), increasing heart failure-NYHA stage categories (p = 0.009) and higher-grade categories of post-operative complications (p = 0.023) were identified as at-risk patients for a significantly prolonged post-operative ICU-LOS. CONCLUSIONS: At-risk patients are prone to need a significantly longer ICU-LOS than others. These patients are those with pre-operative severe renal dysfunction, PVD and/or high NYHA stage categories. Confounding parameters that contribute to a prolonged ICU-LOS in combination with other variables were identified as higher age, prolonged operative time, chronic obstructive pulmonary disease, and intra-operatively transfused blood.

Is there a hidden blood loss in orthognathic surgery and should it be considered? Results of a prospective cohort study.

The aim of this prospective observational study was to investigate the parameter 'hidden blood loss' (HBL) in the context of orthognathic surgery, incorporating undetected bleeding volumes occurring intra- and postoperatively. Orthognathic bleeding volumes were recorded at three different time points. At the end of the operation the visible intraoperative blood loss (VBL) was measured. Additionally, the perioperative blood loss was calculated 24 h and 48 h postoperatively using the 'haemoglobin balance method'. Analysis of the HBL was based on the difference between the visible intraoperative blood loss (VBL) and calculated blood loss (CBL), determined 48 h after surgery. 82 patients (male 33, female 49) were included in this study, of whom 41 underwent bimaxillary surgery and of whom 41 underwent Bilateral Sagittal Split Osteotomy (BSSO). Statistically significant differences with reference to the absolute bleeding volumes were found when comparing the two treatment modalities. In terms of HBL, a bleeding volume of 287.2 ml (±265.9) in the bimaxillary group and 346.9 ml (±271.3) in the BSSO cohort was recorded. This accounted for 32.2% (bimaxillary surgery) and 62.6% (BSSO) of the CBL after 48 h (BIMAX vs. BSSO, p < 0.001). HBL is a valuable adjunct to record within the perioperative management of orthognathic surgery to further improve patient safety and postoperative outcomes.

Robin Sequence: 5-Year Speech Outcomes-A Case-Control Study.

BACKGROUND: Pierre Robin sequence (Robin sequence) is defined as the triad of micrognathia, glossoptosis, and airway obstruction. It is frequently associated with palatal clefting. In recent years, increased interest in speech outcomes of cleft patients diagnosed with Robin sequence has been shown. METHODS: Speech outcomes of cleft patients with Robin sequence were assessed at age 5 in comparison with a cleft palate-only cohort. Speech parameters were evaluated according to the Cleft Audit Protocol for Speech-Augmented and analyzed using the National Audit Standards for Speech (United Kingdom). All patients were treated in the same institution during the same period (2005 to 2012). Subjects who needed nasopharyngeal airway support and those whose airway was managed by positioning only were eligible. RESULTS: Fifty-one cleft patients diagnosed with Robin sequence were included in this study. Outcomes were compared to those of 128 nonsyndromic cleft palate-only patients.Patients with Robin sequence were shown to present with a significantly higher rate of cleft speech characteristics in comparison to the reference cohort (p = 0.001). Furthermore, it was shown that Robin sequence is associated with a significantly higher rate of secondary speech surgery for velopharyngeal dysfunction before the age of 5 (p = 0.016). Robin sequence patients with a nasopharyngeal airway presented with a higher rate of cleft speech characteristics compared to Robin sequence patients managed with positioning only. CONCLUSION: Cleft patients with Robin sequence are more likely to need further surgery to correct velopharyngeal dysfunction before the age of 5 and are more prone to present with cleft speech characteristics at the age of 5. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, II.

Ensuring Sustainability for UK Burns Services: Workforce Planning for Burns Consultants.

INTRODUCTION: Workforce planning is an essential component of organizing any health service. Centralization of burns services pools expertise, although trainees can struggle to achieve adequate exposure to burns training. We aim to review current staffing levels and predict the future consultant numbers required for UK services to remain staffed with appropriately trained surgeons. METHODS: We have compiled a database of all UK burns consultants. Basic demographic data, such as age and sex, were collated. Projected UK population data have been used to estimate whether the number of patients under the care of the UK burns network will change in the coming years. Access to burns fellowship training has also been factored in. RESULTS: There are 34 burns facilities in the United Kingdom and 86 burns consultants. On average, these consultants are 13 years from retirement age. 22 will reach this age within the next decade. During this time, the UK population is expected to increase by 10%, translating to approximately another 6 consultant posts. Since there are only 2 UK recognized burns fellowships, many of the required consultants will have to seek training abroad. CONCLUSIONS: Workforce planning is essential to avoid a short fall in the number of upcoming burns consultants. Plans must be in place to anticipate additional workload with a 10% population rise. With the current struggles of NHS funding, a comprehensive review of burns workforce planning should be undertaken to ensure that sufficient numbers of trainees are completing appropriate burns-specific training and are ready to fill these posts.

The Evidence for Adjunctive Facelift Procedures.

Facelift surgery is a popular treatment but exhibits high variation among practitioners in terms of both core technique and adjunctive measures. This review identified significant evidence addressing the role of pre-infiltration, drains, fat grafting, fibrin tissue adhesives, hilotherapy, and other miscellaneous adjuncts. Based on the authors' assessment of the current literature, there is reasonable supportive evidence for pre-infiltration, fat grafting and laser skin resurfacing, which appear to be safe and effective in appropriately selected patients. Drain use is not mandatory but may confer some benefit. Conversely the evidence for the use of fibrin tissue adhesives and hilotherapy is not compelling.

Time to start putting down the knife: A systematic review of burns excision tools of randomised and non-randomised trials.

AIMS: Dermal preservation during acute burn excision is key to obtaining superior healing/scar outcomes, however, determining the most appropriate excision tool is an ongoing challenge. Novel tool development means the knife is no longer our only option, yet for the majority it remains the gold standard. This systematic review aims to evaluate evidence for burns excision approaches (knife/hydrosurgery/enzymatic). METHODS: CENTRAL, EMBASE, MEDLINE (1946-2017) were searched with MeSH terms: 'debridement', 'burns', 'sharp', 'enzymatic', 'hydrosurgery'. Relevant randomised control trials (RCTs)/non-randomised controlled case series/trials were extracted/analysed. In vitro/burn non-specific studies were excluded. Main methodological parameters were intervention/excision efficacy. RESULTS: Eighteen articles met inclusion criteria (n=7148): three were RCTs, involving comparator enzymatic (NexoBrid™ (EDNX)) or hydrosurgical (Versajet™) excision to surgical Standard of Care. Both showed statistically significant decreased need for excisional excision and auto-grafting by viable tissue preservation allowing spontaneous healing by epithelialisation. CONCLUSION: Level 1 Evidence comparing excision modalities for acute burns is sparse. Although early excision with a knife is still often considered best practice, there is no tool choice consensus or robust comparison with alternate, possibly superior, tools. EDNX or Versajet™ should be considered alternatively. Further RCTs are indicated, with regards final scar outcomes and to allow consensus within current evidence.

The CelluTome epidermal graft-harvesting system: a patient-reported outcome measure and cost evaluation study.

Conventional split skin grafts (SSG) require anaesthesia, specialist equipment and can have high donor site (DS) morbidity. The CelluTome epidermal graft-harvesting device is a novel alternative, providing pain-free epidermal skin grafts (ESG) in the outpatient setting, with projected minimal DS trauma and improved patient satisfaction. This study aimed to compare ESG with SSG by evaluating patient-related outcome measures (PROMs) and the cost implications of both. Twenty patients answered a graft satisfaction questionnaire that evaluated: donor/graft site noticeability, aesthetic concerns, adverse problems and patient satisfaction. Cost/patient was calculated based on total operative expenses and five clinic follow-ups. In 100% of the ESG cases, there were no DS noticeability or adverse problems compared to 25% in the SSG group. Complete satisfaction with DS appearance was observed in 100% of the ESG cases (50% SSG). Noticeability, adverse problems and overall satisfaction were significantly better in ESG cases (P < 0.05). Graft site parameters were comparable with similar healing outcomes. The cost per patient for ESG was £431 and £1489 for SSG, with an annual saving of £126 960 based on 10 grafts/month. For the right patient, CelluTome provides comparable wound healing, with reduced DS morbidity and higher patient satisfaction.

Complete Resolution of Wegener's Granulomatosis Lung Granuloma After Aortic Root Replacement.

Wegner's granulomatosis (WG) is an autoimmune systemic vasculitis that results in necrotizing granulomas. We report a WG patient with a lung granuloma and aortic root dilatation, who underwent aortic root replacement on cardiopulmonary bypass (CPB). Intraoperatively, the patient suffered an aortic dissection, which was repaired immediately under deep hypothermic circulatory arrest (DHCA). Follow-up imaging showed complete granuloma resolution, despite absence of immunosuppressive therapy. Immune stimulation following CPB is well described; here, the opposite was observed and DHCA effects are discussed.

Hair Today; Scalped Tomorrow: Massive Subgaleal Haematoma Following Sudden Hair Pulling in an Adolescent in the Absence of Haematological Abnormality or Skull Fracture.

Subgaleal haematoma (SH) is a rare condition, most frequently observed in neonates as a complication of Ventouse-assisted delivery. There have been few patients reported beyond this period. Those that are present within the literature have typically resulted from significant blunt scalp trauma, with or without associated skull fracture. Those resulting secondary to relatively minor trauma, such as hair braiding or hair pulling, are rare but have been reported and are often associated with underlying haematological abnormalities or nonaccidental injury patients. Most patients resolve spontaneously and without complication. The authors report a rare patient of a delayed presentation of a massive SH in an adolescent following a seemingly innocuous episode of hair pulling whilst play-fighting, in the absence of any underlying haematological or anatomical abnormality. Due to the size of the SH and the appearance of large areas of calcification within the haematoma, early liaison with senior neuroradiologists and haematologists, to rule out underlying anatomical and haematological abnormalities, respectively, was essential to guide appropriate management. Our patient highlights the need for an awareness of the possible aetiologies of SH and the necessity of early active multidisciplinary team involvement in the management of such patients, which is critical to ensure optimum patient outcomes.