Epidemiologic Assessment of Craniosynostosis in Mississippi's Pediatric Population from 2015 to 2020.

OBJECTIVES: This study aimed to report geographic and demographic patterns of patients with craniosynostosis (CS) treated at Children's of Mississippi, the state's only American Cleft Palate-Craniofacial Association-approved craniofacial team. METHODS: Patients with CS were treated at a tertiary pediatric hospital cared for by craniofacial surgeons and neurosurgeons from 2015 to 2020. Demographic, geographic, and CS diagnosis details, including sex, gestational age, race, ethnicity, insurance status, and affected cranial suture type(s), number, and associated syndromic diagnosis were collected, including birth county and total live births from state data. Significant differences between prevalence of CS in four regions of Mississippi were examined using two-tailed t tests (P < 0.05). RESULTS: Among 222,819 live births in Mississippi between 2015 and 2020, 79 pediatric patients presented to Children's of Mississippi with CS, with an overall incidence of 0.355/1000 live births. Most cases were nonsyndromic CS (82%, n = 65) affecting a single major cranial suture (81%, n = 64). The overall incidence of CS was higher in the coastal and central regions compared with northeast Mississippi, at 0.333 and 0.527 vs 0.132/1000 live births (P = 0.012 and P = 0.004), respectively. CONCLUSIONS: Results from this study suggest regional patterns of CS in Mississippi, which may reflect actual incidence patterns or proximity to Children's of Mississippi. Further study could reveal regional differences in risk factors underlying CS incidence or access to specialized CS care for different regions in the state. This will lead to opportunities for institutional outreach to decrease the burden of CS care in Mississippi.

Epidemiologic Trends of Cleft Lip and Palate in a Southern State: A 30-Year Follow-Up.

OBJECTIVES: Children's of Mississippi at the University of Mississippi Medical Center serves as the state's only American Cleft Palate-Craniofacial Association-approved cleft team at the only pediatric hospital in the state. The goal of this study is to report geographic and demographic patterns of patients with orofacial cleft (OFC) treated at Children's of Mississippi, which are lacking. METHODS: Patients with OFC treated at Children's of Mississippi from 2015 to 2020 were included. Demographic data were collected, including birth county and total live births from state data. Significant differences between incidence of OFC among public health regions of Mississippi were examined using analysis of variance (P < 0.05). Cases were compared with historical data from 1980 to 1989. RESULTS: There were 184 patients who presented with OFC, with a statewide incidence of 0.83 per 1000 live births among 222,819 live births in the state across 6 years. The incidence of OFC was 0.83/1000 for Whites and 0.82/1000 for non-Whites versus a historical rate of 1.36 and 0.54, respectively. Significantly fewer children in the northern region (0.25/1000) were born with OFC than in central (1.21; P < 0.001) and southern (0.86; P < 0.001) regions. CONCLUSIONS: Results from this study suggest changing regional patterns of OFC in Mississippi. Although rates increased among non-White infants, the overall incidence of OFC has decreased compared with historical data. The findings may reflect actual incidence patterns in the state or the proximity of certain regions to Children's of Mississippi. Further study may reveal regional differences in risk factors underlying OFC incidence, and/or issues with access to cleft care for different regions in the state.

The Fisher Subunit Anatomical Approach for Cleft Lip Revisions: An Evolution and Case Series.

ABSTRACT: Many techniques exist to reapproximate a cleft lip but can leave unsatisfactory results with nonanatomic scars and a short upper lip, creating a need for revision. Many revisions focus on adjacent tissue transfers and realignment of landmarks, but in the senior authors' experience, recreating the defect and utilizing the Fisher repair for revision have led to aesthetically pleasing results and less noticeable scars. A database was collected that included all cleft lip revisions performed at a large, comprehensive children's hospital from October 2018 to July 2021. Inclusion criteria included any cleft patient with a cleft lip revision performed by two craniofacial surgeons. Data collected included sex, characteristics of the cleft lip, age at initial and index repair, type of initial repair, previous revisions, type of revision with any additional tissue rearrangement, and any nose repair. Sixty-five patients were included in the study for analysis. The type of initial repair was known in sixty-four cases (98%), and fifty-four were Millard repairs (83%). Twenty-two patients (33%) had a previous revision prior to their index revision. Sixty patients (92%) underwent the Fisher repair technique for their index revision and forty-six patients (70%) underwent nasal revision. In follow-up, all patients demonstrated an improvement in lip aesthetics. This study demonstrates a large subset of patients that have undergone cleft lip revision using the Fisher technique. In the senior surgeons' experience, the Fisher repair technique in the setting of cleft lip revision is an ideal way to address the shortcomings of historical repair techniques.

Plastic Surgery Outreach Clinics Expand Access to Cleft and Craniofacial Care in Mississippi.

ABSTRACT: Accessing treatment at ACPA (American Cleft Palate-Craniofacial Association)-approved centers is challenging for individuals in rural communities. This study aims to assess how pediatric plastic surgery outreach clinics impact access for patients with orofacial cleft and craniosynostosis in Mississippi. An isochrone map was used to determine mean travel times from Mississippi counties to the sole pediatric hospital and the only ACPA-approved team in the state. This analysis was done before and after the establishment of two outreach clinics to assess differences in travel times and cost of travel to specialized plastic surgery care. Two sample t-tests were used for analysis.The addition of outreach clinics in North and South Mississippi led to a significant reduction in mean travel times for patients with cleft and craniofacial diagnoses across the state's counties (1.81 hours vs 1.46 hours, P < 0.001). Noteworthy travel cost savings were observed after the introduction of outreach clinics when considering both the pandemic gas prices ($15.27 vs $9.80, P < 0.001) and post-pandemic prices ($36.52 vs $23.43, P < 0.001).The addition of outreach clinics in Mississippi has expanded access to specialized healthcare for patients with cleft and craniofacial differences resulting in reduced travel time and cost savings for these patients. Establishing specialty outreach clinics in other rural states across the United States may contribute significantly to reducing burden of care for patients with clefts and craniofacial differences. Future studies can further investigate whether the inclusion of outreach clinics improves follow-up rates and surgical outcomes for these patients.

Barriers to Remote Burn Care Delivery: An Analysis of Burn Center Proximity and Access to Critical Telehealth Infrastructure.

ABSTRACT: Mounting evidence supports the use of telehealth to improve burn care access and efficiency. However, barriers to telehealth use remain throughout the United States and may disproportionately affect specific populations, such as rural and non-English-speaking patients. This study analyzes the association between physical proximity to burn care and determinants of telehealth access.The relationship between telehealth-associated measures and proximity to burn care was analyzed with linear regression analysis. County-level data was sourced from the Agency for Healthcare Research and Quality's Social Determinants of Health Database (2020) and the American Community Survey (2021). County-level distances to the nearest American Burn Association (ABA)-verified burn center were calculated based on verified centers listed in the ABA burn center directory (n = 59). A subsequent analysis was performed on income-stratified datasets available for subset counties.Distance was negatively correlated with access to a smartphone (P < 0.0001), broadband internet (P < 0.0001), and cellular data plan (P < 0.0001) and positively correlated with the percent of households with no computing device (P < 0.0001) and no internet access (P < 0.0001). Analysis of income-stratified data revealed similar results. The percent population not speaking English well (P < 0.0001) at all (P = 0.0009) and the proportion of limited English-speaking households (P = 0.0001) decreased as a function of distance.People living furthest from an ABA-verified burn center in the United States are less likely to have adequate access to critical telehealth infrastructure compared to their counterparts living closer to a burn center. However, income impacts overall access and the degree to which access changes with proximity. Conversely, language-associated barriers decrease as distance increases.

Implementation of an Enhanced Recovery After Surgery Protocol for Cleft Palate Repair.

OBJECTIVE: This study examines an Enhanced Recovery After Surgery (ERAS) protocol for patients with cleft palate and hypothesizes that patients who followed the protocol would have decreased hospital length of stay and decreased narcotic usage than those who did not. DESIGN: Retrospective cohort study. SETTING: The study takes place at a single tertiary children's hospital. PATIENTS: All patients who underwent cleft palate repair during a 10-year period (n = 242). INTERVENTIONS: All patients underwent cleft palate repair with the most recent cohort following a new ERAS protocol. MAIN OUTCOME MEASURES: Primary outcomes included hospital length of stay and narcotic usage in the first 24 hours after surgery. RESULTS: Use of local bupivacaine during surgery was associated with decreased initial 24-hour morphine equivalent usage: 2.25 vs 3.38 mg morphine equivalent (MME) (P < 0.01), and a decreased hospital length of stay: 1.71 days vs 2.27 days (P < 0.01). The highest 24-hour morphine equivalent a patient consumed prior to the ERAS protocol implementation was 24.53 MME, compared with 6.3 MME after implementation. Utilization of the ERAS protocol was found to be associated with a decreased hospital length of stay: 1.67 vs 2.18 days (P < 0.01). CONCLUSIONS: Use of the proposed ERAS protocol may lead to lower narcotic usage and decreased length of stay.

Longitudinal Speech and Fistula Outcomes Following Primary Cleft Palate Repair at a Single Institution.

INTRODUCTION: Fistula formation and velopharyngeal insufficiency (VPI) are complications of cleft palate repair that often require surgical correction. The goal of the present study was to examine a single institution's experience with cleft palate repair with respect to fistula formation and need for surgery to correct velopharyngeal dysfunction. METHODS: Institutional review board approval was obtained. Patient demographics and operative details over a 10-year period were collected. Primary outcomes measured were development of fistula and need for surgery to correct VPI. Chi-square tests and independent t tests were utilized to determine significance (0.05). RESULTS: Following exclusion of patients without enough information for analysis, 242 patients were included in the study. Fistulas were reported in 21.5% of patients, and surgery to correct velopharyngeal dysfunction was needed in 10.7% of patients. Two-stage palate repair was associated with need for surgery to correct VPI (P = 0.014). Furlow palatoplasty was associated with decreased rate of fistula formation (P = 0.002) and decreased need for surgery to correct VPI (P = 0.014). CONCLUSION: This study reiterates much of the literature regarding differing cleft palate repair techniques. A 2-stage palate repair is often touted as having less growth restriction, but the present study suggests this may yield an increased need for surgery to correct VPI. Prior studies of Furlow palatoplasty have demonstrated an association with higher rates of fistula formation. The present study demonstrated a decreased rate of fistula formation with the Furlow technique, which may be due to the use of the Children's Hospital of Philadelphia modification. This study suggests clinically superior outcomes of the Furlow palatoplasty over other techniques.

Implementation of an Enhanced Recovery After Surgery Protocol for Cranial Vault Remodeling Procedures.

BACKGROUND: Enhanced recovery after surgery (ERAS) protocols have been implemented across surgical disciplines, including cranial vault remodeling for craniosynostosis. The authors aim to describe the implementation of an ERAS protocol for cranial vault remodeling procedures performed for patients with craniosynostosis at a tertiary care hospital. DESCRIPTION: Institutional review board approval was received. All patients undergoing a cranial remodeling procedure for craniosynostosis at the authors' institution over a 10-year period were collected (n = 168). Patient and craniosynostosis demographics were collected as well as operative details. Primary outcome measures were intensive care unit length of stay (ICU LOS) and narcotic usage. Chi squared and independent t-tests were employed to determine significance. A significance value of 0.05 was utilized. RESULTS: During the time examined, there were 168 primary cranial vault remodeling procedures performed at the authors' institution - all of which were included in the analysis. Use of the ERAS protocol was associated with decreased initial 24-hour morphine equivalent usage (p < 0.01) and decreased total morphine equivalent usage (p < 0.01). Patients using the ERAS protocol experienced a shorter ICU LOS (p < 0.01), but the total hospital length of stay was unchanged. CONCLUSION: This study reiterates the benefit of developing and implementing an ERAS protocol for patients undergoing cranial vault remodeling procedures. The protocol resulted in an overall decreased ICU LOS and a decrease in narcotic use. This has implications for ways to maximize hospital reimbursement for these procedures, as well as potentially improve outcomes.

Patients Requiring Multiple Surgeries for Velopharyngeal Insufficiency: Findings From a 10-Year Retrospective Review.

This study analyzed patients undergoing multiple surgeries for velopharyngeal insufficiency (VPI) and reviewed their preoperative evaluations and techniques selected for subsequent surgeries. A retrospective chart review was performed including patients having undergone multiple surgeries for VPI at the authors' institution between 2012 and 2022. All patients were evaluated and managed at the author's institution under the direction of 4 senior surgeons. The objective of this study was to provide insight into preoperative evaluation, surgical technique selection, and other factors that may contribute to patients who require multiple VPI surgeries. Of 71 patients having undergone surgery for VPI, 8 required at least 1 additional operation for persistent VPI following the initial intervention. Six patients who initially underwent a superiorly based posterior pharyngeal flap (PPF) required additional surgery, and for those patients' subsequent operations, 5 different techniques were used throughout their treatment. Of the remaining 2 patients who had multiple VPI surgeries, 1 initially received autologous fat transfer and 1 initially underwent a furlow palatoplasty. Finally, 0 patients that initially underwent buccal flaps or collagen injection required further unplanned surgical intervention. This study demonstrates the importance of selecting an appropriate surgical approach when operating on patients following a failed VPI surgery. The algorithm developed from these findings emphasizes the importance of properly identifying the anatomical deficiency resulting from the failed intervention. A review of the advantages of nasopharyngoscopy as a preoperative evaluative technique of velopharyngeal form and function when compared to lateral barium video fluoroscopy was also included.

Mandibular Distraction in Patients With Pierre Robin Sequence: A Multisurgeon Experience.

OBJECTIVE: Mandibular distraction osteogenesis (MDO) is rapidly becoming a standard of care for management of patients with severe Pierre Robin sequence. The tongue is brought forward to alleviate airway obstruction. This study will look at an institutional, multisurgeon experience with MDO over 10 years. DESIGN: A retrospective chart review was conducted. SETTING: All patients who underwent MDO at the authors' institution from 2012 to 2022 were included. Three craniofacial surgeons performed all interventions. PATIENTS: Demographics, preoperative and postoperative respiratory and feeding status, and distraction data were collected for 27 patients meeting inclusion criteria. MAIN OUTCOME MEASURES: Primary outcomes were avoidance of a gastrostomy tube, avoidance of a tracheostomy, discharge from hospital on room air, and complications. A significance value of 0.05 was utilized. RESULTS: The average age at MDO was 135 days, mean activation phase was 13.6 days, mean distraction length was 14.9 mm, and mean consolidation phase was 64.2 days. A longer activation phase was associated with discharge with a gastrostomy tube and a shorter activation phase was associated with discharge on full oral feeds. The ability to discharge on room air was associated with a shorter latency phase, shorter activation phase, and decreased distance of distraction. CONCLUSIONS: The goal of MDO is to achieve full oral feeds with no respiratory support. Several different latency periods were used in this study, and a short latency period was demonstrated to be safe.

Posterior Vault Distraction in the Acute Setting.

ABSTRACT: Posterior vault distraction osteogenesis (PVDO) has been shown to resolve acute intracranial hypertension (AIH) while carrying an acceptable perioperative morbidity profile. PVDO has been associated with symptomatic improvement and fewer surgeries in those requiring ventriculoperitoneal shunts. The authors' experience using PVDO as an acute intervention is presented, demonstrating its safety and efficacy for management of AIH. Four cases of children with craniosynostosis that underwent PVDO in the acute setting are outlined. All patients presented with papilledema and symptoms of AIH. One patient with slit ventricle syndrome (SVS) presented with a nonfunctioning shunt following multiple shunt revisions. No intraoperative complications during distractor placement or removal were reported. Distraction protocol for all patients began on postoperative day 1 at 1-2 mm per day, resulting in an average total distraction of 30.25 mm. For the 3 cases with no shunt, the average length of stay was 7 days. As part of the planned treatment course, the patient with SVS required externalization of the shunt during distraction followed by early distractor removal and planned shunt replacement. One case of surgical site infection (in an immunocompromised patient) required premature distractor removal during the consolidation period. Computed tomography (CT) in all patients indicated increased intracranial volume following distraction, and symptomatic improvement was reported. Six-month follow-up showed resolution of papilledema in all patients. The authors' experience using PVDO in the acute setting is reported, alongside a review of current literature, in order to provide supporting evidence for the efficacy of PVDO as a tool for resolving AIH.

"Travel Burden to ACPA Approved Cleft and Craniofacial Teams: A Geospatial Analysis".

BACKGROUND: Despite the existence of American Cleft Palate and Craniofacial Association (ACPA)-approved Cleft and Craniofacial Teams, access to multidisciplinary team-based care remains challenging for patients from rural areas, leading to disparities in care. We investigated the geospatial relationship between U.S. counties and ACPA-approved centers. METHODS: The geographic location of all ACPA-approved cleft and craniofacial centers in the U.S. was identified. Distance between individual U.S. counties (n=3,142) and their closest ACPA-approved team was determined. Counties were mapped based on distance to nearest cleft or craniofacial team. Distance calculations were combined with U.S Census data to model the number of children served by each team and economic characteristics of families served. These relationships were analyzed using independent t-tests and ANOVA. RESULTS: Over 40% of U.S. counties did not have access to an ACPA-approved craniofacial team within a 100-mile radius (n=1,267) versus 29% for cleft teams (n=909). Over 90% of counties greater than 100 miles to a craniofacial team had a population <7,500 (n=1,150). Of the counties >100 miles from a cleft team, 64% had a child poverty rate greater than national average (n=579). Counties with the highest birth rate and >100 miles to travel to an ACPA team are in the Mountain West. CONCLUSIONS: Given the time-sensitive nature of operative intervention and access to multidisciplinary care, the lack of equitable distribution in certified cleft and craniofacial teams is concerning. Centers may better serve families from distant areas by establishing satellite clinics, telehealth visits, and training local primary care providers in referral practices.

Access to Certified Burn Centers in the United States: The Geospatial and Transport Cost of Transfer.

Specialized burn centers are critical to minimizing burn-associated morbidity and mortality. However, American Burn Association-verified burn centers are unequally distributed across the United States, and fewer centers are available for pediatric patients relative to adults. The economic burden of transporting patients to these centers contributes significantly to the high cost of burn care. This study quantifies inequitable burn care access in the contiguous United States due to age group and location as a function of physical proximity to a verified burn center and transportation cost. County-level distances to the nearest verified adult or pediatric burn center were determined and mapped. Distance calculations for each population were combined with transport cost data (2022 CMS Ambulance Fee Schedules) to estimate transportation costs for each population (adult vs pediatric, urban vs rural). Pediatric patients reside 30.5 miles further than adults from the nearest center, significantly increasing transportation costs. Ground and air transport costs also increased for rural versus urban patients. Notably, rural patients face almost double the cost of air transport. While physical proximity to burn care appears to differ only modestly across age and region, this marginal increase in distance is associated with significant economic impact. This study highlights physical and economic barriers to burn care access faced by rural and pediatric patients and underscores the critical need to improve equity in burn care access. Future studies should expand on this report's findings to more fully characterize the additional costs associated with inequitable burn care access.

Subacute Ulnar Nerve Compression Neuropathy Following Hand Crush Injury in the Setting of Intracanal Accessory Abductor Digiti Minimi: A Double Crush Phenomenon.

Anatomical variations within Guyon's canal such as an accessory abductor digiti minimi are described as causes of ulnar nerve compression. Here we present a unique case of delayed ulnar neuropathy following treatment of left fourth metacarpal base fracture with percutaneous pinning fixation and an uncomplicated two month postoperative course. He returned with new ulnar sensory loss and motor weakness. EMG demonstrated nerve compression with CT identifying an accessory abductor digiti minimi in Guyon's canal. Following Guyon's canal release with partial accessory muscle resection, there was immediate sensory and progressive motor recovery with resolution of clawing. Delayed compression by an accessory abductor digiti minimi following trauma has not been described, suggestive of double-crush phenomenon. The accessory muscle was an asymptomatic variable (first "crush") and with the second "crush" of post-surgical changes resulting in pathological nerve compression. With delayed onset ulnar neuropathy after trauma, surgeons should consider possible accessory structures.

Squamosal Craniosynostosis Associated with Rickets.

Rickets results from defective bone mineralization, leading to skeletal deformities. Among those deformities, rickets has been associated with craniosynostosis, the premature closure of cranial sutures. Most of these patients have fusion of major sutures. Rarely, squamosal craniosynostosis in association with rickets has been described. Squamosal craniosynostosis is noted as lacking a definitive head abnormality and difficult visualization on standard imaging modalities, leading to poor recognition. Careful attention should be given to rickets patients to monitor for these unusual suture closures. Additionally, craniosynostosis could be a presenting feature of rickets, and further rickets evaluation of the patient is indicated.

A Review on Lumps, Bumps, and Birthmarks: When and Why to Refer.

Skin lesions of the face, trunk, and extremities are commonly seen in the pediatric population. Although most of these lesions are benign, they can be locally destructive or interfere with normal development. Recognition and diagnosis of these lesions allow for timely workup and referral; treatment, if needed; and facilitation of parental discussions. The purpose of this article is to review common pediatric skin and soft-tissue lesions-or "lumps, bumps, and birthmarks"-to assist with diagnosis, workup, and guidelines for referral to pediatric plastic surgery. [Pediatr Ann. 2023;52(1):e23-e30.].

Targeted muscle reinnervation: a brief history of a promising procedure for effective management of amputation pain.

Each year, 27.5% of the 150 000 people in the United States who require lower extremity amputation experience significant postoperative complications, including pain, infection, and need for reoperation. Postamputation pain, including RLP and PLP, is debilitating. While the causes of such pain remain unknown, neuroma formation following sensory nerve transection is believed to be a major contributor. Various techniques exist for management of a symptomatic neuroma, but few data exist on which technique is superior. Furthermore, there are few data on primary prevention of neuroma formation following injury or intentional transection. The TMR technique shows promise for both management of PLP and RLP and prevention of neuroma formation. Following amputation, transected sensory nerves are coapted to nearby motor nerve supplying remaining extremity musculature. Not only does this procedure generate increased myoelectric signals for improved prosthesis control, TMR appears to neurophysiologically alter sensory nerves, preventing formation of painful sensory neuromas. The sole RCT to date evaluating the efficacy of TMR showed statistically significant reduction in PLP. TMR is not limited to use in the setting of major limb amputation. It has also been used in the setting of post-mastectomy pain, abdominal wall neuromas, digital amputations, and headache surgeries. This article reviews the origin of TMR and provides a brief description of histologic changes following the procedure, as well as current data regarding the efficacy of TMR with regard to postoperative pain relief. It also seeks to provide a concise, comprehensive resource for providers to facilitate better discussions with patients about treatment options.

Utilization of the Labial Flap in Anterior Palatal Fistula Repair.

Background: Palatal fistulas are the most common postoperative complications in primary cleft palate surgery, with incidence rates ranging from 10% to 30%. Functional indications for repair include food regurgitating from the nose, food impaction resulting in malodor, and hypernasality with speech. Anterior palatal fistulas (APFs), in particular, present difficult reconstructive cases due to lack of available local tissue. Here, we describe a case series of 3 patients who underwent APF repair with a random pattern labial flap. Methods: The 3 patients included in this report underwent surgical repair of APF. The size of defects measured 2 × 1cm, 2.5 × 1.5cm, and 3 × 2cm. In each case, the labial flap was elevated on the free border of the superior lip mucosa and advanced through the alveolar cleft to cover the oral layer of the fistula. After 3 weeks, the proximal part of the pedicled flap was incised and inset to the alveolar ridge. Results: From 2020 through 2021, 2 lip flaps were successful in providing full coverage to the oral fistula. In one patient, a 3-year-old who did not cooperate with postoperative care, one of the flaps dehisced before division. Conclusions: APFs are common postoperative complications in patients with primary palate repairs and present difficult reconstructions due to lack of local tissue flaps. Here, we describe a 2-stage method in which a random pattern labial flap is used to provide oral fistula coverage. We recommend this procedure when multiple prior traditional attempts at closure have been unsuccessful and the patient can comply with postoperative care.

Management of pediatric sternal wounds following congenital heart surgery: The role of the plastic surgeon in debridement and closure.

BACKGROUND: Management of sternal wound infections (SWIs) in pediatric patients following congenital heart surgery can be extremely difficult. Patients with congenital cardiac conditions are at risk for complications such as sternal dehiscence, infection, and cardiopulmonary compromise. In this study, we report a single-institution experience with pediatric SWIs. METHODS: Fourteen pediatric patients requiring plastic surgery consultation for complex sternal wound closure were included. A retrospective chart review was performed with the following variables of interest: demographic data, congenital cardiac condition, respective surgical palliations, development of mediastinitis, causative organism, number of debridements, presence of sternal wires, and choice of flap coverage. Primary endpoints included achieved chest wall closure and overall survival. RESULTS: Of the 14 patients, 8 (57%) were diagnosed with culture-positive mediastinitis. The sternum remained wired at the time of final flap closure in eight (57%) patients. All patients were reconstructed with pectoralis major flaps, except one (7%) who also received an omental flap and two (14%) who received superior rectus abdominis flaps. One patient (7%) was treated definitively with negative pressure wound therapy, and one (7%) was too unstable for closure. Six patients developed complications, including one (7%) with persistent mediastinitis, two (14%) with hematoma formation, one (7%) with abscess, and one (7%) with skin necrosis requiring subsequent surgical debridement. There were three (21%) mortalities. CONCLUSIONS: The management of SWI in congenital cardiac patients is challenging. The standard tenets for management of SWI in adults are loosely applicable, but additional considerations must be addressed in this unique subset population.

Ten Years of Posterior Cranial Vault Expansion by Means of Distraction Osteogenesis: An Update and Critical Evaluation.

BACKGROUND: The goal of this study was to describe the 10-year evolution of the authors' surgical technique and institutional perioperative outcomes using posterior vault distraction osteogenesis (PVDO) in patients with syndromic and multisuture craniosynostosis. METHODS: The authors performed a retrospective cohort study of patients who underwent PVDO for treatment of syndromic and multisuture craniosynostosis at a single institution over a 10-year period. Demographic data, perioperative outcomes, distraction patterns, and complications were analyzed. Outcomes of patients in the first 5 years (early cohort) were compared with those of the latter 5 years (late cohort). RESULTS: One hundred ten patients underwent a total of 118 PVDO procedures. Patients with a syndromic diagnosis represented 83.6 percent of the cohort ( n = 92) and were significantly younger than patients with a nonsyndromic diagnosis at the time of first PVDO (median [25th percentile, 75th percentile] 14.1 [6.6, 40.1] versus 42.7 [15.2, 59.6] months; p = 0.014). Mean distraction distance in the anterior-posterior direction was 30.8 mm (SD, 7.4). Compared with the early cohort, PVDO in the late cohort had faster median operative times (144.0 [123.0, 189.0] minutes versus 161.0 [138.0, 199.0] minutes; p = 0.038), lower estimated blood loss as a percentage of blood volume (28.5 [20.6, 45.3] versus 50.0 [31.1, 95.8]; p < 0.001), and lower blood replacement as percentage of blood volume (39.5 [23.8, 59.1] versus 56.3 [37.8, 110.1]; p = 0.009). CONCLUSIONS: This 10-year experience with PVDO demonstrates continued overall safety and efficacy with improved perioperative outcomes over time. Although PVDO has become the authors' first line of expansion in syndromic craniosynostosis, shortcomings such as need for device removal, infection concerns, and potential for cerebrospinal fluid leak merit attention by the craniofacial community. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.